Current Directions in ADHD and Its Treatment

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Current Directions in ADHD and Its Treatment
Edited by Jill M. Norvilitis

Published by InTech
Janeza Trdine 9, 51000 Rijeka, Croatia

Copyright 2012 InTech
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First published February, 2012
Printed in Croatia

A free online edition of this book is available at www.intechopen.com
Additional hard copies can be obtained from orders@intechweb.org

Current Directions in ADHD and Its Treatment, Edited by Jill M. Norvilitis
p. cm.
ISBN 978-953-307-868-7

Contents

Preface IX
Part 1 Treatment Considerations 1
Chapter 1 ADHD in Children and Adolescents:
A Good Practice Guidance 3
Somnath Banerjee
Chapter 2 ADHD and Comorbid Conditions 25
Nitin Patel, Mita Patel and Harsha Patel
Chapter 3 Comorbidity in ADHD:
A Neuropsychological Perspective 47
Julio Csar Flores Lzaro and Mara Alejandra Salgado Soruco
Chapter 4 ADHD and Sleep Problems in Children 61
Elizabeth Hastings and Barbara T. Felt
Part 2 Psychopharmacology: Mechanisms and Effects 89
Chapter 5 The Neuropsychopharmacology
of Stimulants: Dopamine and ADHD 91
Paul E.A. Glaser and Greg A. Gerhardt
Chapter 6 Trends in the Prescribing and Adverse
Drug Reactions Patterns of Psychostimulants
Among Danish Children and Adolescents 111
Lise Aagaard and Ebba Holme Hansen
Chapter 7 Do Stimulant Medications for Attention-Deficit
/Hyperactivity Disorder (ADHD) Enhance Cognition? 125
Claire Advokat and Christine Vinci
Chapter 8 Motor Skills in Children with ADHD:
Comparative Study from the Farmacological Treatment 157
Jose Armando Vidarte Claros and Consuelo Velez Alvarez
VI Contents

Chapter 9 Methylphenidate and Dyslipidemia 185
Gideon Charach, Nechemia Kaysar, Alexander Rabinovich,
Ori Argov and Moshe Weintraub
Part 3 Non-Medication Interventions 193
Chapter 10 ADHD and Stress: The Role of Meditation to Reduce Stress,
and Improve Brain Function and Behavior Regulation 195
Sarina J. Grosswald and Fred Travis
Chapter 11 The Value of Coached Behaviour
Modification in the Effective Management of
Attention Deficit Hyperactivity Disorder (ADHD) 211
Tilla Olivier and Ana Gomes
Chapter 12 Distractor or Noise?
The Influence of Different Sounds on Cognitive
Performance in Inattentive and Attentive Children 233
Gran Sderlund and Sverker Sikstrm
Part 4 EEG Biofeedback 247
Chapter 13 QEEG Characteristics and Biofeedback
Modalities in Children with ADHD 249
Nada Pop-Jordanova
Chapter 14 EEG Findings in ADHD and the Application
of EEG Biofeedback in Treatment of ADHD 269
Mohammad Ali Nazari
Chapter 15 The Effect of Psycho-Educational Therapy
on Electroencephalographic Biofeedback
Scores in Attention Deficit Hyperactivity Disorder 287
Irene Nikaina, Aspa Paspali,
Georgia Kleidaria and Antigone Papavasiliou

Preface

Allenlion Deficil Hyeraclivily Disorder is one of lhe mosl videIy diagnosed behavior
disorders in chiIdhood, vilh a vorIdvide ooIed revaIence of 5.29 % (IoIanczyk el
aI., 2007). Il is aIso one of lhe mosl conlroversiaI diagnoses vilh concerns raised aboul
vhelher il is a cuIluraI conslrucl or a neurobehavioraI disorder (arkIey el aI., 2004,
Timimi el aI., 2004) and vhelher il is over diagnosed or under diagnosed. The
lrealmenl of ADHD is aIso a maller of ongoing research and debale, vilh considerabIe
dala suorling bolh sychoharmacoIogicaI and behavioraI aroaches. Researchers
conlinue lo search for nev inlervenlions lo be used in con|unclion vilh or in Iace of
lhe more lradilionaI aroaches. These inlervenlions run lhe gamul from sociaI skiIIs
lraining, lo cognilive behavioraI inlervenlions ,lo medilalion lo neurosychoIogicaIIy-
based lechniques.
This goaI of lhis voIume is lo exIore lhe slale-of-lhe-arl in consideralions of lhe
lrealmenl of ADHD around lhe vorId. The 16 chalers in lhis voIume reresenl lhe
vork of 27 researchers in counlries sanning lhe gIobe from Iran lo CoIumbia,
Denmark lo Soulh Africa , and lhe Uniled Slales. Some of lhe chalers in lhis book
rovide a nev vay of Iooking al veII-eslabIished lrealmenls vhiIe olhers examine
lrealmenls lhal are seeking lhe confirmalion of lhe research communily. This broad
survey covers issues reIaled lo comorbidily lhal affecl lhe lrealmenl choices lhal are
made, lhe effecls of sychoharmacoIogy, and non-medicalion lrealmenls, vilh a
seciaI seclion devoled lo lhe conlroversiaI nev lrealmenl, neurofeedback.
The firsl seclion of lhe book rovides an overviev of lrealmenl of ADHD and
comorbid condilions lhal may be of concern. Chaler 1, ADHD in ChiIdren and
AdoIescenls: A Good Iraclice Guidance rovides a summary of lhe assessmenl and
diagnosis of ADHD. Il aIso conciseIy describes lhe managemenl of lhe disorder,
covering such loics as choices and safely in medicalion, non-medicinaI lrealmenls,
and a consideralion of hov comorbid condilions may affecl lrealmenl. Chaler 2,
ADHD and Comorbid Condilions, examines in more delh lhe idenlificalion and
lrealmenl of sychoIogicaI robIems lhal are associaled vilh ADHD, such as
deression, anxiely, bioIar disorder, and oosilionaI defianl disorder. Chaler 3,
Comorbidily in ADHD: A NeurosychoIogicaI Ierseclive, lakes a differenl
aroach lo lhe issue from lhe firsl lvo chalers by examining lhe sublyes of ADHD
as reIaled lo differenl neurosychoIogicaI rofiIes. These rofiIes are in lurn reIaled lo
X Preface

differenl comorbid cognilive and behavioraI condilions. The finaI chaler in lhe firsl
seclion, ADHD and SIee IrobIems in ChiIdren, focuses on lhe need for lhe
consideralion of sIee robIems in chiIdren vilh ADHD because of lhe overIa
belveen lhe lvo calegories and lhe imIicalions for lrealmenl of ADHD.
The second seclion of lhe voIume examines lhe sychoharmacoIogicaI lrealmenl of
ADHD. Chaler 5, The NeurosychoIogy of SlimuIanls: Doamine and ADHD,
examines hov doamine's roIe in ADHD is reIaled lo lhe aclion of sychoslimuIanl
medicalions, as veII as lhe roIe of olher neurolransmillers and olher medicalions.
Chaler 6, Trends in lhe Irescribing and Adverse Drug Reaclion Iallerns of
IsychoslimuIanls among Danish ChiIdren and AdoIescenls, lakes advanlage of lhe
avaiIabiIily of dala regarding lhe individuaI use of medicalion in Denmark lo exIore
bolh changes in rescrilion rales over a 10 year eriod and lhe revaIence of adverse
reaclions lo lhe various medicalions. Chaler 7, Do SlimuIanl Medicalions for
Allenlion Deficil Hyeraclivily Disorder (ADHD) Inhance Cognilion`, revievs lhe
research on lhis loic and resenls lhe aulhors' ovn dala lhal indicale lhal, lhough
slimuIanls imrove allenlion and concenlralion, changes in olher areas of cognilive
and academic funclioning are inconsislenl such lhal slimuIanls do nol aear lo
imrove Iearning. Chaler 8, Molor SkiIIs in ChiIdren vilh ADHD: Comaralive
Sludy from lhe IharmacoIogicaI Trealmenl, summarizes lhe Iileralure indicaling lhal
50 % of chiIdren vilh ADHD have molor skiII robIems and describes lhe aulhors'
ovn research. AIlhough such robIems are common, lhe effecl of medicalion and
exercise on ADHD symloms and molor dislurbance remains uncIear. Chaler 9,
MelhyIhenidale and DysIiidemia, examines lhe reIalionshi belveen lhe drug
and Iiid rofiIes, concIuding lhal melhyIhenidale is reIaled lo some osilive
changes in lolaI choIesleroI and Iioroleins.
The lhird seclion of lhe book moves from sychoslimuIanls lo an examinalion of non-
medicalion lrealmenls. Chaler 10, Non-Medicalion Trealmenls of ADHD, rovides
an overviev of a variely of inlervenlions, summarizing lhe lechniques and research
regarding efficacy. Chaler 11, ADHD and Slress: The RoIe of Medilalion lo Reduce
Slress, and Imrove rain Iunclion and ehavior ReguIalion, reorls lhe resuIls of lvo
sludies examining TranscendenlaI Medilalion's effecls on ADHD symlomaloIogy lhal
indicale lhal chiIdren vilh ADHD are abIe lo Iearn lhe lechnique and lhal medilalion
may reduce slress and imrove execulive funclions. Chaler 12, The VaIue of Coached
ehavior Modificalion in lhe Iffeclive Managemenl of Allenlion Deficil Hyeraclivily
Disorder (ADHD), describes research suorling lhe use of coaches in lhe lrealmenl of
ADHD. Such coaches are nol reIacemenls for lheraisls, bul come aIongside lhose vilh
ADHD lo heI lhem Iearn lo manage lhe raclicaI chaIIenges lhal arise in lhe ursuil of
goaIs. Chaler 13, Dislraclor or Noise` The InfIuence of Differenl Sounds on Cognilive
Ierformance in Inallenlive and Allenlive ChiIdren, reorls lhe resuIls of a sludy
examining lhe differenliaI resonse of chiIdren vilh and vilhoul inallenlion symloms
lo background audilory noise. The aulhors reorl lhal such noise imroves cognilive
erformance in chiIdren vilh inallenlive symloms and rovide a lheorelicaI framevork
for underslanding lhis henomenon.
Preface XI

The finaI seclion of lhe book exIores lhe fairIy nev fieId of neurofeedback.
Neurofeedback, vhich uses quanlilalive IIG in biofeedback lraining, is a
conlroversiaI lechnique. Crilics oinl lo lhe Iack of conlroIIed research on lhe loic,
bul il remains ouIar vilh raclilioners and cIienls. Granls invesligaling lhe
lechnique are currenlIy funded by lhe NalionaI Inslilules of HeaIlh. CIearIy, more
research on lhis lechnique is needed and, in lhal siril, lhree chalers here address
neurofeedback. Chaler 14, QIIG Characlerislics and iofeedback ModaIilies in
ChiIdren vilh ADHD, describes lhe use of QIIG in lhe diagnosis of ADHD, vilh
resuIls from a sludy highIighling lhe differences among subgrous of lhe disorder.
The chaler aIso rovides a brief overviev of neurofeedback for ADHD. Chaler 15,
IIG Iindings in ADHD and lhe AIicalion of IIG iofeedback in Trealmenl of
ADHD, rovides a more exlensive descrilion of IIG biofeedback, incIuding
summaries of lhe lrealmenl rolocoIs. Chaler 16, The Iffecl of Isycho-IducalionaI
Theray on IIeclroencehaIograhic iofeedback Scores in Allenlion Deficil
Hyeraclivily Disorder, reorls lhe resuIls of a sludy examining lhe effecl of a
combinalion of neurofeedback and a cognilive-behavioraI academic inlervenlion. They
found lhal a combinalion of lrealmenls acceIeraled lhe imrovemenl in brain aclivily.
OveraII, lhe chalers resenled here la inlomuch of lhe breadlh of lhis fieId. I beIieve
lhal lhere is somelhing in lhis voIume for everyone inleresled in lhe lrealmenl of
ADHD, from sludenls examining lhe loic for lhe firsl lime lo researchers and
raclilioners Iooking for insiralion for nev research queslions or olenliaI
inlervenlions. I hoe lhal lhe chalers sark nev lhoughls and, erhas, debales.
This book is lhe resuIl of lhe vork of many individuaIs. I am arlicuIarIy gralefuI for
lhe assislance of Ms. Adriana Iecar and Mr. Igor abic for lheir assislance in
coordinaling lhis book. I aIso lhank aII of lhe aulhors vho conlribuled lo lhis voIume.

"#$$ %& '()*#$#+#,
Dearlmenl of IsychoIogy,
uffaIo Slale CoIIege,
uffaIo, NY 14222,
USA
-./.).01.,
arkIey, R. A., Duncan, M., Loney, }., MiIich, R., Werry, }., Cunningham, C..Hay, D.
(2004). Crilique or misreresenlalion` A reIy lo Timimi el aI. "#$%$&'# "($#)
'%) *'+$#, -.,&(/#/0, 123$245 65 65-69.
IoIanczyk, G., SiIva de Lima, M., Lessa Horla, ., iederman, }., & Rohde, L. A. (2007).
The vorIdvide revaIence of ADHD: A syslemalic reviev and melaregression
anaIysis. 7+28$&'% 9/:8%'# /; -.,&($'<8,5 =>?5 >5 942-948.
Timimi, S., Moncrieff, }., }ureidini, }., Leo, }., Cohen, D., WhilfieId, C.While, R. (2004).
A crilique of lhe InlernalionaI Consensus Slalemenl on ADHD. "#$%$&'# "($#)
'%) *'+$#, -.,&(/#/0, 123$245 65 59-63.

Part 1
Treatment Considerations

1
ADHD in ChiIdren and AdoIescents:
A Good Practice Guidance
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1. Introduction
The syndione of ieslIess, inallenlive, and inpuIsive lehavioui knovn as Allenlion Deficil
Hypeiaclivily Disoidei (ADHD) oi Hypeikinelic Disoidei (HKD) is a connon
neuiodeveIopnenlaI piolIen in chiIdien and adoIescenls. ChiIdien affecled vilh lhis
disoidei aie al iisk of acadenic faiIuie, sulslance aluse, and ciininaIily in adoIescence and
aduIlhood. ADHD is a iefIeclion of an undeiIying deficil lhal nay have seveiaI uIlinale
causes such as genelic piedisposilion, psycho-physioIogicaI faclois and psychoIogicaI
dysfunclion, lul a connon palhvay al lhe lehaviouiaI IeveI (HiII & Caneion, 1999). y
IaleIIing chiIdien vilh difficuIl lehavioui as suffeiing fion a disoidei, ve nake il easiei lo
lieal and lhis caiiies vilh il lhe dangei of ovei-diagnosis (Oifoid, 1998). On lhe olhei hand,
undei-diagnosis is aIso an issue (Dopheide, 2OO1).
2. Incidence
IievaIence of ADHD eslinales lhal 3 lo 7 chiIdien vouId neel lhe ciileiia of Diagnoslic
and SlalislicaI ManueI-IV (DSM-IV) of Aneiican Isychialiic Associalions diagnoslic ciileiia
(AIA, 1994). The ialio of loys lo giiIs is lelveen 3:1 and 9:1 lul lhis nay deciease vilh age
(Svanson ,' +6., 1998). Iail of lhe diffeience lelveen sexes nay le iefeiiaI lias (eideinan
,' +6., 1996). IoIIov-up sludies of chiIdien

vilh ADHD find lhal 15 sliII have lhe fuII
diagnosis al 25

yeais, and anolhei 5O aie in pailiaI ienission, vilh sone

synplons
peisisling (Iaiaone ,' +6., 2OO6).
3. AetioIogy
No genelic naikei has leen idenlified in chiIdien vilh ADHD. Neuioinaging sludies
confiin alnoinaIilies in lhose iegions of lhe liain lhal aie inpIicaled in ADHD (Svanson
,' +6., 1998, CasleIIanos ,' +6., 2OO2). These sludies iepoil significanlIy snaIIei asynneliicaI
piefionlaI and lasaI gangIia sliucluies, in chiIdien vilh ADHD.

CoiieIalions of nagnelic
iesonance inaging-lased analonicaI neasuies and specific-lask peifoinance in chiIdien
suggesl lhal lhe iighl piefionlaI coilex is invoIved in inhililing allenlionaI and lehaviouiaI
iesponses, vheieas lhe lasaI gangIia seen lo le invoIved in lhe execulion of lhese iesponses
(Koniad & Lickhoff, 2O1O). One lhiid of affecled individuaIs have al Ieasl one paienl vho

Current Directions in ADHD and ts Treatment

4
suffeis fion siniIai synplons. ADHD is aIso associaled vilh Iov liilh veighl (<15OOg),
lolacco and aIcohoI use duiing piegnancy (SICN, 2OO1).

AIlhough ADHD is highIy
heiilalIe, no specific suscepliliIily gene has leen idenlified (Iianke ,' +6., 2OO9).
4. Symptoms
The synplons of ADHD aie excessive and inpaiiing IeveIs of aclivily, inallenlion, and
inpuIsiveness. ChiIdien have gieal difficuIly ienaining sealed vhen iequiied in sliucluied
silualions such as in lhe cIassioon oi al lhe dinnei lalIe. They faiI lo pay allenlion lo
insliuclions in acadenic and sociaI silualions. The diffeience lelveen ADHD and noinaI
lehavioui is lhe degiee of inpaiinenl. The aIaining signaIs nay le a chiId vho is
acadenicaIIy undei-achieving lecause of his/hei lehavioui, despile having a noinaI
inleIIecl oi a chiId exhililing lehavioui piolIens lolh al hone and in schooI, vhich aie
consideialIy voise lhan vouId le expecled foi lhe slandaid of paienling and hone
enviionnenl. The synplons of ADHD change lhiough oul lhe IifecycIe. Hypeiaclivily and
inpuIsivily nay deciease as palienls gel oIdei lul lhe denands on lheii allenlion nay
inciease.
5. Assessment
Concein aloul lhe fuluie quaIily of Iife is heighlened vhen paienls olseive lheii chiIdien
sliuggIing lehaviouiaIIy al hone, acadenicaIIy in schooI and sociaIIy on lhe pIaygiound.
When loId lhal a chiId has ADHD, paienls aie ieIieved ly finding a ieason foi lheii chiIds
difficuIlies. The diagnosis confiins lhal il is nol lheii fauIl. Nol aII chiIdien and young
peopIe piesenling vilh difficuIl lehavioui viII vaiianl a speciaIisl iefeiiaI. This depends on
lhe seveiily of chiIds difficuIlies. ADHD can le piovisionaIIy diagnosed in pieschooI
chiIdien lul il shouId le confiined aflei lhe chiId has slailed schooI. Sone aigue lhal
piolIens vilh inallenlion, hypeiaclivily and inpuIsivily aie lhe iesuIls of cuIluiaI
phenonena (Iock, 1977).

Yel lhis poinl of viev appeais lo le changing vilh lhe acceplance
of ADHD as a cioss-cuIluiaI disoidei (Sandleig, 1996). Sone chiIdien aie inheienlIy noie
incIined lo le inallenlive, inpuIsive and hypeiaclive lhan olheis. Such liails nay iun in
faniIies e.g. paienls, silIings, and exlended faniIy nenleis and lheie seens lo le a genelic
piedisposilion lo lhen. MenlaI liails can le inheiiled jusl as heighl and veighl. Whal ve
aie deaIing vilh aie noinaI hunan vaiialions lhal aie onIy undeislood as leing disoideis
vhen lhey aie in confIicl vilh cuIluiaI expeclalions and noins. The ialing scaIes aie an
essenliaI looI lo ollain infoinalion lul aie nol a sulslilule foi a diagnosis. Repoils fion
paienls and leacheis nay nol agiee on lhe lypes of lehaviouis. This does nol nean lhey aie
necessaiiIy inaccuiale, il nay le alliiluled lo lhe facl lhal lhe paienls and lhe leacheis aie
seeing lhe chiIdien in diffeienl sellings. Theie aie nany ialing scaIes avaiIalIe, nosl of vhich
have leen deveIoped in lhe USA. The assessnenl shouId incIude infoinalion galheiing. Apail
fion ollaining lhe conpIeled ialing scaIes, "nfoinalion shouId le ollained fion lhe schooI
aloul peei ieIalionship and lhe chiIds acadenic piogiess. Infoinalion is galheied aloul
chiIds cuiienl difficuIlies, faniIy and sociaI hisloiy, chiIds deveIopnenlaI and nedicaI
hisloiy and lhe educalionaI piogiess. WhiIe inleivieving paienls, one needs lo ollain a
conpiehensive knovIedge of each paienls nedicaI and psychialiic hisloiy. IaniIy silualions,
such as a singIe voiking paienl, sepaialed oi divoiced paienls, oi ieconsliluled faniIies
vheie one oi lolh paienls have ienaiiied, aII affecl lhe chiId.

ADHD in Children and Adolescents: A Good Practice Guidance

5
5.1 MedicaI assessment
Since synplons of ADHD can occui due lo a vide vaiiely of undeiIying condilions, a
conpiehensive appioach lo lhe evaIualion of a chiId vilh ADHD is ieconnended (Reiff ,'
+6., 1993, AACAI, 1997)). MedicaI assessnenl shouId incIude a peiinalaI hisloiy,
lehaviouiaI/deveIopnenlaI hisloiy, faniIy hisloiy (SICN, 2OO1) and a physicaI exaninalion
foi any conliaindicalions foi possilIe nedicalion use, such as sone caidiac dysihylhnias.
IeiinalaI hisloiy shouId incIude aloul piegnancy and liilh, naleinaI exposuie lo diugs,
aIcohoI and snoking cigaielles, cannalis elc and high-iisk piegnancy (e. g. pienaluiily,
LW). ehaviouiaI/deveIopnenlaI hisloiy shouId incIude deveIopnenlaI niIeslones,
difficuIly engaging in quiel pIay and piolIens vilh oleying connands. IaniIy Hisloiy
shouId incIude hisloiy of ADHD, diug oi aIcohoI aluse, psychialiic iIInesses, piolIens vilh
lhe Iav, specific piecipilanl vheie synplons can le daled, evenls piecipilaling ADHD
synplons such as negIecl, physicaI oi sexuaI aluse, paienling issues and caidiac
aiihylhnias oi sudden dealh especiaIIy in 35 yeais oi youngei age, hone Lnviionnenl (key
caiegiveis, fiequenl noves oi fiequenl change in foslei caie, fiequenl changes of schooI,
hone enviionnenl and faniIy dynanics e. g. singIe faniIy, sane gendei pailneis),
inleipeisonaI ieIalionship/s in lhe faniIy, Iooi oi ciovded housing. Hisloiy shouId le
ollained aloul line spenl on TV-valching, conpulei and video ganes. Hisloiy shouId aIso
le ollained aloul peei ieIalionships, acadenic undei-achievenenl, liuancy, does lhe chiId
enjoy schooI, ask lhe schooI age chiId if she/he lhinks she/he has lioulIe concenlialing,
ieviev cuiienl schooI iepoil as veII as lhose fion eaiIiei yeais and psychoneliic evaIualion
ly educalion psychoIogisls foi cognilive aliIilies and acadenic achievenenl IeveIs. Hisloiy
of sIeep pallein needs lo le ollained. Laling Hisloiy shouId incIude appelile and ealing
halils and joining lhe olhei nenleis foi dinnei. IhysicaI exaninalion is done lo docunenl
a laseIine giovlh paianeleis (heighl and veighl) vhich shouId le pIolled on a cenliIe chail
and al each foIIov-up visil if lhe chiId is piesciiled nedicalion, lIood piessuie and puIse
iale aie iecoided and pIolled on lhe cenliIe chail, caidiac exaninalion incIuding
auscuIlalion foi nuinuis and fenoiaI puIses, dysnoiphic fealuies suggeslive of IelaI
AIcohoI Syndione (IAS) oi olhei genelic condilions, culaneous slignala, such as cafe au
Iail spols, liuising oi olhei evidence of injuiy, lonsiIIai hypeiliophy suggeslive of noulh
liealhing, neuioIogic exan and age-appiopiiale nenlaI slalus exan, lics, pIay skiIIs
(pailicuIaiIy piolIen soIving), olseiving lhe chiId/paienl inleiaclion, co-oidinalion lasks
and handviiling, nensliuaI/puleilaI slalus in adoIescenls and if deened necessaiy,
psychoIogicaI assessnenl. The assessnenl piocess shouId lake accounl of lhe olhei
condilions, vhich nay lellei accounl foi lhe chaIIenging lehavioui (AACAI, 1997). These
nighl incIude nedicaI disoideis such as #Ieep apnoea, seizuie disoideis, deveIopnenlaI
disoideis (e. g. InleIIecluaI disaliIily (Leaining disaliIily, LD ), Specific Leaining DifficuIly
(SpLD) foineiIy dysIexia and DeveIopnenlaI Cooidinalion Disoidei (DCI) foineiIy
dyspiaxia), liain injuiy, use of olhei nedicalions (e. g. anli-epiIeplic diug) oi sensoiy
inpaiinenls, nenlaI heaIlh disoideis such as OpposilionaI Defianl Disoidei
(ODD)/Conducl disoidei (CD), anxiely/depiession, adjuslnenl disoidei, allachnenl
disoidei oi sulslance aluse. Olhei condilions incIude Aulisn Specliun Disoidei (ASD)
and lhe noinaI aclive pieschooI chiId. In addilion lo lhe hisloiy nenlioned alove,
evaIualion of an adoIescenl shouId aIso incIude eIiciling hisloiy iegaiding use of aIcohoI
and diugs, cigaielle snoking, nunlei of accidenls and speeding lickels, sexuaI aclivily and
spending hisloiy. The alove assessnenls aie nol indicalive of ADHD lul nay heIp lo iuIe


6
oul lhe possiliIily of olhei undei-Iying nedicaI oi deveIopnenlaI condilions ninicking
ADHD synplons.
6. GuideIines
The guideIines foi assessnenl and liealnenl have leen issued ly Aneiican Acadeny of
ChiId and AdoIescenl Isychialiy (AACAI, 2OO7), lhe Aneiican Acadeny of Iedialiics
(AAI, 2OO1), lhe Luiopean CuideIines

(TayIoi ,' +6., 2OO4, anaschevski ,' +6., 2OO6),
NalionaI Inslilule foi HeaIlh and CIinicaI LxceIIence (NICL, 2OO8) and lhe Scollish
InleicoIIegiale CuideIine Nelvoik (SICN, 2OO4). WhiIe lheie is a degiee of consensus anong
lhese pulIicalions, lheie seens lo le sone inleinalionaI diffeience such as NICL
ieconnends diug liealnenl in seveie ADHD, vheieas lhe Aneiican guideIines advice lo
slail nedicalion and Ialei olhei nanagenenl slialegy nay le consideied (CADDRA, 2O1O).
7. Diagnosis
ADHD is a cIinicaI diagnosis foi vhich lheie aie no lesls. Il is inpoilanl lo galhei lhe
infoinalion fion paienls/caieis and schooI. The diagnosis is nade ly using lhe diagnosis
ciileiia eilhei of DSM -IV (AIA, 2OOO) oi ICD -1O (WHO, 1992). olh najoi syslens of
cIassificalion idenlify idenlicaI 18 synplons (lalIe 1).

$%&''(%'")% *$+, -./(0&1'"2"'. *-, $3/45#"2"'. *$67,
IaiIs lo allend lo delaiIs Iidgels vilh hands oi
feel

DifficuIly suslaining allenlion Leaves seal in
cIassioon

Does nol seen lo Iislen Runs aloul oi cIinls
IaiIs lo finish DifficuIly pIaying
quielIy

DifficuIly oiganising lasks Moloi access (on lhe
go, in DSM-IV)

Avoids suslained effoil TaIks excessiveIy
(DSM-IV)
TaIks excessiveIy (ICD-1O)
Loses lhings Iuils oul ansveis lo
queslions
Disliacled ly exlianeous
slinuIi
DifficuIly vailing luin
IoigelfuI Inleiiupls oi inliudes on
olheis
TalIe 1. Synplon donains foi ADHD in DSM-IV and ICD-1O
7.1 Differences between the two major diagnostic manuaIs (tabIe 2)
89:9: In lhe synplon donains of Inallenlion, Hypeiaclivily, and InpuIsivily, an ICD-1O
diagnosis of HKD needs sone synplons fion aII lhiee gioups vheieas DSM-IV ADHD
does nol, lul inslead specifies sullypes if synplons aie fion onIy one donain. HKD is
lioadIy siniIai lo seveie lype of ADHD.


7
89:9; ecause of lhe high iale of conducl disoidei, ICD-1O uses lhe piesence oi alsence of
conducl disoidei as lhe lasis foi lhe nain suldivision of HKD. DSM-IV does aIIov lhe
diagnosis of conducl disoidei as a conoilid condilion.
89:9< Anolhei diffeience lelveen lhe lvo cIassificalions is lhe use of olhei condilions as
excIusion ciileiia. ICD-1O ains al a singIe diagnosis. DSM-IV ains lo iecognize, as nany
diagnoses as lheie aie synplons.

-=> *$?>@:A,
Six oi Six oi noie fion IN donain, lhiee oi noie fion
H donain and one oi noie fion IMI donain.
B>-> C #4D'./(# *>E6@$F,
Conlined lype Six oi Six oi noie fion IN donain and six oi noie
fion lhe H / IMI donain.
Inallenlive lype Six oi Six oi noie fion IN donain and Iess lhan six
fion H / IMI donain+/- H / IMI Iess lhan 6
Hypeiaclive/InpuIsive Six oi Six oi noie fion H / IMI donain and Iess lhan
six fion IN donain.
IN: Inallenlion, H: Hypeiaclivily, IMI: InpuIsivily
TalIe 2. HKD diagnosis and ADHD diagnosis sullypes
7.2 Limitations of diagnosis criteria
AIlhough lhe DSM-IV and ICD-1O aie videIy used as diagnoslic looIs, lheie aie a nunlei of
Iinilalions (AAI, 2OOO).
89;9: The nunleis of synplons iequiied lo nake lhe diagnosis of ADHD / HKD does nol
vaiy vilh lhe seveiily of lhe synplons oi vilh lhe age. Theiefoie an oIdei chiId vilh a fev
seveie synplons nay nol neel lhe diagnoslic ciileiia, vheieas a youngei chiId vilh nany
Iess seveie synplons nay neel lhe ciileiia, even lhough lhe foinei nay expeiience noie
funclionaI inpaiinenl. Ioi a chiId vilh fev seveie synplons, lhe diagnosis of ADHD nol
olheivise specified lhal is incIuded in DSM-IV nay le used, lul lhe nanuaI piovides no
ciileiia foi vhen lo nake lhis diagnosis.
89;9; The iequiienenls lhal synplons occui in al Ieasl lvo sellings can le piolIenalic al
lines. Il nay hindei lhe diagnosis foi chiIdien vho nay have significanl difficuIlies vilh
allenlion in schooI lul do nol have piolIens al hone.
89;9< AIlhough lhe ciileiia incIude synplons le piesenl lefoie 7 yeais is usefuI in
highIighling lhal ADHD iaieIy is lhe coiiecl diagnosis vhen inallenlion, hypeiaclivily, oi
inpuIsivily is occuiiing foi lhe fiisl line in adoIescence oi in aduIlhood,

hovevei, il nay le
piolIenalic in excIuding chiIdien vhose Iiniled allenlion spans lecones noie nolicealIe
vhen lhey slail secondaiy schooI lecause of incieased schooI and hone voik.
89;9G The leins "significanl" and "sone inpaiinenl" aie suljeclive and uncIeai.
89;9H The diagnosis is aIso enviionnenlaIIy dependenl, vhich expIains vhy cIinicians viII
see diffeiences in lhe chiId's lehavioui lelveen schooI and hone sellings.


8
89;9I Il is a chaIIenge lo nake a diagnosis vhen lheie aie no expIicil ciileiia foi defining
vhal is lypicaI foi a pailicuIai age`
89;98 CuiienlIy lhe najoi diagnosis ciileiia aie onIy appIicalIe lo adoIescenls up lo 18 yeais
of age. Theie aie no diagnosis ciileiia foi aduIls.
8. Management
IoIIoving diagnosis of ADHD, viillen infoinalion and avaiIalIe oplion of vaiious
nanagenenl slialegies, velsile addiesses, and conlacl delaiIs of lhe IocaI suppoil gioups
shouId le given lo lhe paienls and lhe chiId's schooI iegaiding lhe condilion and ils
nanagenenl. Iaienls/caieis shouId le infoined lhal ADHD is a neuio-lehaviouiaI
condilion vilh a possilIe genelic aelioIogy vhich is lhe iesuIl of Iov oi inlaIanced IeveIs of
specific neuioliansnilleis in ceilain aieas of lhe liain. AlnoinaIIy Iov IeveIs of lhese
neuioliansnilleis aie associaled vilh lhe inpaiinenls lhal aie lhe haIInaiks of ADHD. The
need lo iuIe oul olhei possilIe diagnoses shouId le expIained. SulsequenlIy vaiious
liealnenl oplions need lo le expIoied. Lnsuie lhal lhe palienl and faniIy have had an
adequale oppoilunily lo le educaled aloul ADHD (CADDRA, 2O1O). Do ask lhe faniIy lo
find oul noie aloul ADHD lhiough iepulalIe velsiles and ieconnended ieading. They
need lo le infoined of lhe synplons lhal indicale a diagnosis and lhe ains and ialionaIe
foi liealnenl (vilh an undeislanding lhal no nedicalion eIininales aII lhe synplons of
ADHD and lhal olhei slialegies aie aIso indicaled as pail of nanagenenl). Theie needs lo
le a discussion of lhe iisks and lenefils of lhe advised lheiapy and lhe aIleinalives. Theie
shouId aIso le discussion iegaiding lhe polenliaI iisks of no lheiapy. Il is inpoilanl lo
desciile lo lhe paienls lhe findings ollained fion lhe assessnenl, incIuding a cIeai
slalenenl aloul lhe diagnosis and lhe lasis on vhich lhe diagnosis is nade. The faniIy
shouId le loId lhal a copy of lhe cIinic Iellei, vilh lheii consenl, viII le senl lo lhe schooI.
The chiIds suiioundings shouId suppoil ioulines and deciease disliaclions. Consislenl age-
appiopiiale Iinil selling is inpoilanl. Relaining a posilive, enjoyalIe ieIalionship vilh lheii
chiId inpioves lhe chiIds seIf-esleen. Thus, doing lhings lhal lhe chiId enjoys is inpoilanl.
Iaienls/caieis need lo heIp lhe chiId lo deveIop appiopiiale sociaI lehaviouis vilh peeis
and aduIls. Whenevei possilIe, an allenpl shouId le nade lo voik vilh lolh paienls so
lhal lhey aie consislenl vilh each olhei in lheii appioaches. IaniIy suppoil shouId ain lo
inpiove ieIalionships vilhin lhe faniIy, pionole paienlaI enpoveinenl and deveIop
slialegies lo nanage lehavioui, e.g. lhiough a paienling gioup. In addilion, faniIies shouId
le advised of ADHD paienl suppoil gioups exisling in lheii aiea. In nany cases caiefuI
nanagenenl of lehavioui and advice lo paienls and leacheis and voiking vilh lhe chiId lo
conlioI inpuIsiveness and nainlain concenlialion nay le sufficienl lo nanage lhe piolIens
(AAI, 2OO1). Wheie lhese aie nol deened lo le sufficienl, nedicalion nay le liied. Liaison
vilh lhe schooI shouId heIp infoin lehavioui nanagenenl slialegies vilhin lhe cIassioon.
Iuilhei suppoil fion lehavioui speciaIisl leacheis nay le soughl vheie necessaiy. The
chiIds schooI and lhe schooI nuise shouId le nolified al lhe slail of nedicalion. Any change
of lhe dosage nusl le nolified lo schooI and schooI nuise ly lhe piesciiling docloi, ialhei
lhan sinpIy leing ieIayed lo lhen ly lhe paienls oi lhe chiId. IndividuaI counseIIing oi
gioup voik nay le offeied lo lhe chiId lo addiess issues of Iov seIf-esleen as veII as lo
pionole sociaI skiIIs and lhe peei ieIalionships and offei skiIIs in lhe aiea of angei
nanagenenl. Tine shouId le spenl vilh lhe chiId/young peison lo heIp lhen undeisland


9
vhal ADHD is and if nedicalion is lo le used, hov il voiks and ils side effecls. In lhe noie
seveie cases, and usuaIIy foIIoving lehaviouiaI inleivenlions, a liiaI of nedicalion nay le
consideied. ADHD is a chionic condilion iequiiing access lo Iong-lein liealnenl and
suppoil, sonelines ovei nany yeais. Hovevei, lhe IeveI and lype of suppoil needed can
vaiy. The piincipaI ains of liealnenl aie lo pionole lhe chiId's deveIopnenl and lo ieduce
secondaiy difficuIlies.
8.1 Non psychopharmacoIicaI interventions
This liealnenl is a non-diug inleivenlion and is ieconnended in niId and nodeiale
degiee of seveiily of ADHD (NICL, 2OO8). The lheiapisl consuIls vilh paienls and leacheis
lo liain lhen lo change lhe Ieaining enviionnenl foi lhe chiId. Il neans lo physicaIIy
caIning lhe chiId, lo enalIe lhen lo slay sliII, even in a gioup. The goaI is lo leach paienls
and leacheis lo use ievaids and punishnenl consislenlIy and effecliveIy. Togelhei vilh lhe
lheiapisl, lhe paienls and leachei find ievaids lhal viII nolivale lhe chiId lo voik. Cioup
lased paienling piogiannes can heIp paienls/caieis lo deveIop lheii skiIIs and loosl
confidence in nanaging chaIIenging and difficuIl lehavioui of lheii chiIdien. Sone
paienling piogiannes incIude InciedilIe Yeais, vhich use Welslei Sliallon piogianne foi
paienls of chiIdien aged 2 - 8 yeais (InciedilIe yeais), TiipIe I foi paienls and lhe
piogianne iun ly lainaidos (ainaidos). Using effeclive connunicalion skiIIs lo
deveIop a Ioving, guiding, Iinil selling, consequence pioviding lhal ievaids lhe desiied
lehavioui and eIininales lhe undesiied lehavioui is lhe Iong lein ain of non
psychophainacoIogicaI inleivenlion.
8.2 Medications
Advice and suppoil aloul lhe chiIds seIf esleen, peei gioup piogiess, acadenic piogiess
and faniIy ieIalionships viII aIso le iequiied even if nedicalion is used. A posilive
iesponse lo nedicalion is nol diagnoslic and a good iesponse lo diugs does nol vaIidale lhe
diagnosis. The piesenlIy avaiIalIe nedicalions aie synplonalic lheiapies, lhey aie nol alIe
lo cuie lhe condilion. Medicalion ains lo ieduce lhe coie synplons and lo inpiove lhe
effecliveness of olhei inleivenlions. Medicalion liealnenl shouId focus on lehaviouiaI
inpiovenenl and nol on gelling lellei giades in schooI, giades nay le lhe nel iesuIl of a
nany faclois, incIuding Ieaining disaliIilies, nolivalion and faniIy alliludes.
Diugs used in lhe liealnenl of ADHD aie giouped inlo lvo najoi calegoiies: slinuIanls
and non slinuIanls. MelhyIphenidale (MIH) and Alonoxeline (ATX) aie nol Iicensed foi
use in chiIdien Iess lhan six yeais of age oi in aduIls. ATX is Iicensed aflei 6 yeais of age and
nay le conlinued in aduIlhood vheie lhey have leen slailed in adoIescence.
Dexanfelanine (DLX) nay le piesciiled aflei 3 yeais of age. SlinuIanls (MIH and DLX)
aie nol Iicensed foi chiIdien vilh naiked anxiely, agilalion oi lension, synplons oi faniIy
hisloiy of lics oi Touielles syndione, hypeilhyioidisn, angina oi caidiac aiihylhnia,
gIaucona oi lhyioloxicosis. SlinuIanls aie conlioIIed ly lhe Misuse of Diugs Acl 1971 and
aie suljecl lo lhe ieguIalions foi ConlioIIed Diugs. Ioi delaiIs lhe piaclilioneis aie advised
lo consuIl lhe Luiopean liealnenl guideIines (TayIoi ,' +6. 2OO4, anaschevski ,' +6, 2OO6).
Iaienls shouId have leen expIained lhe advanlages and disadvanlages of vaiious avaiIalIe
diugs. Conceins and queslions paienls nay have iegaiding lolh effecls and side effecls
need lo le addiessed. An expIanalion of vhal nedicalion can and cannol do, and vhal


10
olhei inleivenlions aie avaiIalIe shouId le given. Iaienls/caieis shouId le loId lhal nol
eveiy nedicalion is suilalIe foi eveiy palienl. The guiding piincipIe of diug inleivenlion is
lo achieve lhe oplinun iesponse vilh lhe Iovesl dose possilIe lhal does nol give side
effecls. Theiefoie, slail vilh a Iov dose and giaduaIIy incieased unliI lhe naxinun
ieconnended dose IeveI is ieached oi laigel synplons have inpioved oi side effecls
appeai. Theie aie ieconnendalions foi dosing foi diffeienl nedicalions in accoidance vilh
lheii Iicenses. Wheie lheie aie conoilidilies, addilionaI oi nuIlipIe nedicalions nay le
used. The sunnaiy of pioducl chaiacleiislics (SIC) conlains specific advice aloul a diug.
The nosl inpoilanl deveIopnenl in ADHD occuiied in 1937 vilh lhe discoveiy

of lhe
leneficiaI effecl of DLX on allenlion and lehavioui anong chiIdien (iadIey, 1937). The
nain lieaklhiough cane in 1957 vilh lhe inlioduclion of MIH and sulsequenlIy nuneious
liiaIs confiined safely and efficacy of slinuIanls (Laufei, 1971, Lisenleig, 1972). The
nechanisn of aclion of lolh lhe slinuIanls, DLX and MIH is siniIai, lhey acl piincipaIIy as
inhililois of lhe dopanine-uplake nechanisn in lhe liain. DLX, in addilion, pionoles lhe
ieIease of lhis neuioliansnillei, lhus slinuIaling dopanineigic nechanisns. The slinuIanls
aIso acl on noiepinephiine-conlaining neuiones lo pionole an incieased ieIease of lhis
nonoanine.

The nosl exlensiveIy used and ieseaiched slinuIanl is MIH, a deiivalive of
DLX vhich has a iapid onsel of aclion, shoil haIf-Iife. Dosage and fiequency iequiienenls
vaiy vilh each individuaI chiId and aie independenl of lhe veighl oi lhe age. SlinuIanls aie
iapidIy alsoiled and easiIy cioss lhe lIood- liain laiiiei. If lheie is a Iack of inpiovenenl
oi sulslanliaI side effecls, anolhei ADHD diug nay le consideied anolhei (e.g., MIH vs.
DLX). If a palienl is iesponding veII lo one nedicalion, il is advised lhal anolhei nedicalion
shouId nol le liied lo see if lheie is a lellei iesponse. TalIe 3 desciiles lhe piopeilies of lhe
ADHD diugs.

BJ(%' K%#(' 6&L (MM(1' >40&'")% -&5M@5"M( >)#&J(NO&.
EP)0'@&1'"%J 67-
:

MIH-IR
2
2O-3O nin 1-2 his 3- 5 his 2-3 his 2.5-6O ng
DLX
3
2O-6O nin 1-2 his 6 his 4-6his 1.25-4O ng
Q)%J@&1'"%J 67-
Conceila XL
4,
2O-3O nin 2 his 12 his 3.5 his 18-54 ng
Lquasyn XL 2O-3O nin 1-2 his 8 his 2 his 1O-6Ong
Medikinel XL 2O-3O nin 1-2 his 8 his 2 his 1O-6Ong
MIH-SR
5
1-3 his 2 his 5-6 his 2-6 his 2O-6Ong
+)% #'"345&%'
ATX
6
1 vk 1- 2 his 24 his 3.6 his in
iapid
nelaloIis
eis
O.5ng/kg x 7
days, lhen
1.2ng/kg,
nax
1OOng/day
MIH
1
= nelhyIphenidale, MIH-IR
2
= nelhyIphenidale-innediale ieIease, DLX
3
= dexanfelanine,
Conceila XL
4
= Iicensed up lo 54 ng pei day, MIH-SR
5
= nelhyIphenidale sIov ieIease,
ATX
6
=alonoxeline
TalIe 3. Iiopeilies of ADHD diugs.


11
8.2.1 Medications
The Iicense slalus of ADHD nedicalions vaiies in lhe diffeienl Luiopean counliies. On
aveiage lhe diugs Iicensed and avaiIalIe in diffeienl Luiopean counliies aie:
MelhyIphenidale innediale ieIease (IR) avaiIalIe as 5, 1O and 2Ong lalIels (5 and 2Ong
onIy avaiIalIe as Medikinel and nelhyIphenidale lalIels).
Medikinel
XL (nelhyIphenidale SR) avaiIalIe as 5, 1O, 2O, 3O, and 4Ong capsuIes.

Lquasyn
XL (nelhyIphenidale SR) avaiIalIe as 1O, 2O and 3O ng capsuIes.

Conceila

XL (nelhyIphenidale SR) avaiIalIe as 18, 27 and 36 ng lalIels.
Dexediine
(Dexanfelanine) avaiIalIe as: 5 ng lalIels.

Slialleia

(alonoxeline) avaiIalIe as 1O, 18, 25, 4O, 6O and 8Ong capsuIes.
R9;9:9: 6('P.5/P(%"O&'( $33(O"&'( S(5(&#( *67- $S,
MIH is a cenliaI neivous syslen slinuIanl. The naxinun ieconnended dosage is O.7 ng
pei Kg pei dose oi 2.1 ng pei Kg daiIy in divided doses. Il is Iicensed fion six yeais lo
eighleen yeais of age. MIH IR is aclive foi aloul foui houis aflei lhe Iasl dose laken.
R9;9:9; 6('P.5/P(%"O&'( #4#'&"%(O 0(5(&#( *67- ES,
RecenlIy, lheie is an infIux of suslained ieIease slinuIanls. The fiisl one lhal cane in lhe
naikel is OROS MIH, oi Conceila XL (Tii-Iayei capsuIe-shaped lalIels). This lalIel has an
osnolic nenliane and oveicoal of MIH, has lvo conpailnenls foi MIH, and a push
conpailnenl. Il aIso has a Iasei-diiIIed hoIe lhal aIIovs lhe ieIease of nedicalion al a pie-
specified pace. This nedicalion vas deveIoped lo iepIace 3 doses of innediale-ieIease MIH
given 4 houis apail, lheiefoie, lhis diug is aclive foi aloul 12 houis. The lalIel sheII nay
appeai in lhe faeces 2O MIH is excieled due lo an osnolic punp aclion and lheiefoie 18
ng lalIel gives 15 ng IR The second MIH iefoinuIalion lhal cane lo naikel is naikeled as
Lquasyn XL vhich has a 3O shoil-acling lead, 7O Iong-acling lead. Il is a iphasic
ReIease ead-DeIiveiy Syslen diug. This nedicalion vas designed lo iepIace 2 doses of
MIH. Il is advised lo svaIIov vhoIe oi enply capsuIe conlenls onlo one spoonfuI of appIe
sauce oi siniIai sofl food such as yoghuil The lhiid MIH conpound lhal cane lo UK
naikel is caIIed Medikinel XL. Il has inodaI ReIease foi Once-DaiIy Dosing and has a 5O
shoil-acling lead, 5O Iong-acling lead, so lhis nedicalion is designed aIso lo voik foi 6 lo
8 houis lo covei lhe schooI day. This capsuIe is eilhei svaIIoved vhoIe oi capsuIe conlenl
can le enplied onlo one spoonfuI of appIe sauce oi siniIai sofl food TalIe 4 desciiles lhe
innediale and exlended ieIease piopoilions of MIH.

RilaIin sIov ReIease (RilaIin SR) is
nol Iicensed in UK, lul sonelines used. Il is avaiIalIe as 2O ng lalIels.

Conceila XL
T
Lquasyn XL
T
Medikinel XL
T

TalIel IR 22 LR 78 CapsuIe IR

<O LR 7O CapsuIe IR 5O LR

5O
- - - 1O ng 3 ng 7 ng 1O ng 5 ng 5 ng
18 ng 4 ng 14 ng 2O ng 6 ng 14 ng 2O ng 1O ng 1O ng
27 ng 6 ng 21 ng 3O ng 9 ng 21 ng 3O ng 15 ng 15 ng
36 ng 8ng 28 ng 4O ng 812ng 28 ng 4O ng 2O ng 2O ng
45 ng 1O ng 35 ng 5O ng 15 ng 35 ng 5O ng 25 ng 25 ng
54 ng 12 ng 42 ng 6O ng 18 ng 42 ng 6O ng 3O ng 3O ng
TalIe 4. ReIalive piopoilions of Innediale-ReIease (IR) and Lxlended-ReIease (LR)
nelhyIphenidale


12
R9;9:9< >(L&3M('&3"%( *>UV,
DLX is aIso a cenliaI neivous syslen slinuIanl. Ils effecl and adveise evenl piofiIe aie
siniIai lo MIH. The iniliaI dose nay le 2.5ng once oi lvice daiIy and incieased if
necessaiy ly veekIy incienenls of 5-1Ong in lhe daiIy dose. The naxinun Iicensed dose is
4Ong daiIy in divided dosage.
R9;9:9G E&M('. )M #'"345&%' 3(O"1&'")%#
AIlhough sone paienls expiess concein lhal slinuIanls nay cause diug aluse oi
dependence, a ieviev of Iong-lein sludies of slinuIanls and sulslance aluse shoved lhal
diug aluse vas Iess IikeIy in chiIdien vilh ADHD vho veie liealed vilh slinuIanls
conpaied vilh lhose vho veie nol (WiIens ,' +6., 2OO3).

Ialienls oi paienls/caieis, vho aie
al iisk foi sulslance aluse/diug-diveision, shouId nol le piesciiled shoil-acling slinuIanls
unliI piecaulionaiy neasuies have leen pul. One of lhe nosl connon ieasons foi non-
conpIiance is ieIaled lo a Iack of avaieness oi undeislanding of lhe side effecls and Iack of
Iiaison lelveen lhe cIinician and paienls. The connon side-effecls iepoiled vilh MIH aie
insonnia, decieased appelile, pain in aldonen and headache. They aie oflen niId and
liansienl, and nay le aIIevialed ly ieducing oi adjusling lhe dosage. Many paienls
conpIain lhal lheii chiIdien aie 'picky ealeis'. In addilion, lolh slinuIanl and non-slinuIanl
ADHD nedicalion can fuilhei suppiesses appelile. Moieovei chiIdien vilh ADHD nay nol
sil sliII Iong enough lo finish lheii neaIs. Connon sense diclales lhal vhiIe laIanced diel is
nol IikeIy lo cuie ADHD, nuliilious food vouId inpiove oveiaII heaIlh, and lhus indiieclIy
lenefil lehavioui and allenlion. Unvanled effecls of appelile suppiession can le avoided
ly advising lhe diug lo le laken aflei lieakfasl and Iunch. IiolIens vilh sIeep aie a
connon conpIainl anong ADHD palienls. A deciease in sIeep quaIily and/oi quanlily
nay Iead lo voisening of lehavioui. Il is lheiefoie inpoilanl lo scieen foi sIeep difficuIlies.
The acionyn LARS (Ovens & DaIzeII, 2OO8) is usefuI foi lhis puipose: Wedline iesislance
and deIayed sIeep onsel, Uxcessive day line sIeepiness, Bvakenings duiing nighl,
SeguIaiily, pallein and duialion of sIeep and Enoiing and olhei synplons of sIeep-
disoideied liealhing. The causes of sIeep piolIens incIude anxiely, ODD, sIeep disoideis
(Olsliuclive SIeep Apnoea, DeIayed SIeep Ihase Syndione (DSIS) and ReslIess Leg
Syndione). SlinuIanls nay inciease lhe difficuIly of faIIing asIeep. In DSIS, leenagei faIIs
asIeep Ialei lhan lhe expecled line, has a noinaI sIeep al nighl lul vakes up Iale lhe nexl
day. SIeep is oplinized ly nainlaining a quiel and confoilalIe sIeep enviionnenl.
Lxposuies lo TV, conpulei ganes oi inleinel chal Iines disiupl lhe inilialion of sIeep. The
led is nol foi valching TV, ealing, oi doing honevoik. No vigoious exeicise vilhin lvo
houis of ledline is ieconnended. Avoid diinks conlaining caffeine such as chocoIale,
coffee, lea and coIa in lhe Iale afleinoon and evening and advice a lalh lefoie led lo heIp
ieIax. MeIalonin is a naluiaI hoinone pioduced ly lhe pineaI gIand in lhe liain. Il is a sIeep
inducei and heIps lo faII asIeep al nighl. Ceilain foods aie iich in neIalonin such as oals,
iice, sveel coin, laiIey and lonaloes. MeIalonin 2-1O ng nay le adninisleied 3O-6O
ninules lefoie lhe ledline foi chiIdien vilh significanl difficuIly gelling lo sIeep. Theie is
evidence lhal neIalonin is safe vilh shoil lein use, lul addilionaI sludies aie needed lo
deleinine ils Iong lein safely (usceni ,' +6. 2OO6). A veiy iaie lul inpoilanl adveise
ieaclion is lone naiiov suppiession. A iouline fuII lIood counl is nol vaiianled unIess
lheie is a cIinicaI indicalion. The nosl connonIy iepoiled adveise effecls vilh ATX aie
appelile deciease, headache, sonnoIence, nausea, voniling and aldoninaI pain. HosliIily


13
(piedoninanlIy aggiession, opposilionaI lehavioui and angei) is an unconnon adveise effecl
vilh ATX. Aggiession is a connon side-effecl of slinuIanls. SlinuIanls aie advised lo avoid
in lhose vilh suicidaI lendency and suicidaI idealion, aIlhough suicidaI allenpl (incIuding
conpIeled suicide) is veiy iaie. Ialienls vilh eneigenl suicidaI idealion oi lehavioui duiing
liealnenl shouId le evaIualed innedialeIy ly lheii physician. Ialienls on ATX shouId le
cIoseIy noniloied foi lhe appeaiance oi voisening of aggiessive lehavioui, hosliIily oi
enolionaI IaliIily. A fuII Iisl of polenliaI adveise effecls is Iisled in lhe sunnaiy of pioducl
chaiacleiislic (SIC) of individuaI diugs. They aie aIso avaiIalIe onIine on lhe LIeclionic
Medicines Conpendiun velsile (hllp://vvv.nedicines.oig.uk/enc/). Side effecls vhich
nay vaiianl dose onission unliI discussed vilh an ADHD speciaIisl incIude iaised lIood
piessuie, inciease in seizuie fiequency in palienls vilh epiIepsy, heail ihylhn changes,
lIuiied eyesighl oi evidence of iaie lIood disoideis. Anxiely is a connonIy occuiiing
adveise evenl vilh MIH. CIinicaI evaIualion foi anxiely oi agilalion shouId piecede use of
MIH and palienls shouId le ieguIaiIy noniloied foi lhe eneigence oi voisening of lhese
synplons ieguIaiIy. A caulion is needed lo use ADHD diugs in vonen of chiIdleaiing age
as effecls of ADHD nedicalions on lhe foelus and on lieasl-feeding aie unknovn. As pei
lhe SIC, ATX oi MHI shouId nol le used duiing piegnancy unIess lhe lenefil oulveighs
lhe iisk and DLX is conlia-indicaled in piegnancy and duiing Iaclalion. IuII Iisl of
piecaulions / conlia-indicalions aie incIuded in lhe SIC. ATX shouId le disconlinued in
palienls vilh jaundice oi Ialoialoiy evidence of Iivei injuiy. Veiy iaieIy, Iivei loxicily vilh
eIevaled hepalic enzynes and liIiiulin has leen iepoiled. Uses of aII ADHD nedicalions
vilh MAOIs aie conliaindicaled. Il is good piaclice lo expIain lo a leenagei aloul lhe
condilion and lhe oplion of vaiious diugs lo gain hei/his confidence. The use of
nedicalions nay piolecl lhen fion pooi sociaI skiIIs. Conlining nedicalions foi ADHD
vilh iIIicil diugs oi aIcohoI couId le dangeious as lhe effecls nay le exaggeialed.
R9;9:9H $# 'P(0( &%. ')5(0&%1( ') #'"345&%'#X
Acule loIeiance, oi lachyphyIaxis neans in oidei lo nainlain lhe iesponse in lhe neuion, ve
need lo inciease lhe concenlialion of nedicalion lo nainlain lhe iesponse. In facl, lvo of lhe
avaiIalIe slinuIanls, Conceila XL and Lquasyn XL, use lhe piincipIe of vhal's caIIed an
ascending cuive, neaning lhal lhe concenlialion of MIH goes up acioss lhe day lo
counleiacl acule loIeiance. So lhe concenlialion iises acioss lhe day. Thus lhe issue of acule
lachyphyIaxis has leen consideied in lhe deveIopnenl of sone of lhe conpounds avaiIalIe
loday.
R9;9:9I +)%@#'"345&%'
Alonoxeline hydiochIoiide (ATX) is a non slinuIanl diug vilh no aluse polenliaI and is
effeclive foi 24 houis. Il is a seIeclive inhililoi of noiadienaIine ieuplake Iicensed foi lhe
liealnenl of ADHD in chiIdien aged 6 yeais and oIdei, adoIescenls and aduIls. Il nay le
usefuI in chiIdien vho do nol iespond oi deveIop seveie side effecls lo slinuIanls. Ceilain
silualions such as conoilidily vilh lics, Touielles syndione oi sulslance aluse vouId
suppoil ATX as a fiisl Iine oplion. Il is avaiIalIe as Slialleia
1O, 18, 25, 4O, 6O & 8O ng

capsuIes. The ieconnended slailing dose in six yeais oi oIdei and adoIescenls vilh lody
veighl up lo 7Okg is O.5 ng/kg/day (lhe dosing is veighl lased). The iniliaI dose shouId le
nainlained foi a nininun of 7 days piioi lo upvaid dose lilialion accoiding lo cIinicaI
iesponse and loIeialiIily. The dose is usuaIIy adninisleied as a singIe daiIy dose lul can


14
aIso le given in lvo dived doses. The nainlenance dose is 1.2ng/kg/day (depending on
lhe avaiIalIe dosage slienglhs). No addilionaI lenefil has leen denonslialed foi doses
highei lhan 1.2ng/kg/day. The pIasna haIf-Iife is 3.6 houis in exlensive nelaloIizeis and
21 houis in pooi nelaloIizeis. Il is nol a scheduIe II diug. Slialleia has leen sludied in liiaIs
invoIving ovei 4OOO chiIdien and adoIescenls vilh ADHD. Ieak efficacy occuis lelveen 2
and 6 veeks aflei inilialion, in conliasl lo lhe slinuIanls, vhich piovide a iesponse vilhin
houis. Il is safe, veII loIeialed, and effeclive in 6 pulIished liiaIs in chiIdien and adoIescenls
(Coinan ,' +6., 2OO4). LaleIIing foi ATX incIudes "Iack ox" vaining foi seveie Iivei injuiy
since Ieliuaiy 2OO5, and foi suicidaIily since Novenlei 2OO5, lolh of vhich iefIecl a pooIed
anaIysis of shoil-lein pIacelo-conlioIIed cIinicaI liiaIs found an aveiage iisk of suicidaI
idealion of O.4 of chiIdien and adoIescenls (WooIloilon, 2OO5). AIlhough unconnon,
suicidaI idealion is iepoiled lo le significanlIy noie fiequenl in paedialiic ADHD palienls
liealed vilh ATX conpaied lo lhose liealed vilh pIacelo (angs ,' +6., 2OO8).
R9;9:98 ?P))#"%J D('Y((% #'"345&%' &%O %)%#'"345&%' O04J
Tasks lhal iequiie nenlaI effoil change ovei lhe yeais. In chiIdhood lheie nay onIy le a
need lo lieal duiing dayline vhiIe in adoIescenls, lhe need lo covei lhe evenings nay le
necessaiy. This nay le ciilicaI foi lasks such as diiving. When seIecling slinuIanls Vs non-
slinuIanls, il is heIpfuI lo assess and conpaie lhe diffeienl side effecl piofiIes. Anolhei
consideialion vhen choosing a diug calegoiy is lhe onsel of aclion. When palienls iequiie
iapid iesponse, slinuIanls aie lhe liealnenls of choice. Non slinuIanl nay iequiie lvo lo
six veeks lo shov a liealnenl iesponse. MIH/ DLX/ATX dependence is nol a piolIen in
lhe diug lheiapy of ADHD.
8.2.2 Monitoring
Heail iale, lIood piessuie, heighl and veighl shouId le checked ieguIaiIy and iecoided on
a giovlh chail. Diug ieIaled side effecls shouId le checked al each cIinic visil. Iood lesls
shouId nol le vieved as iouline. Ialienls and lheii faniIies/caieis need lo le educaled
aloul ADHD and piesciiled diug. iases againsl lhe use of ADHD nedicalions aie oflen
due lo nisinfoinalion iegaiding side effecls. AIleinaliveIy, paienls/caieis nay have
excessive expeclalion fion lhe diug lheiapy vhich nay Iead lo disappoinlnenl. Il is
inpoilanl lo infoin paienls/caieis lhal nedicalion is a pail of lhe hoIislic appioach lo lhe
nanagenenl of ADHD. Ollain lhe conpIeled ialing scaIes lo noniloi liealnenl iesponse.
Advice lhe paienls lo slop lhe nedicalion duiing veekends and duiing schooI hoIidays if
giovlh appeais lo le adveiseIy affecled. A leIephone caII nay le leneficiaI lo foIIov up lhe
piesciiled ADHD nedicalion. Once a slalIe oplinaI dose has leen deleinined, lhe ideaI
nedicalion foIIov-up is six nonlhs. Non-conpIiance lo liealnenl nay le ieIaled lo Iack of
fiequency of foIIov-up. A noniloiing foin such as in appendix 1 nay le used in lhe cIinics.
8.2.3 PoIypharmacy
When a cIinician feeIs lhal a second nedicalion is needed, il is advised lo legin vilh an
ADHD nedicalion lhal is knovn lo conline safeIy vilh lhe second nedicalion. Ioi
exanpIe, in lhe seIeclion of an ADHD nedicalion foi a palienl vilh seveie conducl disoidei
and aggiessive lehavioui, a psychoslinuIanl couId le conlined vilh an alypicaI
anlipsycholic

(Tuigay, 2OO5). MIH SIC has a caulion aiound lhis conlinalion. Sone of lhe


15
side effecls ieIaled lo diug inleiaclion occui lecause of conpelilion foi Iivei enzynes lhal
nelaloIise lhe diug. MIH incieases pIasna concenlialions of phenyloin and deIays
inleslinaI alsoiplion of phenyloin, phenolaililone and elhosuxinide. MIH inhilils
nelaloIisn of liicycIic anlidepiessanls and vaifaiin. ATX can le conlined vilh slinuIanls
lo augnenl lhe effecl in lhe case lhal lhe cIinician feeIs lhe palienl has nol achieved an
adequale iesponse (WiIens ,' +6., 2OO9). Such a conlinalion shouId le inilialed ly a cIinician
vilh speciaIizalion in ADHD. The conlinalions of ADHD diugs aie used sonelines in
cIinicaI piaclice aIlhough il is nol ieconnended. ResuIls fion lhe handfuI of sludies suggesl
lhal conlining slinuIanl lheiapy vilh nonslinuIanl aIleinalives nay iesuIl in noie
significanl synplon ieduclions in palienls foi vhon nonolheiapy is Iess lhan oplinaI.
Theie aie no sludies lo suggesl lhal conling slinuIanl vilh a non-slinuIanl incieases lhe
iisk of caidiac side-effecls. Conlinalion usage of slinuIanl and non-slinuIanl is nol
incIuded in lhe SICs and hence appiopiiale safely and efficacy have nol leen deleinined.
8.2.4 Length of treatment
Many chiIdien viII need lo le on nedicalion foi yeais, hence lhe need lo le cIeai aloul lhe
diagnosis and ieviev lhe diagnosis if iequiied.
8.2.5 CompIiance
elveen a lhiid and a haIf of nedicines lhal aie piesciiled foi Iong-lein condilions aie nol
used as ieconnended

(NICL, 2OO9). Isychoeducalion is lhe nosl usefuI neans of ensuiing
conpIiance. The ain shouId le lo gel lhe adoIescenl lo lake iesponsiliIily foi his/hei ovn
nedicalions. Iaienls invoIvenenl nay le necessaiy lo ensuie lhal nedicalion is laken as
scheduIed. Once-daiIy dosing inpioves conpIiance.
8.3 Non psychopharmacoIogicaI interventions
ADHD palienls nay lake Iongei line lo inlegiale sociaIIy acceplalIe halils inlo lheii Iives.
They aie al significanl iisk of leing invoIved vilh luIIying as a luIIy, as a viclin oi lolh.
The key facloi is lo cieale a posilive enviionnenl lhal nolivales lhe individuaI. When
faniIies aie ieIuclanl lo use nedicalions oi lheie aie side-effecls lehaviouiaI liealnenls
aIone can le a vialIe aIleinalive, piovided lhal lolh paienls and leacheis aie viIIing lo
undeilake lhe effoil iequiied. NalionaI Inslilule foi HeaIlh and CIinicaI exceIIence (NICL)
ieconnends gioup paienl liaining foi ADHD vilh nodeiale IeveIs of inpaiinenl (NICL,
2OO8). Iaienls/caieis shouId le infoined lhal chiIdien vilh ADHD nay have addilionaI
sociaI, acadenic, and enolionaI piolIens. Inleivenlions such as addilionaI heIp in acadenic
voik, sociaI skiIIs liaining, individuaI psycholheiapy, paienl liaining, faniIy lheiapy oi
expIaining lo lhe chiId aloul ADHD, ienoving guiIl, Iov seIf-esleen nay le needed foi lhe
chiId and faniIy.
8.4 Practice point
Make suie lo ieviev lhe chiIds slienglhs, nol jusl his/hei aieas of veaknesses. This
eslalIishes a iappoil vilh lhe chiId and faniIy lhal nakes fuluie visils easiei and can aid
inleivenlion pIanning. If lheie aie any signs oi synplons of a physicaI iIIness lhal nay le a
facloi in expIaining lhe cIinicaI synplons, lhis lakes piecedence in lhe evaIualion. egin lhe


16
inleiviev ly laIking aloul lhe chiIds slienglhs. Ask lhe chiId lo diav a picluie of
lhenseIves and lhen lheii faniIy on lhe sane page. This heIps lo deleinine lhe chiIds
peispeclive of lhe faniIy. Nole any unusuaI peicepluaI diffeiences Iike diaving lhenseIves
liggei lhan lhe paienls. Make appiopiiale iefeiiaI if one oi lolh of lhe paienls need an
assessnenl foi ADHD oi olhei psychialiic disluilance if il appeais evidenl.
9. Treatment consideration in common comorbidities
Il is eslinaled lhal al Ieasl 65 of chiIdien vilh ADHD have one oi noie conoilid
condilions (iedeinan ,' +6., 1991). When lheie is a conoilid psychialiic disoidei, il is
geneiaIIy advised lhal lhe ADHD shouId le liealed fiisl. Hovevei, if conoilidily puls lhe
palienl al iisk foi hain lo olheis oi lo hinseIf/heiseIf, lhen lhis conoilidily lakes
piecedence foi liealnenl.
9.1 OppositionaI Defiant Disorder (ODD)
In chiIdhood, lhe nosl connon conoilid disoidei is ODD in as nany as 4O of ADHD
chiIdien

(TayIoi ,' +6., 2OO4). ODD is chaiacleiized ly lhe chiIds inaliIily lo accepl paienlaI
aulhoiily and lhe sliong need lo le in conlioI. Dislinguishing lelveen noinaI adoIescenl
seIf-asseilion and ODD nay nol aIvays le easy. Tiealnenl of lhe ADHD nay nol iesoIve
aII ODD synplonaloIogy. Slialegies Ieading lo posilive ieinfoicenenl and laigeling
posilive goaIs aie oflen usefuI. Use of line-oul and appiopiiale slialegies lhal aie appIied
vilh consislency aIso heIp lo deaI vilh lhe opposilionaI defiance. ehaviouiaI inleivenlions
aie effeclive, lul lhey need lo le consislenl and ongoing.
9.2 Conduct Disorder (CD)
The iisk foi lhe deveIopnenl of CD in chiIdien vilh lolh ADHD and ODD is lvo lo lhiee
lines giealei (aikIey, 2OO4). ehaviouiaI inleivenlions aie necessaiy foi lhis disoidei.
Conoilid CD aIso puls chiIdien al iisk foi giavilaling lovaids olhei chiIdien vilh siniIai
piolIens. Slialegies lhal pionole posilive peei ieIalionships and effeclive enpalhy
deveIopnenl aie indicaled. A nedicalion liiaI nay le advised in conjunclion vilh
conpiehensive psychosociaI liealnenl.
9.3 InteIIectuaI DisabiIity (Learning DisabiIity, LD)
ChiIdien vilh ADHD fiequenlIy faII leIov conlioI gioups on slandaidised achievenenl
lesls (aikIey ,' +6., 199O). ChiIdien vilh ADHD oflen have veaknesses in lhe cognilive
aieas of execulive funclioning, voiking nenoiy and piocessing speed. If LD is
docunenled, il nay need noie one lo one suppoil foi lhe age-appiopiiale educalionaI
piogiess. ChiIdien and adoIescenls vilh an IQ Iess lhan 5O shouId nol oidinaiiIy le
piesciiled slinuIanls as lhey aie usuaIIy sensilive lo lhe side effecls.
9.4 Aggression
VeilaI and physicaI aggiession is nol unconnon in ADHD. The nosl connon ieason vhy
chiIdien vilh ADHD vouId acl aggiessiveIy is a conlinalion of ADHD vilh eilhei ODD oi
CD. Tiealing lhe ADHD is usuaIIy lhe fiisl slep. Hovevei, aggiession nighl le pail of


17
anolhei diagnosis. ehaviouiaI inleivenlions and aII ADHD nedicalions nay deciease
aggiessive lehavioui. If needed, nev geneialion anlipsycholic nedicalions can le liied. A
sludy has shovn lhal iispeiidone is effeclive in conlioIIing ADHD, ODD and CD

(Anan ,'
+6., 2OO4). Moniloiing of nelaloIic changes, veighl gain, and exlia-pyianidaI side effecls
aie necessaiy if an anlipsycholic is used.
9.5 BipoIar Disorder (BD)
This is an unconnon disoidei in chiIdhood. D shouId le consideied as lhe piinaiy
diagnosis if lheie aie pioninenl, episodic, cycIing nood synplons. D nay le suggesled
ly a sliong faniIy hisloiy of D oi depiession and paiadoxicaI iesponse lo slinuIanls
(voisening of nood oi iage synplons).If D is suspecled, iefeiiaI lo a ChiId and
AdoIescenl Isychialiisl is ieconnended (CADDRA, 2O1O).
9.6 Pervasive DeveIopmentaI Disorder (PDD)
IDD piesenls vilh difficuIlies in sociaI connunicalion, sociaI inleiaclion and
sleieolyped, iepelilive lehavioui. CIinicaI synplons of IDD supeisede lhal of ADHD
and shouId le lhe piinaiy diagnosis and can co-exisl. The IDA iecenlIy appioved lhe use
of iispeiidone in conlioIIing aggiessive and seIf-injuiious lehavioui and iiiilaliIily

(TayIoi ,' +6., 2OO4).
9.7 Depression
Many palienls vilh depiession nay piesenl vilh liansilionaI inallenlion, shoil-lein
nenoiy piolIens, iiiilaliIily and inpuIsivily (VoeIIei, 2OO4). When lhe depiession is
associaled vilh piolIen in lhe sociaI enviionnenl, liealnenl slialegies incIude individuaI
and faniIy lheiapy. SlinuIanls nay pioduce a niId anlidepiessanl effecl in sone palienls,
vhiIe lhey nay voisen nood in olheis. AII of lhe diugs used lo lieal ADHD have lhe
polenliaI lo unnask a nood disoidei oi lo cause nood synplons.
9.8 Anxiety
Anxiely in ADHD can nanifesl as CeneiaIized Anxiely Disoidei, SociaI Iholia, Sepaialion
Anxiely Disoidei, Iosl Tiaunalic Sliess Disoidei (ITSD) oi Olsessive-ConpuIsive
Disoidei (OCD). ITSD nay le a nisdiagnosed as ADHD as lheie aie siniIai synplon
conpIex. ITSD is IikeIy if lheie is no cIeai faniIy hisloiy of ADHD oi pie-noilid
synplons of ADHD piioi lo lhe liaunalic silualion.
9.9 Tic disorders
SlinuIanl nedicalions can le used lo lieal ADHD vilh lic disoideis, lul caulion shouId le
exeicised as lics nay le exaceilaled in sone chiIdien. If lics appeai vilh slinuIanls,
considei Ioveiing anounl/disconlinue oi change lo a non slinuIanl. The MIH SIC has
vainings foi lics and anxiely. Theie aie cuiienlIy no vainings ieIaling lo lhe use of
alonoxeline in lics oi anxiely. If OCD exisls lhen lhe conlinalion vilh ADHD nay le pail
of a Tic Disoidei (e.g., Touielles syndione) so il is inpoilanl lo Iook foi noloi and phonic
lics.


18
9.10 EpiIepsy
Seizuie conlioI is fiisl piioiily as nunleis of seizuies aie diieclIy ieIaled lo piocessing and
allenlion difficuIlies. SliucluiaI alnoinaIily in liain is piolalIy a iisk facloi foi epiIepsy
vilh conoilid ADHD. Moieovei unconlioIIed seizuies cause disluiled sIeep, vhich in luin
nay iesuIl in allenlion difficuIlies duiing lhe day. Side effecls of sone anli epiIeplic diugs
such as lopiianale, vigalaliin, galapenline aie knovn lo inciease aggiession in LD and
nany chiIdien vilh epiIepsy aie IikeIy lo have LD. SlinuIanls seen lo le safe in chiIdien
vilh veII conlioIIed seizuies. ADHD chiIdien aie noie pione foi unpiovoked
seizuies lhen lhe noinaI popuIalion

(Heisdoiffein ,' +6., 2OO4). The SIC foi MIH slale il
nay Iovei lhe convuIsive lhieshoId in palienls vilh piioi hisloiy of seizuies and in palienls
vilh piioi LLC alnoinaIilies.
9.11 Substance Use/Abuse Disorder (SUD)
ADHD palienls aie al incieased iisk of using iIIicil sulslances. Il is essenliaI lhal a hisloiy
foi sulslance aluse is expIoied vilh lhe individuaI aIone. Ask vhelhei lheii fiiends use
diugs oi aIcohoI. A posilive iesponse suggesls lhey aie IikeIy lo le al high iisk foi sulslance
use. y liealing ADHD, lheie is lellei oulcone in conoilid SUD.
10. Cardiac risks of drugs
Sudden dealh vilh ADHD nedicalions is veiy siniIai lo lhose vilh sudden dealh in lhe
geneiaI popuIalion. SliucluiaI heail diseases, hisloiy of syncope, faniIy hisloiy of sudden
dealh/exeicise induced sudden dealh aie cIues, vhich can heIp lo suspecl a highei iisk. The
usefuIness of LCC scieening in palienls leing liealed vilh diugs is unknovn. The snaII lul
unpioven polenliaI conliilulion of ADHD diugs lo lhe iaie incidence of sudden dealh in
chiIdien nusl le veighed againsl lhe cIinicaI lenefil of lhe nedicalion. In a chiId oi
adoIescenl vilh ADHD, vho has no caidiac synplons, lhe iisk of caidiac adveise evenls
fion ADHD nedicalions is veiy Iov. The Aneiican Heail Associalion Reconnends

(Vellei
,' +6., 2OO8) lhal lefoie lheiapy vilh psycholheiapeulic agenls is inilialed, a caiefuI hisloiy
shouId le ollained vilh speciaI allenlion lo fainling oi dizziness pailicuIaiIy vilh exeicise,
conpIainl of chesl pain oi shoilness of liealh vilh exeicise and aloul seizuies. The faniIy
hisloiy shouId focus on lhe Iong QT syndione, sudden caidiac dealh oi heail allack in
nenleis leIov 35 yeais of age and hisloiy of Maifan syndione. Iiesence of lhese
synplons/iisk faclois vaiianls a caidiovascuIai evaIualion ly a caidioIogisl lefoie
inilialion of diug. Ialienls shouId le asked lhe occuiience of any of lhe caidiac synplons
duiing lhe foIIov up visils. The physicaI exaninalion shouId incIude checking heail iale
and lIood piessuie.
11. CompIimentary and AIternative Medicine (CAM) in ADHD
Ovei lhe yeais, a gieal deaI of nedia allenlion has focused on diels foi liealnenl of ADHD.
Sone suggesled a fev foods appioach eIininalion diel if psychoIogicaI inleivenlions aie
nol effeclive (Cailei ,' +6., 1993, HiII & TayIoi, 2OO1). Mosl of lhese dielaiy nanipuIalions
invoIve eIininaling addilives (IeingoId diel) and foods inciininaled lo inciease
hypeiaclivily, such as sugai, chocoIale and caffeine oi connon food aIIeigens such as
vheal, niIk and eggs. SeveiaI doulIe-lIind pIacelo-conlioIIed sludies have faiIed lo


19
suppoil leneficiaI effecl of dielaiy nanipuIalion on lhe lehavioui, excepl possilIy in a veiy
snaII peicenlage of chiIdien (Lggei ,' +6., 1992, WoIiaich ,' +6., 1995).

Iev sludies have
iepoiled lehaviouiaI inpiovenenl vilh hypoaIIeigenic diels (KapIan ,' +6., 1989, Lggei ,'
+6., 1992, oiis ,' +6., 1994). The iesuIls of lhese sludies iequiie fuilhei iepIicalion lefoie
dielaiy inleivenlion can le consideied efficacious. A voiking gioup of lhe Aneiican
Acadeny of ChiId and AdoIescenl Isychialiy has slaled Civen lhe nininaI evidence of
efficacy and exliene difficuIly of inducing chiIdien and adoIescenls lo conpIy vilh
iesliicled diel, lhey shouId nol le ieconnended (AACAI, 1997). Cuiienl evidence suggesl
lhal diels aie aiduous lo inpIenenl and sone nay le nuliilionaIIy deficienl

(DT, 1995)
and a iesliiclion oi eIininalion of diel in chiIdien vilh ADHD is nol ieconnended (SICN,
2OO1).

The avaiIalIe lesl evidence piaclice is lhal a iesponse lo food nay shov change in
nood slale (iiiilaliIily) ialhei lhan ADHD synplons pei se. An addilive-fiee diel, Iov in
sugai, and avoiding foods lhal aie suspecled of exaceilaling synplons is oflen liied ly
faniIies lo heIp inpiove ADHD synplons. As Iong as needs foi essenliaI nuliienls aie
nel, lhese diels aie safe, aIlhough lheii effecliveness in individuaI chiIdien is difficuIl lo
piedicl.
12. Long term outcomes
Il vas lhoughl lhal hypeiaclivily sinpIy goes avay ly adoIescence. AIlhough
hypeiaclivily Iessens vilh line lul il is oflen iepIaced ly piolIens of anlisociaI
lehavioui. Theie appeais lo le lhiee diffeienl palleins of oulcones- iesoIulion of
synplons in young aduIlhood in aloul 3O, peisislence of sone synplons in aloul 4O
and seveie dysfunclion associaled vilh peisislenl synplons, sulslance aluse and
anlisociaI lehavioui in 3O (CanlveII, 1996). A piospeclive sludy in London connunily
suivey found lhal hypeiaclive lehavioui vas a sliong iisk facloi foi Ialei psychialiic
diagnosis, anlisociaI lehavioui, and sociaI and peei piolIens, even aflei aIIoving foi a
coexislenl CD (TayIoi ,' +6D 1996).

13. Summary
ADHD is a peisislenl and inpaiiing disoidei. AIlhough ils oiigin is unceilain, lioIogicaI,
psychoIogicaI, and sociaI faclois aie inpIicaled. The fiisl slep in lhe nanagenenl is accuiale
diagnosis. ehaviouiaI nodificalion and educalionaI appioaches aie slialegies of fiisl
choice. Medicalion can piovide iespile fion lhe synplons duiing vhich line olhei
essenliaI aspecls of lheiapy can le inpIenenled. Advice and suppoil aloul lehavioui
nanagenenl and allenlion lo lhe chiIds seIf esleen, peei gioup inleiaclion, acadenic
piogiess and faniIy ieIalionships aie iequiied even if nedicalion is used. ChiIdien vilh
ADHD aie caied foi al hone. Iaienls aie lolh pail of lhe lean and caiei foi lhe chiId and
lhe faniIy needs caie lhenseIves. As lheii chiIds piinaiy caieis, lhey nusl le incIuded in
lhe decision of any liealnenl pIans. Sone paienls coIIecl endIess opinions. Sonelines lhe
iniliaI counseIIing oi diagnosis vas inadequale and queslions lhal couId have leen
ansveied veie ignoied oi sideslepped. Theie aie nany paienls vho vanl specific advice
on vhal noie lhey lhenseIves can do lo heIp lhe chiId. Ioi paienls of an ADHD chiId, lhe
nunlei of possilIe inleivenlions can le exlieneIy confusing. They aie IikeIy lo heai aloul a
hosl of liealnenl oplions lhal Iack scienlific suppoil.


20
14. Key points
ADHD is a connon lehaviouiaI disoidei vilh cIeai diagnosis ciileiia.
ADHD co-exisls vilh olhei condilions in a high piopoilion.
Tiealnenl oplions foi ADHD incIude lehavioui nanagenenl, nedicalions and
educalionaI nodificalion.
LaiIy iecognilion and liealnenl of ADHD nay iesuIl in Iess anlisociaI lehavioui,
ciininaIily and sulslance aluse in Ialei Iife.
15. Appendix 1.

Side-effects Questionnaire (parents/carers)
!E&6-F2 9+#,G HHHHHHHHHHHHHHHHHHHHHHHHHHHA I JG HHHHHHHHHHHHH A+',G HHHHHHHHHHHHHHHH
AII nedicalion has side-effecls, sone aie noie lioulIesone lhan olheis. We vanl lo nake
suie lhal chiIdien vho aie laking nedicalion do nol suffei.
Ioi each ilen, pIease lick on each Iine hov nuch lhal slalenenl appIies lo youi chiId ovei
lhe Iasl seven days accoiding lo youi ovn olseivalions
O is nol al aII
1 is a fev occasions onIy
2 is aloul haIf lhe line
3 is nosl of lhe line
4 is aII lhe line

Synplon O 1 2 3 4
TaIks Iess lhan usuaI
Iooi appelile
IiiilalIe
ConpIains of slonach ache
ConpIains of headache
Diovsy
Looks sad, niseialIe
Looks anxious
Seens unsleady
Lxciled
Angiy
Has nighlnaies
DispIays lvilches (lics)

Is lheie anylhing eIse you vouId Iike lo add`
______________________________________________________________________________
______________________________________________________________________________
Thank you veiy nuch


21
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24
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2
ADHD and Comorbid Conditions
Nilin IaleI, Mila IaleI and Haisha IaleI
!"#$%&'#() +, -#''+.&# /%01(2 30&%4
!56
1. Introduction
ADHD slands foi Allenlion Deficil Hypeiaclivily Disoidei. Conoilidilies is lhe nedicaI
lein foi lvo oi noie disoideis lhal occui al lhe sane line vilh lhe piinaiy disease oi
disoidei. In lhis ailicIe ve viII laIk aloul ADHD conoilidily.
ADHD (Allenlion Deficil Hypeiaclivily) is lhe nosl undeidiagnosed condilion in chiIdien.
Il is aIso a nisdiagnosed disoidei. The nain ieason foi lhis is conoilidily since lhe
conoilid condilions have nany siniIai synplons lo ADHD. The niIIion-doIIai queslion
lhough is: Wheie does ADHD slop and vheie do conoilid condilions lake ovei`
ADHD affecls 3-6 of schooI chiIdien (Miisky, AI 2OO1). The iisk of conoilidily vilh
psychialiic disoideis is high, and lhe piesence of conoilid condilions vaiianls a speciaI
consideialion in liealnenl of palienl vilh lhese disoideis. A chiId specificaIIy vilh ADHD
viII IikeIy have olhei difficuIlies.
Tvo-lhiids of US chiIdien vilh ADHD viII have a conoilid Ieaining disoidei, anolhei
nenlaI heaIlh disoidei, oi a neuio-deveIopnenlaI disoidei. UniaveIing psychialiic
conoilidily can oflen le a chicken oi egg conundiun. Which cane fiisl: lhe ADHD oi lhe
supposed conoilidily` The piesence of conoilidily condilions nakes lhe diagnosis of
ADHD noie difficuIl.
The suivey pulIished ly NalionaI Suivey of ChiIdien HeaIlh, vhich invoIved ovei 6O,OOO
chiIdien ages 6-17 yeais incIuding ovei 5,OOO vilh ADHD, shoved lhal psychialiic and
physicaI conoilidilies veie veiy connon in chiIdien vilh ADHD. (Laison 2O11)
OveiaII, 67 of ADHD chiIdien had al Ieasl one olhei nenlaI heaIlh oi neuio-
deveIopnenlaI disoidei conpaied lo 11 of chiIdien vilhoul ADHD. 33 had one
conoilidily disoidei, 16 had lvo, and 18 had lhiee oi noie. ADHD vas associaled vilh
eIevaled pievaIence of lhe foIIoving (Ihend):
1. Leaining disoideis (46 vs 5)
2. Conducl disoidei (27 vs 2)
3. Anxiely (18 vs 2)
4. Depiession (14 vs 1)
5. Speech piolIens 12 vs3)
6. Aulisn specliun Disoidei (6 vsO.6)
7. LpiIepsy/Seizuies (2.6 vsO.6)


26
!"#$%&'()&$ !%#"&$'+
1. Depiession 1. Lnuiesis
2. Anxiely 2. SIeep Disoideis
3. ipoIai Disoidei (D) 3. Lczena
4. Conducl Disoidei (CD) 4. AIIeigies
5. Olsessive ConpuIsive Disoidei (OCD) 5. DeveIopnenlaI Cooidinalion Disoidei
(CIunsy)
6. Sulslance Aluse 6. IilionyaIgia
7. Tics and Touielles Disoidei (TD) 7. Ieilhes Disease
8. Ieivasive DeveIopnenlaI Disoidei
(IDD)
8. Hypeilension
9. Leaining Disoidei 9. Heighl and Weighl IiolIens
1O. DeveIopnenlaI DysIexia 1O. LpiIepsy
11. SuicidaIily
TalIe 1.
The coie synplons of ADHD aie inallenlion, inpuIsivily and hypeiaclivily. ChiIdien vilh
ADHD oflen have difficuIly in concenlialion, aie easiIy disliaclilIe, and aie disoiganized,
hypei and inpuIsive. These synplons of ADHD oflen aie seen in conoilid condilions, as
veII. Vaiious sludies have Iooked inlo lhis oveiIapping of synplons and piovided
evidence lhal ADHD is nol ailifacl vhen shaied vilh olhei psychialiic disoideis and lhe
conoilid condilions lhenseIves aie nol ailifacl of oveiIapping synplons and diagnoslic
ciileiia. (Iaione2OO7)
Theie is a conpIex inlegiily lelveen ADHD and connonIy occuiiing conoilid condilions
such as ODD, CD, elc. Conoilidily giealIy infIuences piesenlalion, diagnosis and
piognosis, conpIicales liealnenl and significanlIy incieases lhe noilidily and disease
luiden of ADHD. When ADHD is co-noilid vilh anolhei psychialiic disoidei, il is oflen
lhe fiisl disoidei lo deveIop. ChiIdien vilh seveie ADHD synplons have a highei chance
of deveIoping olhei psychialiic disoideis.
When evaIualing conoilidily, one shouId deleinine vhal lhe piinaiy disoidei and lhe
synplons piesenl. If lhe piinaiy condilion fuIIy expIains lhe synplons, a conoilid
condilion shouId nol le diagnosed. If ADHD synplons piesenls duiing episodes of
lipoIaiily, ADHD vouId nol le diagnosed. In piaclicaI Iife, vhich synplon causes lhe
palienls inpaiinenl is difficuIl lo deleinine vhen lolh disoideis aie chionic. If lolh
condilions aie conliiluling lo palienls inpaiinenl, lolh ADHD and lhe conoilidily
shouId le diagnosed and liealed. This ieviev viII cIaiify hov lo diagnose and nanage
ADHD vilh conoilid psychialiic and olhei neuio-deveIopnenlaI disoideis.
The lein conoilidily fiisl appeaied in lhe psychoIogicaI and psychialiy Iileialuie in lhe
nid-198Os. Since lhal line, lheie has leen a dianalic inciease in lhe inleiesl in lhis lopic. In
1986, onIy 2 ailicIes veie pulIished and ly 1993, lheie veie 243 ailicIes. Since lhen, lhe
nunlei of ailicIes has incieased even fuilhei. Il has leen suggesled lhal conoilidily has
eneiged as peihaps lhe singIe nosl inpoilanl concepl in psychialiy ieseaich.


27
2. Definition of comorbidity
A vaiiely of definilions of conoilidily has leen offeied fion lhe nedicaI epidenioIogicaI
peispeclive. Di. Ieinislen (197O) has defined co-noilidily as any dislincl addilionaI enlily
lhal has exisled oi nay occui duiing lhe cIinicaI couise of lhe palienl vho has lhe index
disease. IashfieId (2OO9,1994) has iefeiied lo lhe co-noilidily as a concoidance of a
diffeienl disease in lhe sane individuaI. Likevise, Caion and Rullei have defined
conoilidily as lhe sinuIlaneous occuiience of 2 oi noie ."&%10(%7 condilions.
As one can see fion lhe definilion, lhe lein co-noilidily iefeis lo lhe silualion in vhich a
peison vho has leen diagnosed vilh one specific disoidei is found lo aIso neel lhe
diagnoslic ciileiia of one oi noie addilionaI disoideis. Theie has leen a conlioveisy
iegaiding lhe use of lhis lein, lhe piinaiy ieason highIighled ly lhe definilion of Caison
and Rullei (1991). The void unieIaled is lhe nosl ieIevanl. One cannol le ceilain lhal an
individuaI vho neels diagnoslic ciileiia foi noie lhan one psychialiic disoidei acluaIIy has
unieIaled condilions. Il has leen suggesled lhal vhal appeais lo le a sepaiale disoidei nay
acluaIIy le lhe iesuIl of oveiIapping diagnoslic ciileiia oi a diffeienl syndione, Iike a vaiialion
of lhe undeiIying disoidei, foi exanpIe, anxiely disoideis. Whal Iooks Iike a co-noilidily in
youngei chiIdien nay iefIecl nonspecific expiession of psychopalhoIogy associaled vilh
innaluie deveIopnenl of cognilion and enolion, foi exanpIe, anxiely and depiession.
olh ADHD and co-noilidily disoideis have a highIy heleiogeneous elioIogy, inpIying
genelic and enviionnenlaI iisk faclois. (Mick and Iaione, 2OO8) Sone aulhois have leen
advocaled foi dislincl lypes of ADHD lased on conoilid expiessions (aikIey 2OO6)
(Acosla, el aI 2OO8).
Apail fion lhe heleiogeneousily of ADHD, lhe oveiIap lelveen conoilidily and
diffeienliaI diagnosis iendeis lolh cIinicaI and elioIogy ieseaich and ADHD and
conoilidily difficuIl. Conducl disoideis, enolionaI disoideis, lic disoideis, aulisn
specliun disoideis, lipoIai disoideis, oi specific deveIopnenlaI disoideis have leen co-
noilid vilh ADHD lul aII lhese psychialiic condilions aIso have lo le consideied in lhe
diagnoslic piocess as a diffeienliaI diagnosis. Conoilid disoideis of ADHD nay iesuIl in
ADHD Iike synplons, depiessive synplons, foi exanpIe, nay conpiise inallenlion
disliacliliIily, aggiession, and iiiilaliIily: synplons lhal couId ninic lhe phenolype of
ADHD. On lhe olhei hand, ADHD nay le acconpanied vilh lhe depiessive disoideis oi
iesuIl in depiessive nood due lo conslanl oi iepelilive psychoIogicaI faiIuie and
discouiagenenl. Wilh lhis knovIedge of lhese condilions, a cIinician nusl le avaie of lhe
deveIopnenlaI couise ovei line.
Conceining lhe lenpoiaI couise of occuiience, conoilidilies nay le piesenl lefoie
evidence of ADHD synplons (pie-noilidily). The onsel of lhe conoilid disoidei
coincides vilh lhe line lhe ADHD synplons ieach cIinicaIIy significanl IeveI is caIIed
sinuIlaneous conoilidily. Hovevei, lhe najoiily of co-noilidilies seens lo occui Ialei in
lhe couise of disoidei caIIed posl-noilidily (Tauiine-2O1O).
3. EpidemioIogy
The nenlaI disoideis lhal chiIdien deveIop aie connonIy divided inlo lvo gioups:
disiuplive oi exleinaIizing lehavioi disoideis (Lx. ADHD and Conducl Disoideis) and


28
enolionaI and inleinaIizing lehavioi disoideis (Lx. Anxiely and Depiession). Conceining
psychialiic conoilidily, exleinaIizing disoideis veie found lo le noie fiequenlIy
associaled vilh ADHD, conoilidily iales iange up lo 9O (Spencei T 1999, WiIens TL 2OO2)
foi exleinaIizing and 5O foi inleinaIizing disoideis. (}ensen el aI. 2OO1) A 5-yeai foIIov-up
sludy in giiIs vilh ADHD ianged 6-18 yeais in conpaiison vilh giiIs vilhoul ADHD
shoved eIevaled iales of conoilidily associaled vilh lhe ADHD fenaIes. (iedeinan el aI.
2OO8 ) In Iine vilh lhe foinaI iepoils (Slinhausen el aI. 2OO6), a sanpIe of 122 chiIdien and
adoIescenls vilh ADHD lelveen lhe ages of 6-18 yeais ieciuiled ly lhe Depailnenl of
ChiId and AdoIescenl Isychialiy in lhe Univeisily of Wuizluig shoved lhal 73 of affecled
individuaIs had one oi noie fuilhei psychialiic diagnosis accoiding lo a seni-sliucluied
inleiviev. The nosl fiequenl conoilidily vas opposilionaI defianl disoidei (ODD) al
46.9, foIIoved ly nood disoidei al 27.9, CD and eIininalion disoidei (LID) al 18.5,
dysIexia al 17.6, and anxiely al 16. 7, and TD (Touielle disoideis) al 9.5 (Tauiin 2O1O).
In aduIl ADHD palienls, Iifeline conoilidily vilh nood disoidei vas 57.3 and anxiely
disoidei 27.2 (Spencei T. 1999), suipassing lhe aIieady consideialIe iales foIIoving lhe
pedialiic popuIalion. AduIls have a highei pievaIence lhan chiIdien foi sulslance aluse
disoideis, vilh a pievaIence iale of 45.O (}acol el aI. 2OO7). IeisonaIily disoideis can
deveIop lhioughoul chiIdhood and adoIescenl, lul Il is nol unliI aduIlhood vhen
peisonaIily disoideis aie alIe lo le diagnosed in ADHD, foi exanpIe anlisociaI ID
(peisonaIily disoidei). In chiIdhood and adoIescence, lhese polenliaI peisonaIily disoideis
aie knovn as conducl disoideis. The piesence of conducl disoideis in chiIdien vilh ADHD
has leen found lo le significanl coiieIaled vilh aggiessive lehavioi oi deIinquency in
adoIescence and vilh lhe high ioad of anlisociaI peisonaIily in aduIl Iife. Theie has leen
avaieness of a Iink lelveen ADHD and enolionaI disoideis (anxiely and depiessive
disoideis), vhich has an inpoilanl inpIicalion foi a cIinician assessing chiIdien vilh
ADHD (lhal lhey donl niss lhe undeiIying inleinaIizing synplons lecause of lhe
piedoninale piesenlalion). LongiludinaI ieseaich vilh chiIdien and ADHD and co-noilid
najoi depiession suggesls lhal a concuiience of lhe lvo disoideis nay le associaled vilh a
pailicuIaiIy pooi oulcone. The high pievaIence of deveIopnenlaI deIay and
neuiopsychialiic disoideis has Iong leen eslalIished and nay le indicalive of an
undeiIying deveIopnenlaI elioIogicaI palhvay.
4. EtioIogicaI consideration
Many peopIe assune lhal if lhe chiId is hypeiaclive, lhe liain nusl aIso le oveiaclive. This
is nol lhe case, as seen in liain scan ieseaich ly Di. Zanelkin. In his sludy, lhe gIucose
nelaloIisn vas neasuied in lhe liain, vhich is an indicalion of eneigy oi nenlaI aclivily.
When given a piolIen lo lhink aloul, lhe noinaI conlioI suljecl liain indicales eneigy
leing used lo lhink aloul lhe piolIen posed, lul ADHD suljecls liains shov IillIe
aclivily. Does lhese dala shov lhal ADHD is sliiclIy a lioIogicaI piolIen` No. ADHD
appeais lo le infIuenced ly enviionnenlaI faclois such as hone enviionnenl, cIassioon
sliucluies and peeis. Saying lhal ADHD is infIuenced ly enviionnenlaI faclois such as
hone oi cIassioon enviionnenl doesnl nean lhal ADHD is caused ly fauIly paienling oi
educalion. Ralhei il neans lhal ve have an oppoilunily lo nake lhings lellei oi voise. The
elioIogy lo ADHD is conpIex and incIudes neuioanalonic alnoinaIilies, neuiolioIogicaI
dysieguIalion, CNS insuIls, genelics and enviionnenlaI faclois. The neuiolioIogicaI
alnoinaIilies aie in lhe piefionlaI coilex and anleiioi cinguIale gyius invoIvenenl has leen


29
denonslialed. The piefionlaI coilex is invoIved in execulive funclioning, vhiIe lhe
cinguIale gyius is invoIved in focusing allenlion and nedialing iesponse seIeclion. Anong
individuaIs vilh ADHD, consislenl findings have shovn inage iegaiding decieased
dopanineigic liansnission in lhese aieas. A dopanine 4 (D4 ieceploi) is ieIaled lo cognilive
and enolionaI funclioning is denseIy in piefionlaI coilex of lhe liain. Cenelics sludies
indicale lhe DRD4-7 iepeal aIIeIe Iocus al highei iales anong chiIdien vilh ADHD lhan
anong conlioIs. (LesIie L. Iaikei 2O1O) Olhei nuneious enviionnenlaI faclois piedispose
individuaIs lo ADHD, incIuding naleinaI snoking oi aIcohoI aluse and Iov liilh veighl,
vhich nay have lolh genelic and enviionnenlaI causes.
Olhei condilions nusl le iuIed oul lefoie a diagnosis of ADHD is nade lecause lheie aie
nany olhei possiliIilies oi expIanalions foi hypeiaclive inpuIsive lehavioi. A fev of lhe
condilions aie Ieaining disaliIily (lhal Ieads lo pooi schooI peifoinance), fiuslialions, and a
lehavioi pallein vheie lhe chiId slops paying allenlion oi gives up. Allenlion Iapses can le
caused ly pailiaI conpIex seizuie, olsessive lhoughls, oi siIenl inpuIsive iiluaIs. A niddIe
eai infeclion, causing an inleinillenl heaiing piolIen, inleifeies vilh a chiIds aliIily lo
iespond lo an oiaIIy piesenled iequesl. Disiuplive uniesponsive lehavioi can le due lo
anxiely, depiession, oi lipoIai disoideis. LnviionnenlaI faclois oi sliesses, such as divoice
in lhe faniIy, can Iead lo ieslIessness oi inallenlion.
If execulive dysfunclion is a piolIen, lhe chiId oflen faiIs lo give cIose allenlion lo delaiIs oi
nakes caieIess nislakes al schooI oi duiing olhei aclivilies, has difficuIly suslaining
allenlion in lasks oi pIay, oflen does nol foIIov lhoiough insliuclions, faiIs lo finish schooI
voik oi dulies al lhe voikpIace, oflen has difficuIly oiganizing lasks and aclivilies,
avoids/disIikes/is ieIuclanl lo engage in lhe lask iequiied lo suslain nenlaI effoil Iike
honevoik. In oidei lo cIaiify lhe diagnoslic issues, lhe neuiopsychoIogicaI assessnenl nay
le heIpfuI. AIlhough a vaiiely of piofessionaIs incIuding psychoIogisls nay le Iicensed lo
diagnose ADHD, in ny opinion, lhe diagnosis shouId le confiined ly a deveIopnenlaI
pedialiician, loaid ceilified neuioIogisl oi adoIescence psychialiisl vho can iuIe oul olhei
nedicaI piolIens lhal ninic lhe synplons of ADHD and offei liealnenl.
5. CIinicaI presentation
ADHD has hisloiicaIIy leen idenlified piinaiiIy in loys, lul a sulslanliaI nunlei of giiIs
suffei fion ADHD as veII. The naIe lo fenaIe ialio is appioxinaleIy 1O:1 (iedeinan }
1999). In a conpaialive sludy of loys and giiIs vilh ADHD, lolh sexes veie conpaialIe in
iespecl lo iale of inallenlion, inpuIsivily, hypeiaclivily and conoilidily. Hovevei, iales of
conducl disoideis vaiied lelveen loys and giiIs (2O in loys veisus 8 in giiIs).
OpposilionaI defianl disoideis veie nanifesled in appioxinaleIy 62 of loys conpaied lo
32 of lhe giiIs (Iiednan 2OO1).
ADHD is highIy conoilid vilh olhei psychialiic disoideis. Theie has leen conlioveisy
vhelhei il exisls as a piinaiy disoidei oi onIy secondaiy lo olhei psychialiic synplons.
The NosoIogicaI Syslen advocales in lhe DSM lhal in lhe piesence of lvo oi noie
diagnoses, one shouId le consideied piinaiy and accounl foi nany of lhe synplons
olseived in lhe secondaiy syndione. Thus lhe nounling evidence of nany condilions
exisling concuiienlIy vilh ADHD each nodifies lhe oveiaII cIinicaI piesenlalion and
liealnenl iesponses. The conoilid condilions shouId le consideied as sinuIlaneousIy
piesenl in oidei lo lioaden oui undeislanding and naxinizing lhe liealnenl.


30
A depiessed palienl denonsliales dininished concenlialion, vheieas an individuaI vilh
lipoIai disoidei oflen nanifesls psychonoloi agilalion and desliucliliIily. Il nay le
difficuIl lo diffeienliale lhese fion lhe caidinaI synplons of ADHD. Theie aie seveiaI vays
lo deaI vilh lhe synplon oveiIap lhiough ieseaich and cIinicaI sellings. Sulliaclion
nelhod iequiies lhal lhe sane alsoIule nunlei of synplons le piesenl lo diagnose eilhei
disoidei excepl shaied synplons aie sulliacled oi ienoved fion lhe diagnoslic
consideialion. Sone peopIe lhink lhal lhe palienl vilh conoilid depiession and ADHD sliII
ielains lhe diagnosis of ADHD vhelhei sulliaclion oi piopoilionaI nelhod vas used. The
Ionglein foIIov-up sludy had denonslialed lhe individuaI vilh ADHD and conoilid
disoidei had pooi piognosis and giealei hospilaIizalion iale lhan lhose vilh ADHD aIone.
IhainacoIogicaI sludies denonslialed a cIinicaI conliilulion of each of lhe conoilid
disoideis and liealnenl slialegies. Ioi exanpIe, an individuaI vilh a conoilid ADHD
lipoIai nay le fiisl liealed vilh a slinuIanl. AIleinaliveIy, if a nood slaliIizei is used,
significanl inpiovenenl nay le expecled. If synplons of ADHD conlinue lo peisisl aflei a
nood slaliIizei, lhis suppoils a diagnosis of co-occuiiing diagnosis. When a slinuIanl
addilion is indicaled, lheiefoie, lolh conoilid condilions aie equaIIy liealed, lhe ADHD
synplons nay nol le ienil.
5.1 Identify comorbidity with handy tooIs
Theie aie nany efficienl looIs lo galhei dala in a sliucluied nannei lhal quickIy pinpoinl
ADHD, vhich fuilhei heIps youi cIinicaI acunen. In a lusy piinaiy caie selling, a chiId
lehavioi check Iisl can le used as a handoul oi lehavioi assessnenl scaIe foi chiIdien. olh
of lhese geneiaIIy have veiy siniIai lype of oulpul. These aie veiy easy lo scoie, and one
can Iook lo lhe paienl as veII as leacheis lo heIp vilh lhe scoiing.
6. PsychoIogicaI probIems associated with ADHD
6.1 Depression
8+%' (2% 9%&'+" 099%0& '074 :1.% +& 7+;" 0"7 2+; <0" )+. (%11= >' (2% 9%&'+" #&&#(0:1%4 <&0"?)4
0"7 @++7)= A20( 7+%' (2% 9%&'+" 7+ #" 2%& '90&% (#@%= /0' (2% 9%&'+" :%%" 7+#"B (2% 0<(#$#()
+"<% %"C+)%7= 8+%' (2% 9%&'+" (01? 0:+.( '.#<#7% +& 0:+.( .'%1%''"%'' +, 1#,%4 20' (2% 9%&'+"
0((%@9(%7 '.#<#7%=
A lolaI of 1O-4O (Spencei, T 1999) of chiIdien and adoIescenls vilh ADHD shov depiession
vilh synplonoIogy of Iov oi iiiilaled nood, Ioss of inleiesl and pIeasuie of usuaIIy enjoyalIe
aclivilies, sIeep disluilances, and ieduced appelile. Depiessive disoideis in youlh vilh
ADHD lypicaIIy occui as a posl conoilidily seveiaI yeais aflei lhe onsel of ADHD. ADHD
iales in depiessed chiIdien and aduIls iange up lo 57 (AngoId, A 1993). Depiession nay le a
ieaclion lo unpiediclalIe enviionnenlaI sliessois such as leing iejecled ly peeis, gelling
nade fun of ly olheis, oi lhinking lhal schooI is a negalive and oveivheIning pIace. In lhese
cases, a sepaiale diagnosis and liealnenl slialegy is nol necessaiy lecause depiession is
occuiiing in iesponse lo lhe ADHD and viII IikeIy deciease vhen ADHD synplons aie
liealed. In olhei inslances, depiession nay iun in lhe faniIy oi nay le noie diieclIy Iinked lo
lioIogicaI oi genelic causes, lheiefoie, a sepaiale diagnosis and specific liealnenl foi
synplons foi depiession vouId le noie appiopiiale. Dislinguishing lelveen an enolionaI
conpIicalion of ADHD and a sepaiale depiessive disoidei nay le veiy difficuIl. A lheiapisl


31
vouId Iook foi an indicalion vhelhei lhese depiession oi ADHD synplons cane fiisl and
vhelhei lheie is a hisloiy of depiession oi ADHD in lhe faniIy. Il is veiy inpoilanl lo lake
depiessive synplons seiiousIy, iegaidIess of lheii cause. ChiIdien vilh ADHD and
depiession can have suicidaI lhoughls and slalenenls/lehavioi shouId le noniloied and
addiessed ly a nenlaI heaIlh cIinician. Since lhese synplons nay alliilule lo noinaI
chiIdhood lehavioi, lhe diagnosis of depiession nay le nissed foi a Iong line. IaniIy sludies
suggesl lheie is sone genelic Iink lelveen depiession and ADHD. This suggesls genelics can
conliilule lo soIeIy ADHD, soIeIy depiession, oi lolh disoideis.
Wilh iegaid lo lhe liealnenl, nosl liealnenls lhal aie effeclive foi ADHD, Iike slinuIanls,
do nol significanlIy inpiove depiession. In addilion, liealnenls foi nood disoideis aie
geneiaIIy nol heIpfuI foi ADHD. In lhe piesence of conoilid nood disoidei, slinuIanls
lhenseIves aie Iess effeclive foi ADHD. Non-slinuIanl liealnenls lhal aie noiadieneigic
lul nol seioloneigic aie effeclive foi ADHD. In conliasl, seioloneigic nedicine is effeclive
foi juveniIe depiession lul nol foi ADHD.
upiopion, an agenl lhal affecls lolh noiadieneigic and dopadeieneigic neuioliansnilleis,
has leen shovn lo le efficacious foi adoIescenls vilh ADHD and conoilid depiession. Il is
inpoilanl lhal lolh disoideis le liealed sinuIlaneousIy. Sludies shov using lhe
conlinalion of slinuIanl and SSRI foi conoilid ADHD and seveie depiession aie
consislenl vilh lhis olseivalion. Hovevei, one shouId le caulious in using an SSRI in
chiIdien vilh niId lo nodeiale depiession, due lo a lIack lox vaining ly lhe ID lecause
SSRIs nay inciease suicidaI lendencies. If an SSRI is used, lhe chiId shouId le noniloied
cIoseIy, and lhe palienl and guaidian shouId le avaie of lhis vaining.
6.2 SuicidaIity
ChiIdien vilh ADHD and depiession aie al an incieased iisk foi suicide. In loys, najoi
depiession and sociaI pholia aie iisk faclois foi suicide, as opposed lo posl-liaunalic
disoidei in giiIs.
LaiIy slinuIanl liealnenl of ADHD ieduces lhe pievaIence of depiession as a conoilidily,
vhich ieduces lhe iisk foi fuluie suicidaIily.
6.3 BipoIar disorders
6&% (2%&% (#@%' ;2%&% (2% 9%&'+" (2#"?' 2% +& '2% #' 0:1% (+ 7+ 0")(2#"B 2% +& '2% ;0"(= 8+%' (2%
9%&'+" 099%0& .".'.011) %"%&B%(#< 0( (#@%' +& 01@+'( 2#B2 ;#(2+.( 7&.B'= 8+%' (2% 9%&'+" @#''
0 1+( +, '1%%9 0( "#B2( :.( '(#11 0<(' %"%&B%(#< (2% "%D( 70)= 8+%' (2% 9%&'+" 099%0& (+ 20$%
(2+.B2(' (20( 099%0& '+ ,0'( (20( #( #' #@9+''#:1% (+ ?%%9 .9 ;#(2 (2%@=
ipoIai disoidei nay occui vilh ADHD oi nay ninic ils synplons. HaIf of lhe loys and
one-fouilh of lhe giiIs vilh lipoIai disoidei aIso neel lhe ciileiia foi ADHD. ChiIdien and
adoIescenls vilh lipoIai disoidei oflen shov sliong enolionaI feeIings, hypeiaclive
lehavioi, oveileaiing nannei, and difficuIly vaking up in lhe noining. ChiIdien and
adoIescenls vilh seveie lipoIai synplons nay have excessive and Ienglhy lenpei
lanliuns lhal aie desliuclive and oflen lased on gioss disloilion of oljeclive evenls. Ioi
exanpIe, vhen a fiiend vanls lo a pIay diffeienl gane, lipoIai chiIdien nay lhink lhe
fiiend is liying lo puiposefuIIy le nean. The chiId gels angiy al such nisliealnenl. This


32
nay iesuIl in a lenpei lanliun. Olhei synplons incIude excessive laIking, incieased
aclivily, inappiopiiale aclions and veilaI iesponses in sociaI silualions, Iack of inhililion,
chionic iiiilaliIily, and disliacliliIily. The pievaIence is up lo 2O (Singh, MK 2OO6)
(Sliolei, M 1982). Accoiding lo an IlaIian sludy, 24 of 7-18 yeai oId cIinic allendees vilh
lipoIai disease had exisling ADHD (Masi, C 2OO3).
The chiId lehavioi check Iisl scoie lellei disciininales lelveen chiIdien vilh ADHD, co-
nania in conlexl lo pedialiic lipoIai disoideis and conlioI suljecls.
Ioi phainacoIogicaI liealnenl, nood slaliIizeis aie lhe fiisl Iine liealnenl foi peiiodic
lipoIai disoideis. Hovevei, vhen ADHD synplons aie piesenl, suljecls nay lenefil fion
shoil-lein co-conconilanl liealnenl vilh a slinuIanl oi a co-nedicalion of a non-slinuIanl.
The elioIogy of conoilid pedialiic lipoIai and ADHD have dislincl chaiacleiislics. Neuio
inaging sludies suggesl geneiaI changes in piefionlaI aieas in lolh disoideis. Hovevei,
lheie aie a fev piinaiy diffeiences lelveen lhe lvo palienl gioups in lhe aieas in
indiffeience conlioI, voiking nenoiy, pIanning cognilive fIexiliIily and fIuency. SeveiaI
aulhois iepoiled lhal ADHD vilh conoilid pedialiic lipoIai disoidei is ils ovn dislincl
foin of ADHD (iedeinan 2OO8).
Iifly peicenl of lhe piepulescenl depiessed chiIdien in one sanpIe nanifesl lipoIai
disoidei vilhin len yeais of lhe onsel of depiession (CeIIei el aI, 2OO2 a). Anolhei sludy
found 2O of depiessed adoIescenls in anolhei sanpIe had ieveaIed a lipoIai disoidei
vilhin 1-4 yeais (Kovalch RA 2OO5). When conpaiing lo lhe chiIdien vilh ADHD vilhoul
nania, lhe nanic chiIdien have significanlIy highei iales of najoi depiession, psychosis,
nuIlipIe anxiely, conducl disoidei, oi opposilionaI defianl disoidei, as veII as significanlIy
giealei inpaiinenl of psychosociaI funclioning.
As vilh depiession, lipoIai nusl le liealed effecliveIy vilh synplons of ADHD lo iesoIve
conoilidily affecling lhe individuaI. An alypicaI anli-psycholic agenl appeais lo le
effeclive in lhe eIininalion of juveniIe nania. In an open sludy, RispeidaI vas found lo le
effeclive anli-nanic lul did nol heIp ADHD synplons. Anong lipoIai aduIls conolid foi
ADHD, upiopion is effeclive foi ADHD and depiession lul nay Iovei lhe lhieshoId foi
inducing nania.
6.4 OppositionaI defiant disorder
8+%' (2% 9%&'+" 7%,) )+. +& (2% (%0<2%& :) '#@91) '0)#"B "+ +& #B"+&#"B )+.= 8+%' (2% 9%&'+"
099%0& (+ :% 0""+)%7 %0'#1) 0"7 :+(2%&%7 :) (&#$#01 (2#"B'= 8+%' (2% 9%&'+" 099%0& (+ 0""+)
+(2%& 9%+91% +" 9.&9+'%= A2%" 0"7 ;2%&% 7+%' (2#' 2099%"= 8+%' (2% 9%&'+" 099%0& 0"B&)4 2+(
(%@9%&%74 &%'%"(,.14 +& ,.11 +, '9#(%=
ODD is nosl connonIy associaled vilh ADHD. OpposilionaI defianl disoidei synplons
occui in as nany as 21 lo 6O (Cunninghan 2OO2, WiIens, TL 2OO2) of chiIdien vilh
ADHD. Il is vhen lhe individuaI defies iuIes and in sone cases acls oul in angei and
vioIence. ODD synplons lend lo occui noie oflen vilh peopIe vhon lhe chiId is cIose lo
oi knovs veII such as faniIy oi caie giveis. ChiIdien vilh conoilid ADHD and ODD nay
foin an inleinediale gioup lelveen lhose vho have ADHD aIone and lhose vilh ADHD
and conducl disoidei. Hovevei, sludies suggesl lhal chiIdien vilh conoilid ODD and
ADHD viII aIvays deveIop conducl disoidei. Il is jusl a nallei of line lefoie lhal happens.


33
6.5 Conduct disorder
8+%' (2% 9%&'+" 1#% 0 1+(= 8+%' (2% 9%&'+" B%( #"(+ 92)'#<01 ,#B2('= 8+%' (2% 9%&'+" (&) (+ 2.&(
9%+91%= /0' (2% 9%&'+" %$%& '(+1%" +& 70@0B%7 9%+91%E' 9&+9%&()=
Aloul 2O-45 of chiIdien vilh ADHD aIso neel ciileiia foi conducl disoideis. Il is veiy Iov
in chiIdien vilhoul ADHD. This disoidei invoIves aggiession lovaids peopIe oi aninaIs,
piopeily desliuclion, sleaIing, and vioIalion of iuIes of sociely (i.e. nissing schooI oi
iunning avay fion hone).
olh slinuIanl and non-slinuIanl nedicines viII ieduce aggiessive lehavioi and anlisociaI
acls, lul a slinuIanl viII voik noie iapidIy. Mood slaliIizeis oi alypicaI anlipsycholics
nay le needed foi highIy aggiessive cases. esides phainacolheiapy, individuaI oi faniIy
lehavioiaI lheiapy nay le iequiied. Conducl disoidei is a sliong piedicloi foi fuluie
sulslance aluse.
Medicalion jusl used foi ADHD is aIso effeclive foi liealnenl of conoilid ODD/CD as lhe
fiisl Iine of liealnenl. Hovevei, if ODD oi CD peisisls, psychosociaI liealnenl shouId le
added. In cIinicaI piaclice, il is nol connon lo add alypicaI anlipsycholics, lul lheie is
Iiniled dala lo suppoil lhis. (Kunvai, A 2OO7)
6.6 Anxiety
8+%' (2% 9%&'+" 099%0& (+ :% "%&$+.' 0"7 0"D#+.'= 6&% (2%&% (#@%' ;2%" (2% 9%&'+" 099%0&'
90"#<?%74 '(&#<?%"4 +& ,&+F%" :) 0"D#%()= 8+%' (2% 9%&'+" 099%0& $%&) '2) <+@90&%7 (+ +(2%&' 2#'
'0@% 0B%= 8+%' (2% 9%&'+" &%9%0( <%&(0#" 0<(#+"' +$%& 0"7 +$%& 1#?% 0 &#(.01=
Anxiely is a psychoIogicaI and physioIogicaI slale chaiacleiized ly enolionaI, sonalic,
cognilive and lehavioiaI issues. Anxiely is a veII lhoughl oul, noinaI iesponse lo sliess,
lul if lhe anxiely ieaches ils ciesl, il disluils a peisons noinaI iouline. Anxiely vilh
ADHD is a conoilidily vilh an eslinaled iale of 2O-4O. Oflen geneiaI anxiely is lhoughl
lo le lhe nosl pievaIenl disoidei foIIoved ly sociaI pholia, sepaialion anxiely. Sone
chiIdien vilh ADHD nay piesenl vilh noie lhan one anxiely disoidei. Anxiely and ADHD
nay inhilil inpuIsivily so chiIdien vilh ADHD and conoilid anxiely nay have Iess
inpuIsivily lul noie inallenlion. Ioi lhis ieason, il is possilIe lo oveiIook ADHD in
chiIdien vilh anxiely (especiaIIy lhe inallenlive lypes). ChiIdien vilh anxiely aie oflen
pieoccupied vilh a feai lhal inpaiis lheii aliIily lo focus on lhe lask al hand. Ioi anxious
chiIdien vho do nol have ADHD, vhen lheii anxiely inpioves, lheii inallenlion inpioves,
vheieas chiIdien vilh conoilid ADHD/anxiely viII conlinue lo sliuggIe vilh inallenlion
even in lhe alsence of an anxious episode.
Il has leen suggesled lhal anxiely associaled vilh ADHD is a pioducl of lhe inaliIily lo
funclion in daiIy Iife lecause of lhe sociaI and cognilive Iinilalions associaled vilh ADHD
ialhei lhan lypicaI pholic/feaifuI lehavioi. In lhis case, eaiIy iecognilion and liealnenl of
ADHD nay ilseIf inpiove anxiely. In a sul-gioup of an ADHD peison vilh conoilid
anxiely disoidei, vaiious lheiapeulic neasuies have leen pioven lo le effeclive in ieducing
lolh ADHD and anxiely synplons. Isycho slinuIanls pIus lehavioi lheiapy, alonoxeline
aIone, oi alonoxeline vilh a conlinalion of slinuIanls and anlidepiessanls can heIp lieal
lhese synplons. Hovevei, conoilid anxiely synplons in chiIdien and aduIls vilh ADHD
veie Iinked lo pooi liealnenl iesponse vilh a psycho-slinuIanl. Theie is sone evidence


34
lhal lheie is heiilaliIily lelveen ADHD and conoilid anxiely disoideis. Theie is aIso
ieseaich suggesling ADHD and anxiely aie independenlIy liansnilled in faniIies (Iieilag
2O1O).
Il is veiy inpoilanl lo dislinguish lelveen lhe liue anxiely disoideis and lhose chiIdien
vho aie expeiiencing anxiely in iesponse lo ADHD lecause liealnenl is veiy diffeienl.
SlinuIanls, vhiIe heIpfuI foi ADHD synplons, nay acluaIIy voisen lhe synplons of a
liue anxiely disoidei.
6.7 Learning disorders of various kinds
G$%" ;2%" (2% 9%&'+" #' 90)#"B 0((%"(#+"4 #' 1%0&"#"B 7#,,#<.1(= 6&% (2%&% <%&(0#" '.:()9%' (20(
(2% 9%&'+" 20' %D(&%@% 7#,,#<.1() ;#(2= /+; 7+%' (2#' 9%&'+" 7+ #" &%07#"B4 ;&#(#"B4 0"7
@0(2%@0(#<= /0' (2% 9%&'+" %$%& :%%" (%'(%7 ,+& 0 1%0&"#"B 7#'0:#1#()=
Ovei haIf of aII chiIdien vilh ADHD aIso have Ieaining disoideis. ADHD, lhough il affecls
lhe aliIily lo Ieain, is nol a liue Ieaining disaliIily. So liealing lhe synplons of ADHD viII
nol coiiecl lhe Ieaining disoideis lhal a chiId nay have. A Ieaining disaliIily is a specific
disoidei lhal affecls one of lhe foui piinaiy sleps needed foi Ieaining. The sleps aie
iecoiding infoinalion (ex. inpul of a visuaI oi audiloiy peiceplion piolIen), undeislanding
infoinalion (inlegialion: ex. Sequencing and oiganizalion piolIen), sloiing infoinalion
(pIacing infoinalion inlo nenoiy), and ieliieving infoinalion (nenoiy: ex. Innediale
iecaII of lhe iecenlIy Ieained infoinalion). AIlhough ADHD nay gIolaIIy inleifeie vilh lhe
success of lhese sleps, il is lhe inpuIsivily, hypeiaclivily and disliacliliIily lhal inleifeie
vilh lhe Ieaining piocess. ADHD does nol specificaIIy inpacl one of lhese foui sleps.
1. On IQ neasuienenl, nany sludies have idenlified a faiiIy difficuIl piofiIe of lhe
neuiopsychoIogicaI lesl iesuIl in chiIdien vilh ADHD. This is seen connonIy lhiough
ceilain allenlion Ioading sullesls of connonIy used IQ lesls Iike lhe Coding Digil Span and
lhe WechsIei scaIe. Tvo oi noie sullesls on lhe WechsIei scaIe aie oflen depiessed ieIalive
lo olhei sullesls. Coding, digil iesponse, aiilhnelic, and infoinalion sullesls on lhe
WechsIei scaIes aie veiy oflen depiessed ieIaled lo lhe olhei suljecls. Vaiious lesls of
execulive funclions incIuding Wisconsin caid scoiing lesl usuaIIy ieveaIed nodeiale lo
najoi deficils. Hovevei, lheie aie aIso lhose vilh ADHD vho geneiaIIy scoie Iov on aII
lhese lesls vilhoul a pailicuIai Ieaining disoidei piofiIe. 2. OveiaII decIine in aII IQ lesl
vaIues. 3. Highei lhan expecled iale of sulnoinaI inleIIigence in nenlaI
ielaidalion/Ieaining disaliIily anong chiIdien vilh ADHD 4. An incieased iale of chiIdien
vilh sulnoinaI inleIIigence lecause lhe nislakenIy diagnosed individuaI as suffeiing fion
ADHD.
SulnoinaI inleIIigence and ADHD: No foinaI sludy lul cIinicaI expeiience suggesls lhal
chiIdien vilh sulnoinaI inleIIigence vilh no indices of specific sullesl pallein of
neuiopsychoIogicaI lesling nay shov aII lypicaI synplons of ADHD (pailicuIai synplons
of inallenlion is Iack of peisislence and foigelfuIness).
MenlaI ielaidalion/ Ieaining disaliIily and ADHD: IopuIalion sludies shov nenlaI
ielaidalion nay le 5-1O lines as connon in chiIdien vilh ADHD as conpaied chiIdien
vilhoul ADHD. Though lhe iale of ADHD in nenlaI ielaidalion is iaie, il is cIeai lhal
ieIevance has incieased leyond lhe IeveI lhal is encounleied in lhe popuIalion vilhoul


35
Ieaining disaliIilies. In one sludy in lhe US, al Ieasl 15 of individuaIs vilh a piofound
IeveI of nenlaI ielaidalion nay neel ciileiia foi ADHD even lhe nenlaI age has leen laken
inlo accounl (Iox 1998).
Reading disoidei, viillen expiession and dysgiaphia: Reading disoideis aie connon in
ADHD. Aloul 25-4O vilh ADHD have najoi ieading and viiling difficuIlies (Shayvilz,
RA 1992). Sone sludies suggesl ADHD and ieading disoideis conlined nay le a visuaI
noloi piolIen, noie seveie lhan vouId le expecled on lhe lasis of sinpIy adding a lasic
Ieaining disoidei lo anolhei. Disoideis of viillen expiession aie chaiacleiized ly significanl
inpaiinenl in viiling, giannalicaIIy coiiecl senlences and paiagiaph oiganizalion and
occasionaIIy vilh dysgiaphia.
Malhenalic disoideis: The oveiIay lelveen ADHD and nalhenalic disoidei is
consideialIy noie. Il appeais il is noie associaled vilh an inallenlive lype of ADHD.
CoiieIalion of ADHD vilh Ieaining disoideis and cognilive deIay is connon.
DeveIopnenlaI DysIexia: Sone deveIopnenlaI disoideis, such as deveIopnenlaI DysIexia
nay nanifesl as a sinuIlaneous conoilidily vilh ADHD. AIlhough sone ADHD
synplons aie geneiaIIy piesenled in infancy, il is nol unliI lhe schooI age gioup lhal a fuII
exlenl of synplons lecones pievaIenl lecause of lhe highIy sliucluied schooI
enviionnenl. The deveIopnenlaI dysIexia and dyscaIcuIia lecone appaienl vhen lhe chiId
allends schooI and is iequiied lo iead, viile, and do caIcuIalions. DeveIopnenlaI dysIexia,
especiaIIy ieading and speIIing disoideis, is chaiacleiized ly difficuIly vilh ieading
conpiehension, ieading decoding and ieading fIuency and speIIing. Inpaiinenl in nuIlipIe
cognilive funclions, such as execulive funclions, is connon in ADHD and deveIopnenlaI
dysIexia. The synplons nay negaliveIy affecl lhe deveIopnenlaI couise of ADHD and viII
Iead lo slagnalion of lhe piocess of Ieaining lo iead. In sone cases, ADHD and dysIexia nay
nol shaie an elioIogicaI facloi. A dysIexic chiId nay le inallenlive in sone cIasses lecause
he oi she viII le inpaiied due lo geneiaIized ieading piolIens. olh dysIexia and ADHD
aie consideied a conpIex poIygenelic disoidei and pose a shaied genelic iisk facloi exeiling
a unique effecl on eilhei ADHD oi dysIexia.
6.8 Pervasive deveIopmentaI disorders/autism spectrum disorders
Il is connonIy olseived lhal chiIdien vilh ADHD fiequenlIy shov synplons of aulisn
specliun disoideis and vice veisa. Aulisn specliun disoideis aie chaiacleiized ly
inpaiinenl in sociaI inleiaclion and connunicalion and ly iesliicled and iepelilive
lehaviois (Iiielag 2OO7). InleIIigence is oflen inpaiied and lhe aliIily lo Ieain and uliIize
nev infoinalion is naikedIy iesliicled. ehavioi synplons nay incIude hypeiaclivily,
aggiessiveness, inpuIsivily, shoil allenlion span and lenpei lanliuns. SiniIaiilies lelveen
aulisn specliun disoideis and ADHD can Iead lo an eaiIy chiIdhood diagnosis lhal suggesl
lolh aie piesenl. As lhis chiId giovs up lhe diffeience lecones noie dislincl and one
disoidei oflen eneiges as lhe liue condilion. Aulisn specliun disoidei chiIdien vilh
addilionaI ADHD synplons shoved exaggeialed inpaiinenl in execulive conlioI and
adaplive lehavioi. They shov aulislic liails as veII as noie seveie opposilionaI defiance
disoidei lype lehavioi lhan chiIdien vilh aulisn specliun disoidei onIy. Ioi cIaiificalion
of a possilIe elioIogicaI Iink lelveen ADHD and aulisn specliun disoideis, veII designed
faniIy lased sludies aie iequiied.


36
ChiIdien vilh Aspeigeis syndione have a veiy high iale of conconilanl ADHD
synplons. A connunily-lased sludy indicaled lhal up lo 8O of aII peopIe neeling ciileiia
foi Aspeigeis, accoiding lo CiIIleig, aIso neel lhe ADHD ciileiia (LhIeis 1993). Aulislic
fealuies in ADHD viII lenefil fion inleivenlions lhal aie appiopiiale foi aulislic chiIdien
vilhoul ADHD.
6.9 Tics and Tourett's disorder
8+%' (2% 9%&'+" 20$% @+$%@%"( '.<2 0' %)% :1#"?#"B4 @0?#"B 0" +77 ,0<%4 '2&.BB#"B +& @+$#"B
0" 0&@ 0 1+( (20( #' "+( #"(%"(#+"01= 8+%' (2% 9%&'+" @0?% "+#'% ;#(2+.( @%0"#"B (+ '.<2 0'
B&."(#"B4 '"#,,1#"B4 +& '0)#"B <%&(0#" ;+&7'= 8+ (2%'% ')@9(+@' B%( ;+&'% ;2%" 9%&'+" #'
."7%& '(&%'' +& 0"D#%() 0"7H+& 0&% (2%'% ')@9(+@' 9&%'%"( ;2#1% (2% 9%&'+" #' '1%%9#"B=
Tic disoideis incIuding Touiells disoidei (TD) aie neuio-deveIopnenlaI disoideis
chaiacleiized ly vaxing and vaning noloi and /oi phonic lics. Theie is dala lhal suggesls
lhal lics and Touiells aie associaled vilh 47 of ADHD (Sapiio AK 1988). Theie is
evidence lhal lhe chiIdien dispIaying lolh disoideis (Touiells and ADHD) aie noie IikeIy
lo le iefeiied foi assessnenl and liealnenl ialhei lhan le iefeiied lo Ieain vhich disoidei
aIone is pievaIenl.
The coie synplons of lics disoideis aie noloi and vocaI lics vhich vax and vane ovei
line. Touiells shovs conconilanl synplons of nuIlipIe noloi lics and one oi noie vocaI
lics. Aloul 85 of palienls vilh Touiells shov associaled neuiopsychialiic piolIens. These
aie oflen iesponsilIe foi psychosociaI inpaiinenl. Tics can le found noie fiequenlIy as a
conoilidily lo ADHD vhen lheie is a faniIy hisloiy of lic disoideis and oi lheie is an eaiIy
onsel of a lic disoidei of high seveiily of synplonoIogy. ChiIdien vilh Touiells and
ADHD suffei fion noie exleinaIizing and inleinaIizing lehavioi piolIen and Iov sociaI
adaplion lhan chiIdien vilhoul Touiells disoidei.
UsuaIIy ADHD slails 2-3 yeais lefoie lics, vhiIe a siniIai piopoilion of cases of ADHD can
le onIy aflei a lics onsel. Il is nol fuIIy cIeai if ADHD vilh eaiIy onsel nay le ieIaled lo a
giealei piesence of anolhei disoidei lhal viII onIy lecone synplonalicaIIy sliiking nonlhs
lo yeais Ialei. LaiIy ADHD can le seen as a iisk facloi foi fuilhei associaled psychialiic
piolIens Iike lic disoideis.
The palhophysioIogicaI nechanisn of co occuiience of ADHD and Touiells is nol yel
cIaiified. The slinuIanl nedicalion in ADHD palienl possilIy liiggeis lic occuiience. AIpha
2

agonisls and alonoxeline significanlIy inpiove lic synplons. Theie is evidence lhal
supialheiapeulic doses of dexlioanphinine voisen lhe lics lul nelhyIphenidale does nol
voisen lic seveiily in lhe shoil lein. If lics oi TD aie sociaIIy disalIing lhen considei
lehavioi lheiapy.
Ialienls vilh co-exisling lic disoideis nay occasionaIIy need, leside liealnenl vilh a
slinuIanl foi ADHD, addilionaI nedicalion vilh a dopanineigic agonisl, Iike RispeidaI.
6.10 Obsessive compuIsive disorders
Olsessive-conpuIsive disoideis aie chaiacleiized ly iecuiienl inliusive lhoughls and
inages oi iepelilive lehaviois lhal ain lo ieduce anxiely. Up lo 3O (CeIIei 1996) of
chiIdien and adoIescenls vilh olsessive-conpuIsive disoideis aIso piesenl vilh ADHD


37
synplons. The iale of OCD anong chiIdien vilh ADHD is 8-11 (AinoId 2OO1), lul lhal
iale is highei anong chiIdien vilh Touielle s disoidei. Ialienls vilh conoilid ADHD and
OCD veie chaiacleiized ly eaiIy onsel of OCD synplons. Ialienls vilh conoilid OCD
and ADHD synplons seen lo iequiie speciaI caie and liealnenl lecause lhe Iongei lhose
synplons peisisl, lhe noie lhey inciease in seveiily. OCD can le liealed vilh an SSRI, Iike
Iiozac, and lehavioi nodificalion.
6.11 Substance abuse and ADHD
8+ )+. '.'9%<( (2#' 9%&'+" '@+?%'4 .'%' 7&.B' +& 7&#"?' 01<+2+1= A2) 7+ )+. '.'9%<( (2#'=
IndividuaIs vilh ADHD have seveiaI chaiacleiislics lhal nake lhen noie vuIneialIe lo
sulslance aluse. These incIudes seIf-nedicalion (i.e. leenageis laking AddeiaII), inpuIsive
lendency lo associale vilh olhei individuaIs vho aie nol doing veII in schooI, and sociaI
skiII piolIens. AppiopiialeIy piesciiled slinuIanl nedicalion does nol seen lo inciease lhe
chance of Ialei sulslance aluse. SeveiaI sludies nov shov lhal slinuIanl liealnenl of
ADHD does nol inciease lhe iisk of Ialei sulslance aluse and lhal if anylhing, such
inleivenlion consideialIy decieases lhe iisk of sulslance use disoideis.
Snoking is associaled vilh ADHD. The piesence of ADHD incieases lhe iisk he oi she viII
le a cigaielle snokei ly al Ieasl 3 lines lhe IeveI of lhe geneiaI popuIalion. Snoking usuaIIy
legins al an eaiIiei age and peisisls lhioughoul Iife. Il is noie difficuIl lo give up in ADHD
cohoil. AIcohoI anolhei connon lype of sulslance aluse disoidei in ADHD. In
adoIescence, aIcohoI aluse cases aie seen in 1 in 3 individuaIs vilh ADHD in cIinicaI lased
sludies. In cIinicaI piaclice, lhe suspicion of sulslance aluse vaiianls uiine oi lIood
scieening lo confiin lhe diagnosis. AdoIescenls vilh sulslance aluse disoideis conoilid
vilh ADHD aie associaled vilh a giealei seveiily of sulslance aluse conducl piolIens and
voise liealnenl oulcones (SuIIivan 2OO1). Sone have queslions vhelhei lhe Iong-lein
liealnenl of ADHD vilh a slinuIanl incieases lhe iisk foi sulslance aluse in adoIescenls oi
aduIl. The nosl pulIished sludy does nol suppoil lhis opinion. In facl, lhe sludy found lhal
slinuIanl liealnenl in ADHD ieduced lhe iisk foi sulslance aluse disoidei ly 5O,
liinging il lo lhe IeveI of lhe geneiaI popuIalion (Iaione, SV 2OO3). This suggesls lhe
liealnenl of ADHD nay ilseIf ieduce lhe Iong-lein iisk foi deveIopnenl of sulslance use
disoidei and lhus highIighls lhe inpoilance of eaiIy iecognilion and liealnenl of ADHD.
In palienls vilh conoilid ADHD sulslance use disoidei, specific sulslance aluse
liealnenl shouId le insliluled fiisl and once lhe palienl is sulslance fiee, nedicalion can le
used lo lieal lhe inpaiinenl associaled vilh ADHD. Alonoxeline, a non-slinuIanl nay le
noie suilalIe foi liealnenl of ADHD synplons in lhis popuIalion, lhough a slinuIanl can
aIso le used effecliveIy. I oflen encouiage gioup lheiapy in deaIing vilh lhe diug and
encouiage alslinence. IaniIy lheiapy is aIso a good idea. The individuaI nay lenefil fion a
12 slep gioup. upiopion (SoIhkhah, R 2OO5) and liicycIics (Weiss, RD 1989) aie lypicaIIy
consideied lhe fiisl Iine of phainacolheiapy foi conoilid ADHD and sulslance aluse
disoideis in chiIdien and adoIescenls. Second Iine agenls of lhe slinuIanl aie geneiaIIy
lhoughl lo le a safe and effeclive liealnenl of lhe ADHD. If unliealed, ADHD is associaled
vilh high iales of aIcohoI use duiing aduIlhood. A 15 yeai foIIov up sludy shoved ADHD
and aIcohoI aluse aie highIy conoilid anong aduIls. Tiealnenl of ADHD in chiIdien and
adoIescenls nay acluaIIy ieduce lhe Iong-lein iisk foi deveIopnenl of sulslance aluse.


38
6.12 PersonaIity disorders
In lhe aduIl age gioup, individuaIs vilh ADHD aie oflen diagnosed as suffeiing fion one
oi noie of lhe so-caIIed peisonaIily disoideis. Lven in Iale adoIescence, lheie is a veiy high
iale of individuaIs vilh ADHD vilh and vilhoul conconilanl deveIopnenlaI cooidinalion
disoideis vho neel fuII synplonalic diagnoslic foi one oi noie peisonaIily disoideis.
Hovevei, in chiIdien undei 18-yeais-oId, lhese disoideis aie cIassified as conducl disoidei
ialhei lhan a peisonaIily disoidei. These peisonaIily disoideis couId le of any lype, lul il
appeais lhal lhose invoIved in najoi sociaI dysfunclions nay le pailicuIaiIy connon.
These incIude, foi exanpIe, schizoid, schizo lypicaI, paianoid, avoidanl oi olsessive
conpuIsiveness and loideiIine peisonaIily disoideis. Il is uncIeai lo vhal exlenl il is
heIpfuI oi nol lo nake an addilionaI diagnosis of peisonaIily disoideis in a peison vho is
suffeiing a neuio deveIopnenlaI/neuiopsychialiic disoidei such as ADHD. Il is doullfuI
vhelhei lhe peisonaIily disoidei diagnosis conliilules any in lhe vay foi fuilhei
expIicaling lhe undeiIying naluie of piolIen faced ly lhe individuaI. Il is hovevei
inpoilanl foi lhe aduIl psychialiisl lo le avaie lhal nany of lheii palienls vho aie neeling
lhe ciileiia foi one oi noie peisonaIily disoideis aie ieaIIy suffeiing fion ADHD.
7. Non-psychoIogicaI (physicaI) probIems associated with ADHD
Theie is sulslanliaI Iileialuie on lhe pievaIence of psychialiic conoilidily in ADHD, lul
non-psychialiic disoideis co-occuiiing vilh ADHD have iecenlIy gained videi allenlion. In
addilion lo psychoIogicaI issues, lhe peison vilh ADHD nay expeiience physicaI piolIens
incIuding iecuiienl headaches, nuscIe aches and pains, and aldoninaI pain, vhich nay
iesuIl fion lhe lacleiiaI infeclion, paiasiles, food aIIeigies, neuioloxicins, oi enviionnenlaI
loxicily. Seveie faligue aIIeigic disoideis aie aslhna and eczena, iespiialoiy infeclions, and
eai infeclions. Many aduIls suffei fion IilionyaIgia oi chionic faligue syndione. A
piolIen nay aiise vilh lhe nedicalion. Those nedicalions lhal aie given foi conoilid nay
have an undesiialIe affecl on ADHD and vice veisa.
7.1 EIimination disorders
These incIude nocluinaI enuiesis, diuinaI enuiesis, and encopiesis. Accoiding lo one sludy,
chiIdien vilh ADHD nay have significanl highei iales of inconlinence, conslipalion,
uigency, fiequency voiding, nocluinaI enuiesis and dysuiia lhan lhose vilhoul ADHD. Ioi
yeais, cIinicians have anecdolaIIy noled an incieased incidence of enuiesis in chiIdien vilh
ADHD. Olheis have olseived lhal lheii paienls vilh enuiesis have an incieased incidence
of ADHD. ecause lolh condilions aie faiiIy connon, il is inpoilanl lo have noie syslenic
sludies lhal Iook al lhe ieIalionship lelveen enuiesis and ADHD. An ailicIe in Soulhein
MedicaI }ouinaI pulIished in 1997 conpaied a faiiIy Iaige gioup of 6-yeai-oId chiIdien vilh
ADHD lo a non-ADHD conlioIIed gioup seIecled fion a pedialiic cIinic popuIalion. Thal
sludy found 6 yeai oIds vilh ADHD had 2.7 lines highei incidence of enuiesis (Rolson
1997). Sonelines enuiesis nay le noie upselling foi chiIdien vilh ADHD. A non-ADHD
chiId vho successfuIIy oveicones his feais nay le alIe lo accepl his ledvelling noie
easiIy. Hovevei, a chiId vilh ADHD aIieady feeIs diffeienl fion his peeis. His
disoiganizalion and inpuIsivily nay Iead lo peei iejeclion and shane. Such chiIdien nay
covei his shane vilh appeaiance liavado. Sone chiIdien vilh ADHD sIeep deepIy and
have lioulIe vaking up lo go lhe lalhioon vhen lheii lIaddei is fuII. A faniIy sludy


39
suggesled lhal ADHD and lhis lype of eIininalion disoideis aie elioIogicaIIy independenl
psychialiic condilions.
To lieal lhe chiId vilh lolh ADHD and enuiesis, il is inpoilanl lo fiisl do a conpIele
physicaI exaninalion and ask lhe individuaI vilh ADHD aloul cuiienl and pasl ledvelling
piolIens. Donl negIecl lo ask adoIescenls aloul lhis loo. They viII iaieIy voIunleei lhis
infoinalion on lheii ovn. AIso, ask vhal liealnenl has leen liied in lhe pasl. Sone chiIdien
in lheii leens vilh ADHD have liied vilh diffeienl lheiapies in lhe pasl. ecause of lhis,
lhey aIieady nighl expecl lhe liealnenl lo faiI. One nay nodify lehavioi inleivenlion lo
acconnodale foi lhe chiIds shoil allenlion span. One nusl piioiilize synplons. If lhe chiId
has a nyiiad of lehavioi difficuIlies, lhe faniIy cannol addiess aII of lhen al once. When
lhe faniIy decides lhis is lhe iighl line lo lieal lhe enuiesis, lhey nay have lo lack off vilh
sone of lheii olhei lehavioi goaIs lo avoid leing oveivheIned. The chiId and lhe faniIy
shouId le nade avaie lhal lheie aie seveiaI vays lo lieal lhe enuiesis. If one does nol voik,
you aie nol a faiIuie. Thal shouId Iead lo naking a diffeienl pIan foi lhe fuluie.
7.2 SIeep probIems
Sludies suggesl lhal chiIdien vilh ADHD aie noie IikeIy lo have sIeep piolIens lhan
chiIdien vilhoul ADHD. As nany as 56 of chiIdien vilh ADHD have piolIens faIIing
asIeep, conpaied lo lhe 23 of noinaI chiIdien (Coikun 1998). Up lo 39 of chiIdien vilh
ADHD shov a piolIen of vaking up in lhe niddIe of lhe nighl. Resislance lo go lo led and
fevei lolaI houis of sIeep seens lo le a najoi piolIen vilh nany chiIdien vilh ADHD and
IikeIy adds lo lheii difficuIlies in funclioning al schooI. Sludies on sIeep pallein do nol
lypicaIIy suggesl specific difficuIlies vilh lhe naluie of sIeep ilseIf in lhese chiIdien. SIeep
ieIaled and invoIunlaiy novenenls appeai lo le noie connon in chiIdien, and lhese nay
le specificaIIy Iinked lo ADHD and coexisling disoideis oi liealnenl. One sludy suggesled
a Iink lelveen ADHD and ieslIess Ieg syndione in chiIdien (Iiccheielli 1998).
If sIeep disoideis aie seveie, poIysonnogiaphy shouId le conducled. Tiealing sIeep
disoideis nay inpiove a chiIds allenlion al schooI. ADHD liealnenl vilh slinuIanl
nedicalion nay cause insonnia. One shouId considei sIeep hygiene lefoie using nedicine
lo ieeslalIish nev sIeep-vake cycIes.
7.3 AIIergies
Minoi aIIeigic disoideis have leen inpIicaled as a possilIe conoilid condilion in ADHD.
Mosl of lhe evidence iuns lo counlei lhe nolion lhal lheie is liue associalion lelveen
aIIeigies and ADHD. Despile vaiious discussions in iegaids lo lhe ieIalionship lelveen
aIIeigies and ADHD, sludies on ADHD and aIIeigic ihinilis and aslhna have piovided
IaigeIy negalive iesuIls, suggesling lhe ieIalionship nay le snaII, if il exisls al aII.
7.4 Eczema
A seiies evidenl innunoIogicaI invesligalion ieveaIs lhe sliong associalion of ADHD and
eczena (alopic eczena oi alopic deinalilis). This eczena is a ieIevanl cause of pedialiic
sIeep disiuplion. Since disiupled sIeep is a fiequenl fealuie of ADHD, lhis nay conslilule a
pulalive causaI Iink lelveen lolh disoideis. Lven noie inleieslingIy, lvo independenlIy


40
IongiludinaI lased liilh cohoil sludies found a peisisling effecl of eaiIy deleclion of alopic
eczena on nenlaI heaIlh. ChiIdien vho suffeied fion eczena duiing lhe fiisl yeais of Iife
and shoving iennanls of synplons lheieaflei viII have an incieased iisk foi lehavioi
piolIens al age 1O. Lven lhough lhe causaI ieIalion is sliII uncIeai, lhis dala denonsliales
lhal eczena duiing eaiIy chiIdhood piedisposes kids lo deveIopnenlaI lehavioi piolIens
Ialei on. In a popuIalion lased sludy on aduIl eczena, an associalion vas olseived vilh a
vide iange of psychialiic issues incIuding depiession and peisonaIily disoideis, indicaling
lhal eczena nay piedispose individuaIs lo age-dependenl nenlaI heaIlh piolIens. (Schnill
el aI, 2OO9)
7.5 Height and weight probIems
ADHD occuiied in as nany as 27 of chiIdien ieceiving liealnenl foi olesily (AIlfas, }R
2OO2). In addilion, seveiaI sludies suggesl a negalive effecl on heighl and veighl aflei yeais
of liealnenl vilh cenliaI slinuIanl in ADHD. The evidence is equivaIenl and noie iecenl
sludies say lhal a ieduclion of finaI heighl nay le nininaI oi nonexislenl. AIlhough nol
ieIaled lo lhe alopic nechanisn, lhe assunplion lhal nuliilionaI conponenls nay cause oi
exaceilale ADHD synplons fuilhei fueI vaiious lheiapeulic diels and enphasizes lhe
inpoilance of dielaiy adjuslnenls in ADHD chiIdien.
7.6 Hypertension
Iood piessuie is significanlIy incieased in individuaIs vilh ADHD liealed vilh cenliaI
slinuIanl and/oi alonoxeline. Il is uncIeai al lhis slage vhelhei such liealnenl nay have a
Iasling effecl on lIood piessuie oi incieased iisk foi Ialei hypeilension.
7.7 FibromyaIgia
IilionyaIgia is a connon condilion in aduIls, pailicuIaiIy in vonen. Sone aduIl
psychialiisls vilh vasl expeiience in lhis age gioup leIieve lhe iale of ADHD has incieased
lhe laseIine popuIalion pievaIence foi lhis condilion.
7.8 Perthe's disease
This hip disoidei is lypicaIIy encounleied in chiIdien of pieschooI age vho noie oi Iess
slail Iinping. Il is Iisled heie nol lecause of lheie has leen pulIished enpiiicaI sludies of
possilIe conneclion lelveen ADHD and Ieilhes disease lul lecause sone pedialiic
oilhopedics have suggesled lhal nany young palienls vilh a hip piolIen nay have ADHD.
7.9 CIumsiness
This occuis in 5O of chiIdien vilh cIinicaI diagnosis of ADHD. AIso, neaiIy haIf of chiIdien
vilh cIunsiness dispIay ADHD. Il is associaled vilh allenlion, ieading, and viiling
piolIens. ChiIdien vilh ADHD aie noie IikeIy lo expeiience injuiies due lo accidenls lhan
noinaI chiIdien.
CIunsiness inpioves ovei line, lul 1/3 of chiIdien viII caiiy il inlo aduIl Iife, causing
piolIens vilh fine and/oi gioss noloi novenenls (Kadesjo, 1999).


41
7.10 EpiIepsy
Thiee peicenl of chiIdien vilh ADHD have sone kind of seizuie disoidei. Tvenly five
peicenl of chiIdien vilh epiIepsy viII have ADHD. Mosl chiIdien vilh ADHD and
conoilidily viII have slaiing episodes. Il can le diffeienlialed fion any kind of seizuie ly
asking lhe paienls lo nake lhe chiId lIink. If lhe chiId lIinks, il is veiy unIikeIy lhal il is a
seizuie. If lhe slaiing is ieIaled lo seizuies, lhen lheie viII le noie aulononic neivous
syslen ieIaled signs, such as incieased heail iale and pupiI diIalion. Lveiy chiId vilh lhe
diagnosis of ADHD needs a iouline LLC lo iuIe oul lhe nosl connon disoidei, chiIdhood
alsence epiIepsy. Though pailiaI conpIex and geneiaIized seizuie disoideis nay exisl, an
LLC can confiin lhose findings.
Appiopiiale anli-epiIeplics shouId le used as liealnenl, in addilion lo liealnenl of ADHD.
Theie is a 1-3 chance lhal slinuIanl nedicalion nay voisen lhe undeiIying seizuie
disoidei.
8. Discussion
Il can le chaIIenging lo idenlify and lieal chiIdien vilh ADHD, especiaIIy in lhose vilh
conoilidily. The high pievaIence couId le due lo incieased avaieness ly cIinicians. Iaienls
nay iefuse lo accepl lheii chiIds diagnosis of ADHD, and nuch Iess lhal of a conoilidily.
The high conoilidily iale lelveen ADHD and olhei disoideis have essenliaIIy ciealed
confusion iegaiding lhe definilion of a liue ADHD diagnosis. Since nosl chiIdien oi aduIls
vilh ADHD aIso have a second diagnosis vheie lolh sels of synplons fiequenlIy oveiIap,
ciilics suggesl lhal lhe nev scenes of ADHD have nol leen adequaleIy desciiled. Sone
even suggesl lhal naking an eaiIy ADHD diagnosis in a veiy young chiId is inappiopiiale.
Ioi inslance, iecenlIy idenlified condilions in lhe DSM of eaiIy onsel lipoIai disoidei
ninics ADHD in lhe aieas of inpuIsivily, nood inconsislencies and hypeiaclivily. Il nay
nol le cIeai vhelhei a veiy young chiId suffeis fion ADHD, eaiIy onsel lipoIai disease oi
anolhei condilion lhal ninics ADHD synplons. OlviousIy eslalIishing an accuiale
ADHD diagnosis is veiy chaIIenging foi even lhe lesl cIinician.
Iiisl poinl I vouId Iike lo discuss is in iegaids lo nenlaI ielaidalion. The diagnosis of
ADHD shouId le given onIy vhen lhe synplons of inallenlion oi hypeiaclivily aie piesenl
lo lhe degiee in excess of nenlaI ielaidalion of a chiId. Hovevei, lheie aie no ciileiia foi
evaIualing deveIopnenlaI inappiopiialeness in lein of nenlaI age. Sone invesligalions
considei il insufficienl lo eslalIish devialion in leins of chionoIogicaI age-appiopiiale
lehavioi vilhoul speciaI consideialion lo lhe nenlaI age. Lven vilh lhis difficuIl dala
deleinining deveIopnenlaI appiopiialeness, il is lellei lo excIude lhe palienl undei nenlaI
age of 4 yeais and lhe palienl of nodeiale lo seveie nenlaI ielaidalion vilh IQ undei 5O.
The cases of nenlaI ielaidalion and loideiIine inleIIigence logelhei shov lhe significance of
conconilanl deIay and nenlaI deveIopnenl. Theie aie no iepoils of an ADHD palienl vilh
nenlaI ielaidalion and loideiIine inleIIigence. This finding nakes il necessaiy lo
incoipoiale inleIIigence lesling in ADHD diagnosis foi evaIualing vhelhei lhe palienl has
naIadaplive lehavioi aiising nol onIy fion ADHD lul fion nenlaI deIay, as veII.
Il is cIeai lhal lhe issues of conoilidily have inpoilanl inpIicalions foi undeislanding
assessnenl and liealnenl of lhe chiIdien vilh ADHD. ChiIdien vilh ADHD significanlIy


42
dispIay a Ieaining disaliIily, OCD, CD, anxiely disoidei oi depiessive disoidei vhiIe sliII
olheis nay shov evidence of a co-occuiiing lic disoidei oi peihaps a lipoIai disoidei. Sone
shov nuIlipIe conoilid disoideis. The piesence of conoilid condilions IikeIy has a
significanl inpIicalion foi Iong-lein oulcone. ChiIdien vilh conoilid fealuies oflen shov
noie seiious IeveIs of inpaiinenl, aie noie IikeIy lo have conlinuing piolIens and iequiie
a giealei uliIizalion of nenlaI heaIlh seivices lhan do lhose vilhoul evidence of
conoilidily. Assessing lhe piesence of conoilid fealuies conpIicale lhe cIinicaI picluies
essenliaI in voiking vilh chiIdien vilh ADHD.
Civing lhe piopei assessnenl shouId Iead lo oplinaI liealnenl. A liealnenl piogian foi
chiIdien vilh ADHD and conoilid condilions shouId addiess lhe fuII iange of piolIens
highIighled ly assessnenl findings. Ioi exanpIe, vhen a chiId nol aIso onIy shovs lhe
fealuie of ADHD lul aIso neels lhe diagnoslic ciileiia foi opposilionaI defiance disoidei
and Ieaining disoideis, liealnenl shouId focus on aII lhe piolIens associaled vilh each of
lhese aieas. This nighl invoIve phainacoIogicaI liealnenl foi deaIing vilh lhe chiIds
hypeiaclivily, inpuIsivily, and inallenlive lehavioi. Iaienls nusl le oiienled lo lehavioi
nanagenenl appioaches lo nodify opposilionaI defiance lehavioi. SpeciaIIy designed
educalionaI appioaches aie avaiIalIe lo assisl lhe chiId acadenicaIIy. Likevise, in lhe case of
a chiId vilh ADHD and conoilid depiession, il viII le necessaiy lo lieal lhe chiIds
depiession as veII as ADHD synplons. Wilh chiIdien dispIaying olhei palleins of
conoilidily, olhei conlinalions oi appioaches lo liealnenl nay le suilalIe.
SinpIy liealing synplons of ADHD is nol enough. Appiopiiale case nanagenenl invoIves
addiessing lhe fuII iange of cIinicaI piolIen dispIayed. Indeed, effeclive liealnenl foi
chiIdien vilh ADHD and conoilid condilion is IikeIy lo le nuIli-discipIinaiy in naluie and
noie exlensive and conpIex lhan lhe liealnenl foi chiIdien vilh unconpIicaled ADHD.
Moie ieseaich is needed lo guide liealnenl of chiIdien vilh ADHD vho dispIay a specific
pallein of conoilidily.
Thus, ADHD is a conpIex condilion, affecling al Ieasl 5 of chiIdien popuIalion and
lheiefoie, needs lo le lellei idenlified and liealed (Iaione, S 2OO3). Those vho seek nedicaI
oi psychoIogicaI heIp have al Ieasl one oi noie najoiIy associaled disoideis oi piolIens.
These piolIens need lo le appiopiialeIy idenlified and liealed, as veII.
Co-exisling disoideis affecl lhe oulcones of individuaIs vilh ADHD. Il is nol veII knovn
aloul lhe Iong-lein oulcone of chiIdien vilh ADHD and conoilidily. Sone of lhese
condilions Iike ODD and conducl disoideis have a Iong-lein negalive piognosis in leins of
Ialei sulslance aluse and anli-sociaI peisonaIily disoidei. The cIunsiness nay affecl Iong
lein acadenic piolIens.
A Iong-lein foIIov sludy is needed lo addiess lhe oulcones of lhese conoilidilies vilh
ADHD.
9. References
Acosla MT, el aII (2OO8). Lalenl CIass Sullyping of ADHD and Conoilid condilion. } An
Acad ChiId AdoIsc Isychialiy 47, 797-8O7
AIlfas }R. (2OO2) IieveIence of Allenlion Devicil/Hypeiavlivily disoidei. Anong AduIls in
Olesily Tielnenl. io Med CenliaI Isychialiy 2 (1): 9.


43
AngoId A, CosleIIo L}, (1993) Depiessive conoilidily in chiIdien and adoIescenls.
LnpeiicaI, lheoiilicaI and nelhodoIogicaI issues. An } Isychialiy. 15O, 1729-
1791.
AiceIus }on, Voslanis Ianos. (2OO5) Isychialiic conoilidily in chiIdien and adoIescenls,
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46
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3
Comorbidity in ADHD:
A NeuropsychoIogicaI Perspective
}uIio Cesai IIoies Lzaio and Maia AIejandia SaIgado Soiuco
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:=>*0,
1. Introduction
ADHD is connonIy defined as a condilion lhal affecls allenlion, Ieaining and lehavioi
(Aneiican Isychialiic Associalion, 2OO1). Despile lhal ovei lvenly yeais of scienlific
ieseaich has defined ADHD as a neuiodeveIopnenlaI disoidei, vilh lhe highei
heiedilaliIily anong psychialiic disoideis, cIinicaI-enpiiicaI laxonony (DSM-IV) sliII
pievaiI (McCough & McCiacken, 2OO6).
Iion an enpiiicaI poinl of viev, ,)?25 difficuIlies and aIso disoideis lhal acconpany lhis
condilion aie consideied conoilid (neaning: secondaiy). Hovevei seveiaI sludies have
found lhal quaIily of Iife in adoIescenls and aduIls vilh ADHD-chiId-diagnoslic is nol onIy
ieIaled vilh allenlion deficils-seveiily, lul aIso-nainIy lo conoilidily (KIassen, MiIIei &
Iine, 2OO4). Yang el aI. (2OO7) sludied a sanpIe of 1OOO chiIdien and adoIescenls vilh
ADHD, finding lhal conoilidily synplons incieases in ieIalions lo age, ieaching lhe
highesl inpacl on lehavioi ly lhe end of adoIescence. Olhei sludies aie in agieenenl lhal in
liansilion lo aduIlhood conoilidily lends lo: a) inciease in inlensily, and/oi l) lo appeai
foi lhe fiisl line (KessIei el aI., 2OO6).
IailicuIaiIy conducl and negalivislic disoideis aie highIy ieIaled vilh olhei lypes of
conoilidily (Rhee, WiIIcull, Hailnan, Ienninglon & Defiies, 2OO7), sone sludies have
found lhal conoilidily-lype couId le noie inpoilanl lhan allenlion-deficils-seveiily lo
pioduce and expIain cIinicaI lehaviois: in geneiaI Iileialuie indicales lhal vhen ADHD and
conducl disoidei aie cIeaiIy piesenl and conlined, lhe psychoIogicaI inpacl is fai noie
inpoilanl lhan lhe effecls pioduced sepaialeIy ly each disoidei (Waschlusch, 2OO2), lhis
inpacl is nol found in lhe sane nagnilude foi anxiely, depiession oi lipoIai disoidei
(IIiszka, 2OO6). IIoiy el aI. (2OO3) sludied 481 aduIls vilh chiIdhood-ADHD diagnosis,
finding lhal suljecls vilh highei chaiacleiislics foi conducl disoidei piesenled highei IeveIs
of diug consunplion, in lhis sane peispeclive Donohev el aI. (1999) iepoiled a ieIalionship
lelveen lhe sensalion seeking lehavioi piofiIe and diug consunplions in adoIescenls
(aIcohoI and naiihuana). Haily el aI. (2OO9) sludied 87 chiIdien vilh ADHD, seIecling fion
lhis sanpIe suljecls vilh opposilionaI defianl disoidei diagnosis, and conducl disoidei,
appIying diveise lehavioiaI scaIes lo sel an iniliaI evaIualion duiing chiIdhood (aggiession,
angei, and hosliIily), and a second evaIualion leen yeais Ialei. Iinding lhal lhe ADHD-


48
conducl disoidei gioup piesenled highei IeveIs of physicaI aggiession in adoIescence, lolh
conoilid gioups piesenled significanl incienenl of angei (conpaied vilh adoIescenls vilh
ADHD-onIy). Aulhois piopose lhal 2@,)*,'/1 3A(52<+1/)*,' couId le an inpoilanl
conponenl foi ADHD duiing liansilion fion chiIdhood lo adoIescence.
Specific iesuIls on ADHD fion lhe nalionaI conoilidily suivey iepIicalion (KessIei el aI.,
2OO6) shov a veiy inpoilanl negalive ieIalion lelveen yeais of schooI and synplons
pievaIence: aduIls vilh ADHD piofiIe piesenls fevei yeais of educalion, even aduIls vilh
chiIdhood onsel vilhoul cuiienl fuII-synplons piesenls a lendency lo have nid lo Iov
educalion IeveI (conpaied vilh lhe geneiaI popuIalion).
This iepoil oulIines lhal a diveise nunlei of sludies lhal have docunenled high socielaI
cosls foi anxiely, nood and sulslance use disoideis, have nol incIuded lhe ioIe of conoilid
ADHD. Indicaling lhal onIy 1O of iespondenls diagnosed vilh ADHD iepoiled having
ieceived liealnenl foi aduIl ADHD, lhis peicenlage is significanlIy Iovei lhan lhe iepoiled
iales foi anxiely, nood, oi sulslance use disoideis. ReveaIing lhal nany peopIe vilh aduIl-
ADHD aie in liealnenl foi olhei nenlaI oi sulslance use disoideis lul nol foi ADHD
(KessIei el aI., 2OO6).
ADHD synplons oveiIap and aie fiequenlIy pievaIenl anong palienls vilh olheis
psychialiic disoidei (nood, anxiely, sulslance use, and inpuIse conlioI disoideis).
MelanaIysis have shovn lhal DSM-IV ciileiia foi aduIl-ADHD has uncIeai vaIidily, piovoking
undeidiagnosis (Sinon el aI. 2OO9). This cIinicaI undei-iecognilion nay negaliveIy infIuence
liealnenl effecliveness and oulcone success (aikIey & iovn, 2OO8).
McCough el aI. (2OO9) inleivieved 435 paienls in 23O faniIies vilh al Ieasl one affecled
chiIdien (piesenl oi pasl) vilh ADHD, using diffeienl ialing scaIes lased on DMSM-IV.
Iaienls affecled vilh ADHD (pasl oi piesenl affeclion) piesenled Iovei educalionaI and
occupalionaI achievenenl, highei iales of Iifeline conoilidily foi depiession, anxiely,
disiuplive lehaviois, and sulslance use disoidei. Highei iisk foi disiuplive disoidei vas
piedicled onIy ly naIe sex and ADHD, sulslance use disoidei vas nainIy piedicled ly
disiuplive lehavioi disoideis, naIe sex, and Iovei socioecononic slalus.
Sex diffeiences in conoilidily have aIso leen found: in vonen diug consunplion is nainIy
ieIaled lo depiession and anxiely (McCough el aI., 2OO5). RuhI el aI. (2OO9) sludied 2O64
young-vonen (aged 18-25) vilh a sliucluied inleiviev accoiding lo DMS-IV ciileiia.
Iinding a 1.5 Iifeline pievaIence foi ADHD, vilh 14 sliII suffeiing fion ADHD since
ChiIdhood. Lifeline pievaIence foi conducl, sonalofoin, oi poslliaunalic sliess disoidei
vas significanl highei in ADHD-vonen. IenaIes vilh pasl oi cuiienl ADHD-diagnosis
veie aInosl lvice vuIneialIe lo suffei fion depiessive oi pholic disoidei (lhan vonen
fion lhe geneiaI popuIalion). Aulhois aIso highIighls lhal even vhen ADHD-diagnoslic
ciileiia is no Iongei fuIfiIIed in aduIlhood, vonen vilh ADHD since chiIdhood piesenls
and incieased pievaIence foi psychialiic conoilidily.
2. Is comorbidity a psychoIogicaI science?
Diake and WaIIachs (2OO7) ailicIe lilIe is a peifecl fiane lo deveIop lhis issue, Iike
Slefanalos and aion (2OO7) lhey piopose scienlific fianes foi concepluaIizing and sludying
ADHD-conoilidily, inslead of cIinicaI-enpiiicaI ciileiia.

Comorbidity in ADHD: A Neuropsychological Perspective

49
aikIey (2OO9) and olhei scienlisls (i.e. Dianond, 2OO5) have denonslialed concepluaI
Iinilalions in DSM-IV concepluaIizalion foi ADHD: accoiding lo aikIey diagnoslic
sensilivily lo inpuIsivily synplons is undeiiepiesenled in DSM-IV, poinling oul lhal fion
a scienlific-cognilive peispeclive, lehavioiaI and cognilive conlioI does nol depend of
allenlionaI lul on execulive funclions (lhese funclions aie nainIy dependenl on piefionlaI
coilex deveIopnenl -Dianond, 2OO1, van Leijenhoisl el aI., 2O1O-). They aIso highIighls lhal
olheis synplons-lehaviois-chaiacleiislics lhal couId diffeienliale inpuIsivily Iike anolhei
possilIe calegoiy in ADHD aie nol appiopiialeIy iepiesenled in DSM-IV ciileiia.
Manassis el aI. (2OO7) have found lhal chiIdien vilh anxiely disoideis piesenl an enhanced
peiceplion foi negalive enolions, specificaIIy an incienenled iesponse in allenlion and
nenoiy piocessing lo lhiealening slinuIi, vheieas ADHD-anxiely chiIdien didnl
exhililed lhis piofiIe. Aulhois considei lhal foi each gioup anxiely nay piesenl diffeienl
psychophysioIogicaI causes and chaiacleiislics.
Sludies lhal conpaied chiIdien vilh ADHD-onIy vs chiIdien vilh ADHD-opposilionaI
defianl disoidei, iepoils allenualed eIecliophysioIogicaI iesponses (Iess I3OO aclivalion lo
cues) duiing allenlionaI lasks (Conlinuous Ieifoinance Task: CIT) specificaIIy foi chiIdien
vilh ADHD-onIy, indicaling difficuIlies vilh anlicipalion and iesponse piepaialion. This
eIecliophysioIogicaI pallein is alsenl in ADHD-opposilionaI defianl disoidei, indicaling
lhal conoilidily shouId nol le vieved as a sinpIe cIinicaI-addilion (Lunan el aI., 2OO9).
A consislenl ieIalionship lelveen iighl henispheie aclivalion and a peicepluaI lias foi
negalive enolions (feai, anxiely and sadness) has leen fiequenlIy docunenled: noie iighl-
fionlaI aclivily is found in shy-evilalive chiIdien, and in suljecls vilh depiession and
anxiely, in conliasl noie Ief-fionlaI aclivily is found in socialIe and Iov-sociaI-feai chiIdien
(McManis, Kagan, Snidnan & Woodviad, 2OOO). y sludying chiIdien vilh ADHD and
lheii paienls (affecled and nol affecled), vilh eIecliophysioIogicaI iecoiding duiing an
allenlionaI lask (CIT), HaIe el aI. (2O1O) found lhal affecled suljecls (chiIdien and paienls)
piesenled an incieased iighlvaid asynneliy acioss fionlaI and cenliaI iegions. An
inleiesling ieIalionship has leen found: incieased ADHD-faniIiaI Ioading coiieIaled vilh
incieased iighlvaid fionlaI asynneliy, inslead incieased iighlvaid paiielaI asynneliy
vas coiieIaled vilh ieduced ADHD-faniIy Ioading. OveiaII, lhis psychophysioIogicaI
piofiIe couId piedispose suljecls vilh ADHD lo le peicepluaIIy-liased lo negalive-
enolionaI piocessing.
Schvailz el aI. (2O1O) neasuied lhe oililo-fionlaI coilex densily in noinaI suljecls (18 yeais
oId) pieviousIy chaiacleiized in infancy as Iov-ieaclive oi high-ieaclive suljecls, finding
lhal pailicipanls vilh Iov-ieaclive infanl lenpeianenl piesenls giealei lhickness in lhe Iefl
oililo-fionlaI coilex, vhiIe suljecls vilh high-ieaclive infanl lenpeianenl piesenl giealei
lhickness in lhe iighl oililo-fionlaI coilex.
In Iileialuie ils leen desciiled lhal chiIdien vilh conducl disoidei piesenl nainIy
nolivalionaI piolIens, vheieas chiIdien vilh ADHD piesenl nainIy allenlion deficils,
Rulia el aI. (2OO9) sludied (ly funclionaI nagnelic iesonance inaging) 14 chiIdien vilh
conducl disoidei, and 18 chiIdien vilh ADHD, using a ievaid conlinuous peifoinance
lask, and a suslained allenlion lask. ResuIls shov liain aclivalion diffeiences lelveen
gioups: conducl disoidei suljecls piesenled undeiaclivalion in paiaIinlic iegions vheieas
ADHD suljecls piesenled undeiaclivalion in diveise ceieliaI aieas incIuding piefionlaI


50
coilex. Duiing lhe ievaid condilion, conducl disoidei suljecls piesenled undeiaclivalion in
iighl oililo-fionlaI coilex, vhiIe ADHD piesenled undeiaclivalion in posleiioi cinguIaled
and piecuneus, indicaling neuiocognilives diffeiences anong diffeienl cIinicaI piofiIes.
Lunan el aI. (2OO9) found sone neuiopsychoIogicaI diffeiences anong ADHD-chiIdien vs.
ADHD-opposilionaI defianl disoidei (ODD): chiIdien vilh ADHD-onIy piesenled
difficuIlies in inhililion, lining eslinalion and ieinfoicenenl sensilivily, vheieas chiIdien
vilh ADHD-ODD piesenled an incieased vaiialiIily in lining eslinalion. Aulhois
concIuded lhal ADHD-ODD do nol iepiesenl a @,52 (2B252 foin of ADHD, inslead a
diffeienl one.
These sludies indicale lhal neuiocognilive/neuiopsychoIogicaI piofiIes aie noie specific
and cIinicaIIy iIIuslialive foi undeislanding conoilidily. Diveise aulhois has oulIined lhal
conoilidily is nol onIy acconpanying lhe disoidei, and do nol iepiesenl a 01*'*0/1
/@C*<+,+( B/5*/') foi a given disoidei. Inslead lhe disoidei ilseIf and olhei -appaienlIy no
piinaiiIy ieIaled- cIinicaI chaiacleiislics couId depend on connon cognilive, psychoIogicaI
and/oi neuiopsychoIogicaI nechanisns.
Due lhal ADHD-conoilidily physiopalhoIogy is highIy heleiogeneous, ils leen pioposed
lhal -scienlific- nodeIs of conoilidily shouId le pioposed. (Diake & WaIIach, 2OO7,
Slefanalos & aion, 2OO7, Tauiines el aI. 2O1O). And aIlhough a neuiopsychoIogicaI
appioxinalion lo undeisland lhe lasic nechanisns of psychoIogicaI disoideis is
conlinuousIy incieasing, lhe neuiopsychoIogicaI piofiIe foi each disoidei hasnl yel
acquiied a cenliaI ioIe in diagnosis and liealnenl (elIo, Sinnanon & aune, 2O11:
.2+5,;(A0?,1,<A D2B*2E). Hovevei vilh lhis appioxinalion an oplinaI conpiehension foi
lhis allenlionaI disoidei couId le achieved (Dianond & Anso, 2OO8).
3. A neuropsychoIogicaI perspective in ADHD
Iion a neuiopsychoIogicaI peispeclive conoilidily is consideied pail of lhe sane liain
and cognilive nechanisns lhal pioduces allenlionaI and oi lehavioiaI difficuIlies (aikIey,
2OO9, Dianond, 2OO5): chiIdien vilh allenlionaI-vaiianl piesenls a diffeienl (opposile)
pallein of cognilive and lehavioiaI piofiIe lhan chiIdien vilh lhe hypeiaclive-vaiianl.
Inallenlive piofiIe incIudes sociaI isoIalion, lehavioiaI passivily, and cognilive sIovness, in
conliasl hypeiaclive piofiIe incIudes aggiessive lehavioi, enolionaI inslaliIily, cognilive
inpuIsivily and sociaI disiupliveness (IIoies Lzaio, 2OO9, Maedgen & CaiIson, 2OOO).
AllenlionaI nechanisns do nol iepiesenl a geneiaI-vaIid consliucl lo expIain: iejeclion lo
foIIov iuIes and lo peifoin oiganized-sliucluied aclivilies, innediale seeking foi
gialificalion, Iov nolivalionaI diive, enolionaI IaliIily, elc (Dianond, 2OO5). Inslead of
conoilidily (+@@/)*,', lasics and connon neuiopsychoIogicaI nechanisn aie pioposed in
oidei lo expIain fion videi peispeclive allenlionaI, lehavioiaI and psychoIogicaI piofiIes
(aikIey, 1997, 2OO9, Slefanalos & aion, 2OO7).
The piincipaI neuiopsychoIogicaI chaiacleiislics seen in ADHD couId le expIained ly
deficils in execulive funclion, lhese funclions depends on diffeienl liain ciicuils nainIy
Iocaled in piefionlaI coilex (aikIey, 2O1O), foi exanpIe chiIdien vilh conlined-ADHD
piesenl noie deficils in slialegic nenoiy -an execulive funclion- lhan chiIdien vilh
inallenlive-ADHD lype (CasleI, Hunpieys & Mooie, 2O11). Lxeculive funclions peinils


51
conpIex cognilive and lehavioiaI conlioI, and aie ciilicaI foi success in schooI and daiIy Iife
(Dianond, 2O11).
4. AttentionaI sub-type as an ADHD-cortical form
MelanaIysis of 19 deveIopnenlaI-funclionaI neuioinaging sludies in noinaI suljecls has
found lhal: fionlo-paiielaI nelvoiks-inleiaclion aIIovs conscious-cognilive conlioI of
allenlionaI piocesses. Duiing liain deveIopnenl, funclionaI inlegialion lelveen lhese and
olheis nelvoiks is consliucled, lhis phenonena aIso peinils funclionaI inlegialion anong
seveiaI execulive funclions Iike inhililoiy conlioI, sel svilching and voiking nenoiy (Iaii
el aI., 2OO7). Inallenlive piedoninanl piofiIe in chiIdien vilh ADHD incIudes difficuIlies in
voiking nenoiy, voIune and piocessing speed, piinaiy Ieaining difficuIlies, and sociaI
isoIalion, lhe alsence of lehavioiaI difficuIlies as doninanl piofiIe, inpIicales neo-coilicaI
nechanisn lhal expIains piedoninanl cognilive consequences (Dianond, 2OO5).
AllenlionaI conlioI (focusing, slaliIily, and aIleinalion) and allenlionaI piocessing (voIune,
piocessing speed) foi cognilive acadenic and voiking enviionnenlaI denands, depends
nainIy on coilicaI conlioI -lop-dovn ieguIalion-, duiing chiId deveIopnenl, deIay and
inadequale inlegialion lelveen fionlo-paiielaI nelvoiks Ieads lo difficuIlies in allenlionaI
conlioI and olhei execulive funclions (Iaii el aI., 2OO7). SlinuIanls Iike alonoxelin enhances
piefionlaI coilex funclioning in ADHD-suljecls -liough adieneigic and dopanine
ieceplois- (Cano el aI., 2O1O), vilh posilive psychophysioIogicaI iesuIls.
5. Hyperactive sub-type as a ADHD-fronto-striatal form
Hypeiaclivily, conslanl seek foi gialificalion, nolivalionaI inslaliIily, cognilive inpuIsivily
(E,5F( E*)? ?+55A) and anxiely, has leen lhe coie synplons in hypeiaclive sul-lype (Rulia
el aI., 2OO9). Iionlo-sliialaI ciicuils aie highIy iepIicaled in Iileialuie foi hypeiaclive
chiIdien, phainacoIogicaI liealnenl vilh slinuIanls Iike MelhyIphenidale pioduces
posilives psychophysioIogicaI changes in coilicaI (cognilive) and fionlo-sliialaI (dopanine-
ievaid syslens) funclioning (Zhu el aI., 2O11). Ils leen eslalIished lhal inhililoiy conlioI is
lhe coie nechanisn foi lhis vaiianl (aikIey, 2OO9), lhis execulive funclion peinil oplinaI
cognilion and lehavioi ieguIalion, nelanaIysis on 19 sludies using Slioop inleifeience
neasuie (inhililoiy conlioI), indicales lhal lhis piocess is consislenlIy conpionised in
ADHD (Lansleigen, Kenenans & van LngeIand, 2OO7).
Duiing deveIopnenl dynanic inleiaclions lelveen liain iegions changes, especiaIIy in
fionlo-esliialaI ciicuils, as a iesuIl hypeiaclivily significanlIy dininishes duiing Iale
chiIdhood-adoIescence, inslead sensalion seeking (foi ievaid-goaI oiienled aclivilies)
deveIops in a |-shaped aIong chiIdhood-adoIescence-aduIlhood. MolivalionaI cues foi
polenliaI ievaid aie specificaIIy incienenled in adoIescence (sliiale hypei-iesponsiveness),
and can Iead lo iiskiei choices duiing goaI-oiienled lehavioi (SoneiviIIe & Casey 2O1O).
Diveise sludies lhal incIudes funclionaI neuioinaging have found lhal onIy duiing
adoIescence a sliiale hypeiaclivalion foi ievaid expeclalion occuis (Van Leijenhoisl el aI.,
2O1O), and aIlhough iisk-deleclion capacily (in noinaI suljecls) is aduIl-conpelenl since 13
yeais oId (Cione el aI., 2OO5), in ADHD-aduIls is cIinicaIIy dininished (MaIIoy-Diniz el aI.,
2OO7).


52
LnolionaI dysieguIalion (e.g. high sensalion seeking despile iisk consequences) in ADHD
couId Iead lo giealei iisk foi psychopalhoIogicaI conoilidily (Iaskey, Haiiis & Nigg,
2OO8). CiaII-ionec el aI. (2O11) sludied 85 aduIls vilh palhoIogicaI ganlIing (lhis disoidei
is chaiacleiized ly inadequale ievaid-ieguIalion - ieveis el aI., 2O11-), finding lhal noie
lhan 25 of lhis sanpIe piesenled hisloiy of ADHD, lhis sulgioup piesenled eIevaled
anxiely and inpuIsivily, noie seveie ganlIing piolIens, a highei fiequency of psychialiic
conoilidilies and an eIevaled suicidaI-iisk.
6. ImpuIsivity as a fronto-temporal-ADHD type
ehavioiaI inpuIsivily, aggiessiveness, conducl disoidei, and enolionaI oulluisl, aie lhe
coie synplons in inpuIsivily vaiianl (Haily el aI., 2OO9). Iionlo-lenpoiaI nechanisns aie
iesponsilIe foi oplinun ieguIalion of enolionaI-lased lehavioi (Cupla, Koscik, echaia &
TianeI, 2O11), adequale fionlaI ieguIalion lo enolionaI-lased iesponses iepiesenl an
inpoilanl pieiequisile foi inleipeisonaI and sociaI inleiaclions, aIIoving suljecls lo ieguIale
veilaI and lehavioiaI inleiaclions, lhese piocesses aie fundanenlaI foi sociaIIy-adjusled
lehavioiaI and peisonaIily deveIopnenl duiing chiIdhood (Danasio, 2OO5). ased on
genelics sludies Iov seiolonin nelaloIisn has leen oulIined as lhe key neuioliansnillei
syslen foi lehavioiaI-inpuIsivily and aggiession in ADHD (Oades el aI., 2OO8). y using
nagnelic iesonance inaging oes el aI. (2OO8) sludied lhe ieIalionship lelveen inpuIsive
conlioI and voIune-size foi diveise liain iegions (incIuding anygdaIa, anleiioi cinguIale
coilex and piefionlaI coilex) in 61 noinaI-loys fion 7 lo 17 yeais oId, finding lhal suljecls
vilh pooiei inpuIsivily conlioI piesenled (significanlIy diffeienl) Iess voIune in lhe iighl
venlio-nediaI -oililaI- coilex.
Lileialuie indicales lhal ADHD and conducl disoidei conlinalion iepiesenl a veiy
inpoilanl cIinicaI condilion (Waschlusch, 2OO2). aikIey and Iischei (2O1O) sludied lhe
infIuence of enolionaI inpuIsiveness ovei sociaI, IaloiaI and daiIy Iive aclivilies , in 135
ADHD-young-aduIls, finding lhal if ADHD-synplons aie sliII peisislenl in aduIlhood,
enolionaI inpuIsiveness seveiily conliilules lo significanl inpaiinenl in occupalionaI,
educalionaI, IegaI, and financiaI aspecls. Aulhois highIighl lhe inpoilance of inpuIsivily in
ADHD-ciileiia, consideiing ils al Ieasl as inpoilanl as inallenlion/hypeiaclivily dinension
foi lhe deveIopnenl of adequale sociaI, occupalionaI and inleipeisonaI funclioning.
AIlhough highIy inpoilanl, inpuIsivily dinension is undei-iepiesenled in DSM-IV ciileiia
foi ADHD (aikIey, 2OO9).
7. Comorbidity cIassification by neuropsychoIogicaI criteria
In nosl cases in Iileialuie conoilidily is iepoiled in ieIalionship lo pievaIence (cIinicaI-
epidenioIogicaI appioach), hovevei ADHD-sullypes in aduIls aie associaled vilh diffeienl
cIinicaI conoilid coiieIales (Spiafkin el aI., 2OO7), iesuIls coincide in desciiling
piedoninanl lehavioiaI-psychoIogicaI disoideis in conlined-ADHD, and piedoninanl
cognilive disoideis al inallenlive lype (Muiphy, aikIey & ush, 2OO2). To expIoie
conoilid piofiIes fion a neuiopsychoIogicaI poinl of viev, a sanpIe of 61 naIe-chiIdien
vilh ADHD-diagnosis (DSM-IV ciileiia) veie seIecled. Iailicipanls had lelveen 6 and 1O
yeais-oId (nean: 7.6). IncIusion ciileiia veie: nol-nedicaled foi ADHD (oi any olhei
neuiodeveIopenenlaI/psychialiic disoidei), no hisloiy of psychoIogicaI liealnenl, noinaI
I.Q. (WISC), excIusion ciileiia: olheis non-ieIaled neuiodeveIopnenlaI disoidei (epiIepsy,


53
cognilive deficil, elc). AII suljecls veie evaIualed vilh diveise neuiopsychoIogicaI lesls,
and evaIualed ly cIinicaI-psychoIogicaI ciileiia (see IIoies Lzaio, 2OO9 foi delaiIs). On lhe
fiisl anaIysis 2O suljecls vilh ADHD-allenlive lype (ADD) (gioup one) veie conpaied vs.
1O suljecls vilh ADHD-conlined (ADHD-C) lype and 1O suljecls vilh ADHD-inpuIsivily
vilh oi vilhoul hypeiaclivily-vaiianl (ADHD-I-H) (gioup lvo: ADHD-C-I).
ased on Dianond (2OO5) pioposaI, conoilidily vas divided in lehavioiaI-psychoIogicaI,
and cognilive. SlalislicaI anaIysis vas peifoined ly Iisheis exacl lesl (ILT). AII iesuIls
incIuding lalIes aie adapled fion IIoies Lzaio (2OO9)
*

Dala piesenled in lalIes 1 and 2, suppoils aikIeys and Dianonds lasic division,
iIIuslialing lhal lolh gioups aie significanlIy diffeienl in lehavioiaI-psychoIogicaI and
cognilive dinensions. These iesuIls coincide vilh olhei sludies (CapdeviIa-iophy, el aI.,
2OO5, Maedgen & CaiIson, 2OOO). ADHD-C-I gioup is nainIy chaiacleiized ly lehavioiaI-
psychoIogicaI conoilidily, vheieas cognilive conoilidily iepiesenls lhe nain
chaiacleiislic foi ADD gioup.

82?/B*,5/1%;(A0?,1,<*0/1 0,@,5C*3*)A #GHG%I%& #GG JKL
Mood disoideis 43 1O .O17
Conducl disoidei an/oi agiessivily 39 8 .O4O
Negalivislic defianl disoidei 39 O .O32
Anxiely/anxiely disoidei 35 8 .O4O
SociaIizalion difficuIlies 35 4O .432
Avoiding lo foIIov iuIes-insliuclions 39 O .OO1
InfanliIizalion 39 O .OO2
Lov loIeiance lo fiuslialion 35 17 .1O1
Insecuiily (Iov seIf-concepl) 13 36 .O22
TalIe 1. Ieicenlage on lehavioiaI-psychoIogicaI conoilidily and diffeiences lelveen
ADHD-C-I and ADD

I,<'*)*B2 0,@,5C*3*)A #GHG%I%& #GG JKL
VisoespaliaI difficuIlies 39 7O .O14
Malhenalics Ieaining disoidei 17 4O .O32
Reading Ieaining disoidei 26 35 .356
CeneiaI Ieaining disoidei 4 35 .OO1
Language difficuIlies/dysphasia 4 3O .O12
TalIe 2. Ieicenlage on cognilive conoilidily and diffeiences lelveen ADHD-C-I and ADD
Ils inpoilanl lo oulIined lhal sociaIizalion difficuIlies aie due lo diffeienl causes in each
gioup (evilalive vs disiuplive), ieading Ieaining disoidei aie aIso due lo diffeienl
neuiopsychoIogicaI causes (RoseIIi, Malule & AidiIa, 2OO6). Lven vhen geneiaI-cIinicaI-

*
IailiaIIy/lolaIIy iepioduced fion "Caiacleislicas de conoiliIidad en Ios difeienles sullipos de liasloino
poi deficil de alencin con hipeiaclividad" de }.L. IIoies Lzaio, 2OO9, Isicolhena, 21(4), p. 594, 595.
Copyiighl 2OO9 deI CoIegio OficiaI de IsicIogos deI Iiincipado de Asluiias. Repioducido con peiniso"


54
ciileiia 0,*'0*324 psychoIogicaI and neuiopsychoIogicaI anaIysis peinils lo scienlificaIIy
diffeienliale specific diffeienliaI-causes foi lhe (/@2 ciileiia. Lileialuie has piogiessiveIy
denonslialed lhal 01*'*0/1%2@;*5*0/1 dinensions vilhoul psychoIogicaI, psychophysioIogicaI,
oi neuiopsychoIogicaI scienlificaIIy lases shouId nol seive as ;5,M2((*,'/1 laxononic ciileiia
(McCough & McCiacken, 2OO5, Slefanalos & aion, 2OO7).
8. Hyperactive, inattentive and impuIsive variants anaIysis
Duiing liansilion fion chiIdhood lo adoIescence, enolionaI ieguIalion iepiesenls a cenliaI
conponenl foi ADHD-nenlaI heaIlh (aikIey & Iishei, 2O1O), due lhal inpuIsivily vaiianl
is undeiiecognized in DSM-IV ciileiia (aikIey, 2OO9), and lhal enolionaI dysieguIalion is a
coie chaiacleiislic foi inpuIsivily sullype (Haily el aI., 2OO9), ADHD-InpuIsivily vaiianl
sliII iepiesenls a veiy inpoilanl cIinicaI sulgioup foi scienlific sludy.
Cuiienl knovIedge on cognilive neuioscience and neuiopsychoIogy peinils lo vaIidale lhe
peilinence lo invesligale diffeiences anong hypeiaclive vs. inpuIsive suljecls. Theiefoie a
second anaIysis vas peifoined vilh a lhiee-gioup division: 2O chiIdien vilh inallenlive
vaiianl (ADD), 2O chiIdien vilh conlined vaiianl (ADHD-C), and 21 chiIdien vilh
inpuIsivily vaiianl -vilh oi vilhoul hypeiaclivily- (ADHD-I). ResuIls aie piesenled in
lalIes 3 and 4, dala shovs a cIeai cognilive lo lehavioiaI-psychoIogicaI conoilidily
liansilion: inallenlive-hypeiaclive-inpuIsive. As expecled ly neuiopsychoIogicaI ciileiia,
inpuIsivily vaiianl piesenls lhe highesl significanl-fiequenl lehavioiaI-psychoIogicaI
conoilidily, Inallenlive vaiianl conlinues lo piesenl lhe highesl significanl-fiequenl
cognilive conoilidily. InleieslingIy Hypeiaclive vaiianl Iies in lhe niddIe iange on lhis
gioup-division. ResuIls iIIusliale aikIeys poinl of viev lhal inpuIsivily-vaiianl iepiesenls
a sufficienlIy diffeienlialed cIinicaI-gioup.
InpuIsivily-vaiianl suggesls fionlo-lenpoiaI nechanisns as lhe nain causes foi
conoilidily, diffeienlIy lo fionlo-sliilaI nechanisn on hypeiaclive-vaiianl. Hovevei
specifics neuiopsychoIogicaI, psychophysioIogicaI, sliucluiaI and funclionaI neuioinaging
sludies shouId diffeienliale fionlo-paiielaI, fionlo-sliialaI and fionlo-lenpoiaI nechanisns
foi each cases.

82?/B*,5/1%;(A0?,1,<*0/1 0,@,5C*3*)A #GHG%& JKL #GHG%I JKL #GG
Mood disoideis 47 .2O2 31 .118 1O
Conducl disoidei an/oi agiessivily 42 .191 26 .2O4 1O
Negalivislic defianl disoidei 31 .OO2 O O
Anxiely/anxiely disoidei 37 .415 31 .118 1O
SociaIizalion difficuIlies 45 .191 26 .25O 4O
Avoiding lo foIIov iuIes-insliuclions 52 .O38 25 .O24 O
InfanliIizalion 26 .329 42 .OO2 O
Lov loIeiance lo fiuslialion 31 .585 35 .137 15
Insecuiily (Iov seIf-concepl) 5 .284 15 .137 36
TalIe 3. Ieicenlage on lehavioiaI-psychoIogicaI conoilidily and diffeiences lelveen
gioups


55
I,<'*)*B2 0,@,5C*3*)A #GHG%& JKL #GHG%I JKL #GG
VisoespaliaI difficuIlies 7O .1OO 42 .222 26
Malhenalics Ieaining disoidei 4O .25O 25 .O81 5
Reading Ieaining disoidei 34 .5OO 4O .O65 15
CeneiaI Ieaining disoidei 34 .O22 5 .488 O
Language difficuIlies/dysphasia 3O .118 1O .232 O
TalIe 4. Ieicenlage of cognilive conoilidily and diffeiences lelveen gioups
9. Comorbid profiIes according to ADHD-variants
Conoilid chaiacleiislics anong diffeienl ADHD-sullypes anaIyzed aie specific,
lehavioiaI-psychoIogicaI conoilidily is Iisled fion noie lo Iess fiequenl:
- Inallenlive piofiIe: sociaIizalion (evilalive -lype), and Iov seIf-concepl.
- Hypeiaclive piofiIe: infanliIizalion, Iov-loIeiance lo fiuslialion, anxiely/anxiely
disoidei, nood disoideis, conducl disoidei/aggiessiveness, sociaIizalion, and avoiding
lo foIIov iuIes and insliuclions,
- InpuIsivily vaiianl: foIIoving iuIes, Iinils and insliuclions. Mood disoideis,
sociaIizalion (disiuplive-lype), conducl disoidei/aggiessiveness, anxiely/anxiely
disoidei, negalivislic defianl disoidei, Iov-loIeiance lo fiuslialion, and infanliIizalion.
Cognilive conoilidily is Iisled fion noie lo Iess fiequenl:
- Inallenlive: visoespaliaI, nalhenalics, ieading, and geneiaI Ieaining difficuIlies,
Ianguage/dysphasia.
- Hypeiaclive: visoespaliaI, ieading, and nalhenalics Ieaining difficuIlies.
- InpuIsive: visoespaliaI, ieading Ieaining disoidei.

82?/B*,5/1%;(A0?,1,<*0/1 0,@,5C*3*)A JKL
Mood disoideis .O12
Conducl disoidei an/oi agiessivily .O25
Negalivislic defianl disoidei .OO3
Anxiely/anxiely disoidei .O48
SociaIizalion difficuIlies .6O7
Avoiding lo foIIov iuIes-insliuclions .OOO
InfanliIizalion .O14
Lov loIeiance lo fiuslialion .181
Insecuiily (Iov seIf-concepl) .O15
TalIe 5. Diffeiences on lehavioiaI-psychoIogicaI conoilidily lelveen 2>)52@2 <5,+;(:
ADD vs ADHD-I-H
10. Extreme groups division
As shovn in lalIes 3 and 4, ADD and ADHD-I gioups iepiesenl 2>)52@2 0,@,5C*3*)A:
lehavioiaI-psychoIogicaI vs cognilive. In oidei lo anaIyze slalislicaI diffeiences anong lhese
gioups ILT has leen appIied. ResuIls aie piesenled in lalIe 5 and 6, dala indicale


56
cIeaiei/nosl fiequenl significanl diffeiences lolh conoilidily-lypes, incIusion of chiIdien
vilh Hypeiaclive-vaiianl (a liansilionaI gioup) lends lo dininish slalislicaI diffeiences (see
lalIes 3 and 4).

I,<'*)*B2 0,@,5C*3*)A JKL
VisoespaliaI difficuIlies .OO5
Malhenalics Ieaining disoidei .OO6
Reading Ieaining disoidei .1OO
CeneiaI Ieaining disoidei .OO3
Language difficuIlies/dysphasia .OO7
TalIe 6. Diffeiences on cognilive conoilidily lelveen 2>)52@2 <5,+;(: ADD vs ADHD-I
11. ConcIusions
NeuiopsychoIogy peinil lo eslalIish a concepluaI liidge lelveen cIinicaI and lasics
sciences (psychoIogy and neuiosciences). AppIied neuiopsychoIogicaI ieseaich posses high
enviionnenlaI vaIidily in cIinicaI sellings (elIo el aI., 2O11). SeveiaI ieseaicheis have
ciilicized lhe ieIuclance of psychialiy-piaclice lo nove lovaid scienlificaIIy oiienled
palhophysioIogy -neuiosciences- noie connon in acluaI days lo geneiaI nedicine and
psychoIogy (McCough & McCiacken, 2OO5), fion a neuiopsychoIogicaI poinl of viev
ADHD is nainIy a disexeculive disoidei in vhich seveiaI cognilive, lehavioiaI and
psychoIogicaI consequences aie piesenl, in diffeienl foin, al diveise onlogenelic nonenls.
In ADHD, allenlion is ,'1A ,'2 of lhese consequences, and foi an inpoilanl nunlei of cases
is nol lhe nosl inpoilanl. Diveise cIinicians and ieseaiches in lhis fieId legan lo undeiIine
lhe need foi syslenalic neuiopsychoIogicaI evaIualion in oidei lo oljeclify allenlion
disoideis (Chanliy el aI., 2O11), inleipielalions on lhese iesuIls shouId le nade vilhin
vaIid scienlific nodeIs (Diake & WaIIach, 2OO7, Slefanalos & aion, 2OO7). IiofessionaIs
shouId undeisland lasic neuiopsychoIogicaI and psychoIogicaI nechanisn causing ADHD:
allenlion is ONLY one of lhe cognilive piocesses invoIved, due lo inadequale deveIopnenl
in execulive funclion conlioI, in nosl cases conoilidily is ALSO expIained ly lhe sane
psychophysioIogicaI and/oi neuiopsychoIogicaI nechanisns, lased on lhis conpiehension
inleivenlion piogians viII le noie specific, and alove aII: noie scienlificaIIy oiienled.
Diake and WaIIachs fundanenlaI queslion foi psychoIogy nay le lellei ansveied in lhis
foin: #GHG%0,@,5C*3*)A *( %@/*'1A% / '2+5,;(A0?,1,<*0/1 (0*2'02N
12. References
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aikIey, R.A. (1997). ehavioiaI inhililion, suslained allenlion and execulive funclions:
Consliucling a unifying lheoiy of ADHD. $(A0?,1,<A0/1 8+112)*', !7!, 65-94.


57
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58
Donohev, R.L., HoyIe, R.H., CIaylon, R.R., Skinnei, W.I., CoIon, S.L. & Rice, R.L. (1999).
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Al-Risk CanlIeis Seeking Tiealnenl: A Hidden Disoidei. K+5,;2/' #33*0)*,'
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I?*13 /'3 #3,12(02') $(A0?,1,<A, 39,6,761-75.


59
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60
Rulia, K., HaIaii, R., CuliIIo, A., Mohannad, A.M., iannei, M., TayIoi, L. (2OO9).
MelhyIphenidale noinaIises aclivalion and funclionaI conneclivily deficils in
allenlion and nolivalion nelvoiks in nedicalion-nave chiIdien vilh ADHD
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Slevail, S.L., Snidnan, N.C., VangeI, M.C. & WaIIace, S. (2O1O). SliucluiaI
diffeiences in aduIl oililaI and venlionediaI piefionlaI coilex piedicled ly infanl
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,M #))2')*,' G*(,5325(, 11,2, 114-24.
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allenlion deficil hypeiaclivily disoidei in diffeienl age gioup. 82*_*'< G/ `+2 `+2
8/,4 YW, 229-232
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and opioid ieceploi inleiaclions: A phainacoIogicaI laigel foi pievenlion of
slinuIanl aluse. .2+5,;?/5@/0,1,<A, 61,1-2, 283-92.
4
ADHD and SIeep ProbIems in ChiIdren
LIizalelh Haslings and ailaia T. IeIl
!"#$%&' &) *"+",&-."'$/, 0"1/+%&2/, 3"4%/$2%#56 *%+%5%&' &) 71%,4 0"1/+%&2/, 8"/,$16
*"-/2$."'$ &) 3"4%/$2%#5 /'4 7&..9'%#/:," *%5"/5"56
;'%+"25%$< &) =%#1%>/'6
;!?
1. Introduction
In lhe evaIualion of Allenlion Deficil Hypeiaclivily Disoidei (ADHD), nedicaI and
lehavioiaI piolIens ieIaled lo sIeep aie inpoilanl lo considei. A ieIalionship lelveen
ADHD and sIeep has leen acknovIedged foi sone line. SIeep disluilances veie anong
ciileiia foi ADHD diagnosis in lhe pasl and ialing scaIes foi ADHD incIuded ilens ieIaled
lo sIeep disluilance (Aneiican Isychialiic Associalion |AIAj, 1987, Conneis, el aI. 1998,
1998). WhiIe oui knovIedge aloul lhe ieIalionship lelveen ADHD and sIeep piolIens has
inpioved in iecenl yeais, il ienains chaIIenging lo lease apail lhe effecl of insufficienl oi
pooi quaIily sIeep on allenlion, aIeilness, Ieaining and lehavioi and vhal nighl le due lo a
piinaiy ADHD, nood oi lehavioi piolIen (Sinonds, 1984). This inleiface of nenlaI heaIlh
disoidei and sIeep disoidei is a chaIIenge nany cIinicians face in piaclice. MedicaI, nenlaI
heaIlh, lehavioiaI and psychosociaI faclois can diieclIy affecl lhe quaIily and duialion of
sIeep. Iooi sIeep, in luin, can have effecls on dayline funclioning and heaIlh. In addilion,
such nedicaI and nenlaI heaIlh piolIens can have diiecl effecls on allenlion, Ieaining and
lehavioi. Soiling oul lhe inpoilanl conliiluling faclois duiing a conpiehensive evaIualion
can le chaIIenging due lo sIeep and ADHD piolIens connonIy co-occuiiing. The piinaiy
puipose of lhis chaplei is lo highIighl lhe inpoilance of incIuding lhe evaIualion of sIeep as
a pail of lhe assessnenl of disoideis such as ADHD lecause lhe lesl nanagenenl foi lhe
individuaI palienl depends on lhe accuiacy of lhe diagnoslic evaIualion.
As discussed in olhei chapleis in lhis look, ADHD is a connon disoidei lhal piesenls in
chiIdhood. Il is eslinaled lo affecl 5-1O of schooI-age chiIdien and adoIescenls (Connillee
on QuaIily Inpiovenenl, 2OOO). Synplons such as disliacliliIily, foigelfuIness and faiIuie
lo conpIele voik lypify inallenlive-lype ADHD. InpuIsivily, ovei aclivily and leing
fidgely aie anong synplons lhal aie connon foi individuaIs vilh hypeiaclive-inpuIsive
lype ADHD. Having synplons lhal neel ciileiia foi lolh sullypes is iequiied foi a
diagnosis of conlined-lype ADHD. DSM-IV ciileiia iequiie lhal synplons have onsel
lefoie age 7 yeais (AIA, 2OOO), hovevei, lhe synplons of inallenlive-lype ADHD aie oflen
sullIe and nol iecognized unliI Ialei schooI yeais vhen lhe acadenic cuiiicuIun is noie
chaIIenging and iequiies giealei execulive funclioning skiIIs lo keep pace and do veII. In
addilion, lhe synplons of ADHD aie non-specific on lheii ovn and can le ieIaled lo olhei
faclois, conlexls and diagnoses. Due lo lhis, il can le chaIIenging lo deleinine if lhe pallein
of an individuaIs lehavioi is lesl desciiled ly lhe diagnosis of ADHD.


62
SIeep piolIens occui connonIy, fion infancy lhiough chiIdhood and adoIescence and aie
ieIaled lo dayline lehavioiaI conceins. Ioi inslance, ledline iesislance and nighl vaking
aie connon anong loddIeis and pieschooIeis, affecling 3O oi noie. A significanl
ieIalionship lelveen sIeep piolIens and paienl-iepoiled conceins aloul inleinaIizing and
exleinaIizing lehaviois has leen denonslialed foi lhis age gioup (Reid, 2OO9, MindeII,
2O1O). Anong schooI-age chiIdien, 11 lo 37 have piolIens vilh sIeep and nany desciile
feeIing sIeepy duiing lhe day (SIeep in Aneiica IoII Sunnaiy of Iindings |SAIj, 2OO4).
Sludies of adoIescenls and lhe 2OO6 NalionaI SIeep Ioundalion IoII of US adoIescenls
nalionvide aIso desciile a high pievaIence of sIeep piolIens al lhis age (Ovens, 2OO5, SAI,
2OO6). Ioily-five peicenl of adoIescenls iepoil shoil nighl line sIeep duialions and noie
lhan haIf iepoil feeIing liied oi sIeepy duiing lhe day. Many adoIescenls aIso iepoil feeIing
unhappy and lhal lhey aie nol gelling enough sIeep.
In lhis chaplei, ve viII discuss: lhe neuiolioIogicaI aspecls of ADHD and sIeep, lypicaI
palleins of noinaI sIeep foi chiIdien and expecled age-ieIaled changes, connon sIeep
disoideis and lheii effecls on dayline funclioning vilh pailicuIai allenlion lo ADHD, sIeep
chaiacleiislics foi chiIdien vilh ADHD and lhe effecls of nedicalions, and lhe inpoilance
of scieening foi sIeep conceins in lhe evaIualion and nanagenenl of ADHD.
2. NeurobioIogy
2.1 NeurobioIogy of ADHD
To ieviev oui cuiienl undeislanding aloul lhe oveiIap of ADHD and sIeep fion a
neuiolioIogicaI peispeclive, ve viII liiefIy ieviev key concepls foi ADHD, and sIeep in
lhis seclion. AIlhough lhe palhophysioIogy of ADHD is quile conpIex and IikeIy iesuIls
fion a conlinalion of nuIlipIe faclois, genelic and enviionnenlaI vaiialIes have leen
idenlified as possilIe conliiluling conponenls (Iaiaone, 1998). AnalonicaI sludies have
isoIaled alnoinaIilies in liain iegions associaled vilh cognilion, execulive funclioning and
lehaviois consislenl vilh ADHD (DahI, 1996). IunclionaI MRI (fMRI) sludies have siniIaiIy
denonslialed alnoinaI aclivalion in lhese aieas, incIuding lhe piefionlaI coilex, anleiioi
cinguIale gyius and lhaIanus (Duislon, 2OO3, Rulia el aI., 2O11). Cioss analonic sludies
have denonslialed a Iovei lolaI liain voIune in chiIdien vilh ADHD (CuialoIo el aI., 2OO9,
Makiis el aI., 2OO9, Tiipp, 2OO9). AddilionaIIy, decieased size of lhe iighl fionlaI Iole (RIL),
coipus caIIosun, sliialun and ceieleIIun have leen olseived in chiIdien and adoIescenls
vilh ADHD (CuialoIo el aI., 2OO9, Makiis el aI., 2OO9, Tiipp, 2OO9). The aieas found lo le
diffeienl in ADHD aie lhose vhich suppoil enolion and highei liain funclions incIuding
execulive funclion and allenlion (Makiis el aI., 2OO9). AlnoinaIilies olseived in lhe
ceieliun and ceieleIIun have leen found lo peisisl vilh advancing age, vheieas,
alnoinaIilies in lhe caudale noinaIize vilh age (CuialoIo el aI., 2OO9, Koniad & Lickhoff,
2O1O).
These analonicaI sludies and eIucidaling lhe nechanisns of slinuIanl nedicalions used lo
lieal ADHD, have heIped lo fuilhei oui undeislanding of lhe neuiolioIogicaI lasis of lhis
condilion. ADHD is associaled vilh calechoIanine dysieguIalion, specificaIIy ieIaled lo
dopanine and noiepinephiine (CuialoIo el aI., 2OO9, Iaiaone, 1998, 2OO5, Conon, 2OO9,
Makiis el aI., 2OO9, Rosa-Nelo el aI., 2OO5, Svanson, 2OOO, Tiipp, 2OO9). The dysieguIalion of
dopanine in ADHD has leen lhe focus of nuch inquiiy. One neuiophysioIogic finding

ADHD and Sleep Problems in Children

63
chaiacleiislic of ADHD, vhich is lhoughl lo undeiIie sone ADHD synplons, is an alypicaI
iesponse lo ievaid (Tiipp, 2OO9, Nigg, 2OO5). Dopanine is lhoughl lo le an inpoilanl
conponenl of lhe neuiaI syslen of ievaid (Tiipp, 2OO9), as veII as foi ADHD. The liain
iegions leIieved lo le inpoilanl in chiIdien and aduIls vilh ADHD, in vhich gioss
analonic diffeiences have leen denonslialed, aie iich in dopanine signaIing (CuialoIo el
aI., 2OO9, Makiis el aI., 2OO9, Tiipp, 2OO9). AddilionaIIy, genes associaled vilh ADHD aie
invoIved in lhe ieguIalion of exliaceIIuIai dopanine (Iaiaone, 1998, 2OO5, Svanson, 2OOO).
The lheiapeulic nechanisn of slinuIanl liealnenl is ieIaled lo dopanine and olhei
calechoIanines, and slinuIanl liealnenl is nosl oflen used in ADHD (DeI Canpo el aI.,
2O11, Rosa-Nelo el aI., 2OO5, Rulia el aI., 2O11). MelhyIphenidale exeils a lheiapeulic effecl
foi ADHD ly incieasing lhe exliaceIIuIai avaiIaliIily of dopanine (and noiepinephiine) ly
lIocking lhe ieuplake of dopanine via lianspoilei linding (DeI Canpo el aI., 2O11, Tiipp,
2OO9, Iaiaone, 1998). Anphelanines voik siniIaiIy lo nelhyIphenidale, lul aIso inciease
lhe ieIease of dopanine and noiepinephiine and deciease lhe calaloIic aclivily of
nonoanine oxidase (DeI Canpo el aI., 2O11). ILT inaging sludies have shovn acule
incieases in exliaceIIuIai dopanine vilh nelhyIphenidale adninislialion (Rosa-Nelo el aI.,
2OO5). Thus, lhe slinuIanl nedicalions aie lhoughl lo coiiecl an undeiIying deficil ieIaled lo
dopanine ieguIalion and avaiIaliIily.
AddilionaI calechoIanines, incIuding noiepinephiine and seiolonin aie lhoughl lo pIay a
ioIe in ADHD, hovevei lhe ioIes of lhese neuioliansnilleis aie Iess veII undeislood
(Zinnei, 2OO9, DeI Canpo el aI., 2O11). Noiepinephiine neuions aie nainIy Iocaled in lhe
Iocus ceiuIus, pail of lhe ielicuIai aclivaling syslen, vhich is lhoughl lo le an inpoilanl
cenlei in ieguIaling allenlion and aiousaI (Ovens, 2OO5). As discussed alove, exliaceIIuIai
noiepinephiine IeveIs aie incieased vilh lhe use of psychoslinuIanl nedicalions (DeI
Canpo el aI., 2O11). Non-slinuIanl nedicalions, alonoxeline and aIpha-agonisls, effecliveIy
inciease exliaceIIuIai noiepinephiine IeveIs and have aIso leen successfuIIy used in lhe
liealnenl of ADHD. A seiolonin lianspoilei has leen associaled vilh ADHD (Iaiaone,
2OO5), aIlhough seiolonins ioIe in ADHD has nol yel leen cIaiified.
2.2 NeurobioIogy of sIeep
The neuiolioIogy of sIeep has aIso leen a focus of sludy in iecenl yeais, and has lecone
nuch lellei undeislood. As ievieved leIov, sIeep has lvo dislincl slages, non-iapid eye
novenenl (non-RLM) and iapid-eye novenenl (RLM) lhal aIleinale in cycIes lhiough lhe
nighl. non-RLM sIeep is a peiiod of ieIaliveIy Iov liain aclivily, aIlhough lhe liains
ieguIaloiy capacily is sliII aclive, and lody novenenls aie pieseived. non-RLM sIeep can
le fuilhei divided inlo slages 1-3 ly lhe 'deepness of lhe sIeep, slage 3 leing lhe deepesl.
RLM sIeep is a peiiod of desynchionized coilicaI aclivily, high nelaloIic iale, Iack of
nuscIe lone and episodic luisls of iapid eye novenenls (MindeII, 2O1O). AiousaI opposes
sIeep in lhe sIeep-vake cycIe, and lhe daiIy shifl lelveen lhese slales iequiies a fine-luned
syslen of neuiaI inleiaclions (DahI, 1996). MuIlipIe, diffeienl neuiaI syslens have leen
inpIicaled in lhe conlioI of lhe vaking slale (Lu, 2O1O, Lspana, 2OO4).
A 2-piocess nodeI has leen pioposed lo expIain lhe inleiaclions of diffeienl lioIogic
nechanisns of sIeep. The honeoslalic piocess, vhich ieguIales Ienglh and deplh of sIeep,
inleiacls vilh lhe endogenous ciicadian ihylhn syslen, vhich infIuences lhe inleinaI sIeep
oiganizalion and lhe lining and duialion of daiIy sIeep-vake cycIes (Ovens, 2OO5, Iace-


64
Scholl & Holson, 2OO2). The honeoslalic piocess oi sIeep diive is dependenl upon lhe
quaIily and quanlily of pievious sIeep, as veII as lhe peiiod of line spenl avake, lhe sIeep
diive incieases vilh Iongei vaking peiiods, and pooiei sIeep quaIily oi duialion (Ovens,
2OO5). The ciicadian ihylhn is synchionized vilh a 24 houi day, vilh piediclalIe peiiods of
incieasing aiousaI and sIeepiness, vhich aie Iinked lo anlienl Iighl exposuie (Ovens,
2OO5). The Iighl-daik cycIe is a poveifuI zeilgelei oi cue lhal enliains lhe ciicadian cIock lo
lhe 24-houi day. The supiachiasnalic nucIeus of lhe hypolhaIanus iesponds lo lhese cues
ly infIuencing lhe pioduclion of neIalonin. Undei lypicaI ciicunslances, as one neais lhe
usuaI daik peiiod, neIalonin pioduclion incieases and faciIilales sIeep onsel. In addilion lo
enviionnenlaI cues vhich heIp lo keep lhe ciicadian cIock on liack, genelics is aIso lhoughl
lo pIay a ioIe. IndividuaIs appeai lo have a genelic piopensily lo le a Iaik (sIeep-vake
cycIe sel eaiIiei) oi a nighl ovI (sIeep-vake cycIe sel Ialei).
The ascending aiousaI syslen consisls of nuIlipIe neuioliansnilleis and pioduces coilicaI
aiousaI lhiough lvo palhvays. The doisaI ioule ascends lhiough lhe lhaIanus, and lhe
venliaI ioule lhiough lhe hypolhaIanus and lasaI foieliain (IuIIei, el. aI, 2OO6). The
aiousaI syslen is opposed ly lhe venlioIaleiaI pieoplic nucIeus (VLIO), vhich is aclive
duiing sIeep (IuIIei, el. aI, 2OO6). The VLIO iniliales sIeep aflei inpul fion lhe ciicadian
ihylhn, and honeoslalic piocess (sIeep diive) (Iace-Scholl & Holson 2OO2).
Many neuioliansnilleis have leen inpIicaled in lhe ieguIalion of lehavioiaI slale in lhe
sIeep-vake cycIe. Duiing vakefuIness and iapid eye novenenl (RLM) sIeep, choIineigic
neuions in lhaIanus, hypolhaIanus & doisaI nidliain aclivale lhe lhaIanocoilicaI
signaIing lo pioduce fasl coilicaI ihylhns (Lspana, 2OO4, Lu, 2O1O). In non-RLM sIeep,
hovevei, lhese neuions aie ieIaliveIy inaclive (Lspana, 2OO4, Lu,, 2O1O). Neuions in lhe
Iocus ceiuIeus (nainIy pioducing noiepinephiine) aie aclive duiing vaking, Iess aclive
duiing non-RLM sIeep and denonsliale aInosl no aclivily duiing RLM sIeep (Lspana,
2OO4). Noiepinephiine induces coilicaI aclivalion & vakefuIness, especiaIIy in lhe selling of
sliess (Lspana, 2OO4, Lu, 2O1O). SiniIaiIy, neuionaI hislanine is found in lhe
luleionanniIIaiy nucIeus, vhich is aclive duiing vakefuIness, vilh Iess aclivily duiing
non-RLM sIeep and even Iess duiing RLM sIeep (Lspana, 2OO4). Hislanine pionoles
vakefuIness, especiaIIy al lhe line of vaking and duiing condilions lhal iequiie high
lehavioiaI aiousaI (Lspana, 2OO4). Seiolonin has aIso leen connecled lo lhe ieguIalion of
lehavioiaI slale. The doisaI iaphe nucIeus is an inpoilanl souice of seiolonin, and has
(siniIaiIy lo olhei anineigic neuions) leen found lo le nosl aclive duiing vakefuIness, Iess
so duiing non-RLM sIeep and viiluaIIy inaclive duiing RLM sIeep (Lspana, 2OO4).
Oiexin/hypocielin neuions aie nosl aclive duiing vakefuIness, pailicuIaiIy duiing peiiods
of incieased aiousaI oi Ioconoloi aclivily (Lspana, 2OO4, Lu, 2O1O). Oiexin/hypocielin
neuions appeai lo le inhililed ly lhe anines, and aie al lheii highesl IeveI al lhe end of lhe
day, possilIy voiking lo oppose lhe incieasing sIeep diive (Lspana, 2OO4).
Dopanine is lhoughl lo have vake-pionoling piopeilies, lul ils ioIe in lhe sIeep-vake
cycIe has leen difficuIl lo undeisland due lo lhe Iack of olvious change in dopanineigic
fiiing iale lhioughoul lhe sIeep-vake cycIe (Lspana, 2OO4, Lu, 2O1O). Yel, exliaceIIuIai IeveIs
of dopanine aie eIevaled duiing vakefuIness and dopanine ieceploi agonisls inciease
vaking vhiIe ieducing non-RLM and RLM sIeep (Lspana, 2OO4). Il has aIso leen noled lhal
palienls using dopanine anlagonisls, such as anlipsycholics, and palienls vilh Iaikinsons
Disease (deficienl in dopanine) aie oflen sIeepy (Lspana, 2OO4, Lu, 2O1O). This suppoils
IikeIy vake-pionoling piopeilies of dopanine.


65
RecenlIy, lheie has leen incieasing evidence iegaiding lhe neuiolioIogicaI oveiIap of sIeep
and ADHD (Ovens, 2OO5). A pioposed ieIalionship foi sIeep disiuplion and ADHD is an
aIleied pallein of neIalonin secielion oi iesponses lo enviionnenlaI cues such as Iighl.
AIleinaliveIy, connon analonicaI palhvays nay piovide lhe Iink lelveen sIeep and
ADHD. The ielicuIai aclivaling syslen and piefionlaI coilex have leen inpIicaled in lhe
ieguIalion of lolh allenlion/aiousaI and sIeep (Ovens, 2OO5). The lhaIanus is lhoughl lo
pIay a ioIe in voiking nenoiy and lehavioiaI inhililion alnoinaIilies in ADHD, and in
lhe ieguIalion of non-RLM sIeep (Ovens, 2OO5). AddilionaIIy, aleiialions in dopanine and
noiepinephiine signaIing have leen idenlified in lolh sIeep disluilances and ADHD
(Ovens, 2OO5, Lspana, 2OO4). The ioIe of olhei neuioliansnilleis inpoilanl in sIeep such as
hislanine and acelyIchoIine in ADHD, if any, have nol yel leen idenlified. AIlhough ve do
nol fuIIy undeisland lhe ieIalionship lelveen sIeep and ADHD, lheie appeais lo le
sulslanliaI oveiIap. We viII fuilhei expIoie lhis ieIalionship lhioughoul lhis chaplei.
3. TypicaI sIeep in chiIdren and adoIescents
As noled alove, sIeep is a conpIex piocess desciiled as a iapidIy ieveisilIe slale of ieduced
iesponsiveness lo lhe enviionnenl. Thiough lasic piocesses inheienl in sIeep, oui
nenoiies aie consoIidaled, giovlh is oplinized, and lhe nexl day ve hopefuIIy feeI Iess
sIeepy, have iesloied eneigy and allenlion and lhe piospecl of lellei Ieaining and nood.
Duiing chiIdhood and adoIescence, sIeep duialions and palleins and olhei aspecls such as
associaled lehaviois change vilh noinaI deveIopnenl. Heie ve liiefIy ieviev lhe
aichilecluie of sIeep and hov lhe palleins of sIeep-vake cycIes change vilh age (Ovens,
2OO5, MindeII, 2O1O).
The aichilecluie of sIeep invoIves uIliadian ihylhns oi cycIes lhal consisl of lvo sIeep
slages, non-RLM and RLM sIeep. The duialion of lhese uIliadian cycIes changes vilh
deveIopnenl, leing aloul 5O ninules in infancy and Ienglhening lo aduIl IeveIs (9O-12O
ninules) ly schooI-age. Il is lypicaI foi individuaIs lo have a liief aiousaI al lhe end of lhese
cycIes, aloul 4 lo 6 lines duiing lhe sIeep peiiod. Non-RLM sIeep incIudes slage 1 oi
liansilionaI sIeep fion vhich a peison can le ieadiIy aioused, slage 2 vhich accounls foi
lhe najoiily of non-RLM sIeep and slage 3 oi sIov vave sIeep (SWS), fion vhich il is noie
difficuIl lo aiouse. RLM sIeep is chaiacleiized ly an aclive LLC pallein and luisls of eye
novenenls aie a haIInaik of lhis slage lhal incIudes dieaning. Non-RLM sIeep is noie
piedoninanl eaiIy in lhe sIeep peiiod, aloul lhe fiisl lhiid, and RLM sIeep accounls foi a
giealei peicenlage of sIeep in lhe Iasl lhiid. Inpoilanl lioIogicaI funclions aie alliiluled lo
each sIeep slage, foi inslance giovlh and neuioendociine funclion foi non-RLM sIeep and
nenoiy consoIidalion and Ieaining foi RLM sIeep. The slages of non-RLM sIeep deveIop in
infancy and lhe ieIalive peicenlage of SWS peaks duiing eaiIy chiIdhood and decIines ly
adoIescence. In infancy, RLM sIeep accounls foi aloul 5O of sIeep. This decIines duiing
chiIdhood and ieaches aduIl IeveIs (aloul 25-3O of sIeep) ly adoIescence (MindeII, 2O1O).
The oveiaII duialion and pallein of sIeep changes vilh age and deveIopnenl (IgIovslein el
aI., 2OO3). Olhei faclois aIso infIuence sIeep palleins incIuding (anong olheis) chiId heaIlh
and lenpeianenl, aclivilies and ieguIaiily of faniIy ioulines and cuIluiaI expeclalions.
TypicaIIy, infanls and loddIeis sIeep 11-13 houis acioss day and nighlline sIeep and lhis
decIines lo 9-1O houis ly schooI age. WhiIe adoIescenls nighl seIf-desciile needing Iess


66
sIeep, lypicaI adoIescenls do lesl vilh aloul 9 lo 9.25 houis. Naps accounl foi 3-4 houis of
lolaI sIeep foi infanls, disliiluled as 2-4 a day and decIine lo 1 nap ly aloul 18 nonlhs of
age. Napping conlinues inlo loddIei lo pieschooI yeais, aloul 5O of chiIdien al age 3 yeais
conlinue lo nap, 25 al 4 yeais and 15 al 5 yeais. Al schooI age, chiIdien aie lypicaIIy
quile aIeil duiing lhe day and have IillIe dayline sIeepiness oi napping unIess diiven ly
cuIluiaI piefeiences. Al lhis age, dayline sIeepiness vouId le a synplon deseiving of
fuilhei invesligalion, pailicuIaiIy in lhe conlexl of Ieaining, allenlion and lehavioiaI
piolIens. Hovevei, iecenl sludies in lhis age gioup suggesl lhal even in lhe alsence of
oveil sIeepiness, dayline lehavioiaI conceins nay indicale insufficienl sIeep duialion oi
quaIily. y adoIescence, lhe noinaI physioIogicaI phenonena of Ialei sIeep-vake cycIes,
caIIed deIayed sIeep phase, lypicaIIy piedoninales such lhal ledlines and sIeep onsel lines
diifl Ialei, oflen ly seveiaI houis. Concuiienl eaiIy schooI slail lines sel lhe slage foi
insufficienl duialion of nighl line sIeep, lypicaIIy 7 lo 7.5 houis foi nany adoIescenls. In
addilion, leenageis have noie vaiialiIily in lheii sIeep-vake palleins as lhey liy lo pay
lack lheii sIeep dell on lhe veekend. Such iiieguIai scheduIes add lo lhe iisk of sIeep
piolIens and chionic sIeep depiivalion affecls seveiaI aspecls of dayline funclioning
incIuding allenlion, Ieaining, and nood. Ovei haIf of adoIescenls iepoil lhal lhey feeI liied
and sIeepy duiing lhe day and aloul 25 iepoiled faIIing asIeep in schooI al Ieasl once a
veek (SAI, 2OO6). Sonelines caffeine viII le used in lhe allenpl lo slay aIeil and iesuIl in
fuilhei deIay of sIeep onsel vhen consuned loo cIose lo ledline.
Il is aIso inpoilanl lo iecognize lhal lhe aliIily of paienls lo iepoil a sIeep piolIen foi lheii
chiId aIso appeais lo le age-ieIaled. Accoiding lo a iecenl nalionaI poII, aloul 16 of
adoIescenls iepoil having sIeep piolIens, hovevei, onIy aloul 7 of paienls iepoil
piolIens vilh sIeep foi lheii leenageis (SAI, 2OO6). Iaienls of youngei chiIdien nay le
noie IikeIy lo le avaie of lhe chaiacleiislics of lheii chiIdiens sIeep and liing il up as a
concein lul nol unifoinIy. Thus, il is inpoilanl lo inquiie vilh chiIdien and adoIescenls
diieclIy as veII as lhe paienl vhen evaIualing foi sIeep piolIens (Ovens, 2OOO).
4. SIeep disorders
In lhe foIIoving seclion, ve desciile lhe nedicaI and lehavioiaI chaiacleiislics of seveiaI
sIeep disoideis and ieviev associaled sludies lhal exanine dayline funclioning,
pailicuIaiIy ieIaled lo allenlion, Ieaining and lehavioi. The najoiily of pedialiic ieseaich
lhus fai has cenleied on lhe fiisl lvo condilions desciiled, sIeep disoideied liealhing and
ieslIess Iegs oi peiiodic Iinl novenenl disoidei.
4.1 SIeep Disordered Breathing
The lein sIeep disoideied liealhing (SD) iepiesenls a specliun of disoideis vhich
incIudes al lhe seveie end, olsliuclive sIeep apnea (OSA). The SD specliun aIso incIudes
olhei condilions such as, piinaiy snoiing (aiifIov causes aiivay vilialion lul no olhei
olseivalIe alnoinaIily), uppei aiivay iesislance syndione (hypovenliIalion and incieased
inlialhoiacic piessuie iesuIling in fiagnenled sIeep lul vilhoul fiank apneas, oi lhe
cessalion of liealhing), and apnea due lo cenliaI neivous syslen piocesses. OSA is naiked
ly snoiing and apnea, and acconpanied ly hypoxenia oi oxygen desaluialion. To
deleinine vhelhei lhe synplon of snoiing is associaled vilh peiiods of apnea oi hypopnea
(Iov aiifIov and associaled oxygen desaluialion) a poIysonnogian oi sIeep sludy is


67
needed. OSA is lypicaIIy naiked ly iepealed and sonelines pioIonged peiiods of ieduced
oi no aiifIov iesuIling in Iov oxygen deIiveiy (hypoxia) lo lhe liain and disiupled sIeep
(MindeII, 2O1O).
Aloul 3O of chiIdien snoie and aloul 3-4 have OSA. The paienls of chiIdien vilh OSA
nighl iepoil heaiing Ioud oi heioic snoiing and pauses in liealhing, snoils oi gasps.
Hovevei, lhe synplons of OSA nay le Iess pionounced. ChiIdien vilh OSA nay piesenl
vilh ieslIess sIeep, nocluinaI svealing, unusuaI posilions vhiIe sIeeping (e.g., neck
exlended), noining headache and diy noulh. One iisk foi OSA eneiges fion piocesses of
noinaI deveIopnenl. Duiing pieschooI lo eaiIy schooI age, chiIdien expeiience a ieIalive
inciease of Iynphoid lissue incIuding lonsiIs and adenoids. When lhis inciease oulpaces lhe
giovlh of lhe noinaI aiivay, a iisk of aiivay olsliuclion occuis especiaIIy duiing peiiods
of Iovei nuscIe lone, e.g., duiing sIeep. Olhei faclois aIso inciease lhe iisk of olsliuclion
duiing liealhing and incIude (anong olheis), chionic nasaI congeslion, Iovei nuscIe lone
due lo nedicaI condilions, oiophaiyngeaI fealuies, and olesily (MindeII, 2O1O, Hodges,
2O11).
Cioving conceins aloul SD and lhe effecl on day dayline funclioning have fueIed
invesligalions aloul lhe ieIalionship lelveen ADHD and SD in chiIdien piesenling vilh
one oi lhe olhei condilion oi lolh. A nunlei of nelhods have leen used. Suiveys have
leen conducled in geneiaI popuIalions of chiIdien oi in individuaIs suspecled lo have lhese
specific disoideis. Sludies have aIso assessed foi ieIalionships lelveen ADHD and SD
concuiienlIy and piospecliveIy as veII as, lefoie and aflei suigicaI inleivenlion lo ienove
lonsiIs and adenoids. Iaienls of chiIdien vilh an ADHD diagnosis veie noie IikeIy lo
endoise synplons of haliluaI snoiing foi lheii chiIdien lhan paienls of non-snoieis, 22
veisus 12, iespecliveIy (Cheivin, 2OO2). In addilion, lhose chiIdien vho veie ialed as
having high SD scoies veie noie IikeIy lo desciile ADHD synplons of inallenlion and
hypeiaclivily (Cheivin, 1997). In a sludy of chiIdien ages lvo lo lhiileen yeais (al
enioIInenl), lhose endoised as haliluaI snoieis al laseIine veie noie IikeIy lo have
hypeiaclive lehavioi foui yeais Ialei (Cheivin, 2OO5). LaiIy case sludies iepoiled ADHD
synplons in chiIdien iefeiied foi evaIualion of SD synplons (CuiIIeninauIl C., 1981). In
a sludy ly DiIIon el aI, of chiIdien five lo lveIve yeais of age scheduIed foi
adenolonsiIIeclony, neaiIy 37 had evidence of ADHD and disiuplive lehavioi disoidei
(incIuding opposilionaI and conducl disoidei) and aloul 28 had ADHD (DiIIon, 2OO7).
This sludy aIso assessed lehavioiaI oulcones aflei adenolonsiIIeclony. Iifly peicenl of lhe
chiIdien vho nel ciileiia foi ADHD al laseIine lefoie adenolonsiIIeclony no Iongei did so
aflei suigeiy (DiIIon, 2OO7). In a ieviev of sixleen sludies, paienls vho iepoiled highei SD
synplons foi lheii chiIdien aIso iepoiled lhey had highei inallenlion and hypeiaclivily
synplons (Hodges, 2OO8, Coilese, 2OO9). Thus, lheie is sulslanliaI evidence suppoiling a
ieIalionship lelveen ADHD and SD.
In chiIdien vilh SD, excessive dayline sIeepiness is a connon synplon lhal affecls
funclioning ieIaled lo allenlion and aclivily. Wheieas liied oi sIeepy adoIescenls nay iepoil
noie piolIens slaying avake, youngei sIeepy chiIdien nay piesenl vilh hypeiaclive and
agilaled lehaviois (Hodges, 2O11). In schooI-age chiIdien vilh SD, line lo faII asIeep on
sliucluied nap lesls (nean sIeep Ialency lesl) vas associaled vilh lhe seveiily of SD lefoie
adenolonsiIIeclony. One yeai aflei suigeiy, hovevei, vhen SD synplons had inpioved,
lhis associalion vas no Iongei olseived (Cheivin, 2OO6, CozaI, 2OO1). In a nela-anaIysis


68
ieviev of 16 sludies, dayline sIeepiness vas anong lhe vaiialIes associaled vilh ADHD. A
iecenl sludy aIso found a significanl ieIalionship lelveen dayline sIeepiness and
inallenlive lype ADHD (Coilese, 2OO9, Mayes, 2OO9). Olhei sludies have denonslialed
siniIai neuiolehavioiaI oulcones ieIaled lo SD and/oi excessive dayline sIeepiness
incIuding inpaiied allenlion, lesls of execulive funclioning, lehavioiaI ieguIalion and
scoies of inleIIecluaI funclioning in sone sludies (eele, 2OO5, Ovens, 2OO5, eele, 2OO4,
CollIiel, 2OO4). In nany chiIdien vilh SD, adenolonsiIIeclony iesuIls in inpiovenenls in
neuiolehavioiaI oulcones, and inpiovenenl in sIeepiness is feIl lo pIay a ioIe.
Theie does nol appeai lo le a cIeai dose-iesponse ieIalionship lelveen SD and ADHD.
In a connunily-lased sludy, paienls ialed lheii 5-7 yeai oId chiIdien foi ADHD synplons
and a sulsel of lhe chiIdien undeivenl poIysonnogian. OSA vas olseived foi 26 of lhe
chiIdien vilh niId ADHD synplons veisus 5 foi lhose vilh seveie ADHD oi no ADHD
conceins. This sludy suggesled lhal SD nighl Iead lo niId ADHD synplons lul nol
expIain noie seveie ADHD synplons (Oiien, 2OO3). Cheivin suggesls lhal lhe
ieIalionship lelveen ADHD and SD in al-iisk chiIdien nay le due lo noie sullIe aspecls
of disoideied liealhing (Cheivin, 2OO5). The nechanisns ly vhich SD and OSA in
pailicuIai nay ieIale lo neuiolehavioiaI sequeIae have leen pioposed and invoIve lhe
effecl of sIeep disluilance on lhe piefionlaI coilex, sIeep fiagnenlalion, hypoxia, and
hypeicailia (eele, 2OO5, Hodges, 2O11) . The ieIalionship of such coie faclois vilh
individuaI vaiialIes of iisk aie undei invesligalion. Inpoilanl individuaI vaiialIes incIude
iesiIience, enviionnenlaI conlexl and denands, and lhe piogiession of lhese ovei line vilh
deveIopnenl.
As noled alove, lheie is sulslanliaI oveiIap lelveen liain aieas lhal ieguIale sIeep, aiousaI
and allenlion iaising lhe possiliIily lhal sIeep disiuplion nay have diiecl effecls on cenliaI
neivous syslen funclioning. In addilion, sIeep disiuplion duiing deveIopnenl suggesls lhe
possiliIily lhal sliucluies such as lhe piefionlaI coilex nay suslain Iongei lein
neuioanalonic oi funclionaI aIleialions as a iesuIl of eaiIy sIeep piolIens. Iiospeclive
sludies viII piovide inpoilanl conliilulions iegaiding lhe ieIalionship lelveen ADHD
synplons and SD and lhese aie ongoing cuiienlIy.
4.2 RestIess Ieg syndrome and periodic Iimb movement disorder
ReslIess Iegs syndione (RLS), peiiodic Iinl novenenls of sIeep (ILMS) and peiiodic Iinl
novenenl disoidei (ILMD) aie oveiIapping condilions lhal nay occui sepaialeIy oi
logelhei and affecl sIeep quaIily. Theie is evidence of a genelic lasis foi RLS vilh ILMS
invoIving chionosone 6p.(Iicchielli, 2OO8) ReslIess Iegs syndione is a diagnosis nade
lased on piesenling cIinicaI synplons such as unconfoilalIe sensalions (e.g,. feeIing lhings
ciavIing oi lingIing) and lhe uige lo nove, lolh lypicaIIy invoIving lhe Iovei Iinls. RLS
synplons usuaIIy occui vhiIe silling oi Iying dovn, lovaid evening houis, and lhe
synplons aie lypicaIIy ieIieved ly novenenl. In chiIdien, lhe piesenlalion of synplons
nay le noie vaiialIe and desciiled diffeienlIy, such as shaik liles oi gioving pains
foi sone chiIdien (Rajaian, 2OO4). Specific ciileiia foi RLS veie pulIished in 2OO3 ly NIH
(AIIen, 2OO3). WhiIe fiisl olseived in aduIls, RLS has leen iecognized in chiIdien foi ovei
fifleen yeais and is eslinaled lo occui in aloul 2 of chiIdien (WaIleis, 1994, Iicchielli,
1998, Iichielli, 2OO7, Caicia-oiiegueio, 2OO6, Iicchielli, 2OO8).


69
ILMS aie liief, iepelilive and ieguIai sleieolyped jeiks duiing sIeep, lypicaIIy occuiiing al
lhe Iovei exlienilies and Iasling up lo 5 seconds. ILMD iequiies a poIysonnogian lo
nake a diagnosis vhich iequiies five oi noie chaiacleiislic novenenls pei houi (ciileiia
foi chiIdien and adoIescenls), associaled vilh sIeep disluilance (e.g., aiousaI) oi effecls on
dayline funclioning (e.g., faligue), and no olhei piinaiy sIeep disoidei ieason foi lhe
ILMD. The pievaIence of ILMD in lhe geneiaI popuIalion is nol knovn. Hovevei, lased
on suivey infoinalion, ILM synplons aie lhoughl lo affecl aloul 8-12 of chiIdien
(Iicchielli, 2OO8). Theie is evidence lhal aIleied dopanineigic cenliaI neivous syslen
funclioning undeiIies RLS and ILMD foi nany individuaIs. In addilion, MRI and aulopsy
sludies have idenlified Iovei iion sloies in lhe sliialun and olhei cenliaI neivous syslen
aieas foi aduIls affecled vilh RLS oi ILMD. Iuilhei, seiun feiiilin <5O ng/nI has leen
associaled vilh RLS synplons oi findings of ILMD and iion suppIenenlalion has leen
denonslialed lo inpiove synplons. Theiefoie, iion deficiency nay le a liealalIe nedicaI
iisk facloi foi RLS, ILMS and ILMD pailicuIaiIy associaled vilh gioving chiIdien, vonen
duiing piegnancy and foi individuaIs vilh chionic nedicaI condilions (ienaI disease and
Ieukenia) (KonofaI, 2OO7, MindeII, 2O1O).
RLS and ILMD have leen associaled vilh dayline synplons of ADHD. In a sludy of 143,
lvo lo eighleen yeai-oId chiIdien allending chiId psychialiy oi geneiaI pedialiic cIinics,
paienls indicaled ILMS nighl le ieIaled lo ADHD synplons (Cheivin, 1997). In a
queslionnaiie sludy of 83O chiIdien lvo lo lhiileen yeais of age, aloul 4 of paienls
endoised ILM synplons foi lheii chiIdien (Cheivin, 2OO1). Iicchielli and olheis Iooked al
lhe occuiience of ILMD foi chiIdien vilh oi vilhoul ADHD synplons. In lheii sludy, 26
of chiIdien vilh ADHD synplons had ILMD, conpaied lo 5 of chiIdien vho did nol
have ADHD synplons (Iicchielli, 1998). In a sludy conpaiing chiIdien iefeiied foi
cIinicaIIy defined ADHD veisus lvo olhei gioups, lhose idenlified as al iisk foi ADHD
fion a connunily suivey and chiIdien vilhoul ADHD, lhose vilh cIinicaIIy deleinined
ADHD had highei ILMs lhan lhe olhei gioups suggesling a giealei iisk foi noie aclive and
disiupled sIeep (Oiien, 2OO3). In addilion, in chiIdien vilh ADHD, seiun feiiilin Iess lhan
12 ng/nI vas noie pievaIenl in chiIdien vilh RLS synplons (Onei, 2OO7). Thus, RLS,
ILMS and ILMD appeai lo le ieIaled lo dayline ADHD synplons, hovevei, lul fuilhei
voik is needed lo cIaiify lhe ieIalionship and lhe ioIe of iion specificaIIy in lhe elioIogy and
nanagenenl.
4.3 Other sIeep disorders
In lhe foIIoving seclion, olhei sIeep disoideis aie desciiled lhal affecl sIeep quaIily and/oi
duialion lul have fevei sludies ieIaled lo dayline lehavioiaI consequences in chiIdien and
adoIescenls. This is foIIoved ly a seclion desciiling lhe consequences of insufficienl sIeep in
geneiaI.
4.3.1 BehavioraI insomnia of chiIdhood
ehavioiaI insonnia of chiIdhood, lhe difficuIly inilialing and/oi nainlaining sIeep due lo
a lehavioiaI elioIogy, is veiy connon, vilh a pievaIence of 1O-3O. Il is noie oflen
encounleied in young chiIdien (Mooie & MeIlzei, 2OO8). Theie aie 2 lypes of ehavioiaI
Insonnia of ChiIdhood: SIeep Onsel Associalion, and Linil Selling. SIeep Onsel Associalion


70
lype of lehavioiaI insonnia occuis vhen lhe onsel of sIeep is deIayed in lhe alsence of a
ceilain ilen oi ciicunslance. The chiId lecones dependenl upon ceilain condilions leing
piesenl duiing sIeep onsel, such as sucking on a pacifiei oi having anolhei peison cIose ly.
When lhe specific sIeep onsel condilions aie nel, sIeep onsel is quickIy achieved. Hovevei,
shouId lhe condilions nol le nel (i.e. lhe pacifiei is on lhe fIooi, oi nolhei is avay) al sIeep
onsel, lhen a sliuggIe aiound gelling lo sIeep nay occui. In addilion, vhen lhe chiId
expeiiences a noinaI pailiaI aiousaI duiing lhe nighl (connonIy eveiy 1-3 houis), lhe chiId
vho is used lo ceilain condilions al ledline viII have difficuIly ieluining lo sIeep if lhe
condilions aie no Iongei avaiIalIe. This ciicunslance of ehavioiaI Insonnia of ChiIdhood,
SIeep Onsel Associalion lype lypicaIIy iesuIls in a nighl vakening and paienl invoIvenenl
lo 'coiiecl oi ieluin lhe condilions foi gelling lo sIeep. ehavioiaI Insonnia of ChiIdhood,
Linil Selling lype occuis vhen lheie aie ledline sliuggIes. The chiId lypicaIIy slaIIs oi
iefuses lo go lo led ly iequesling lhings such as a gIass of valei, oi lo go lo lhe lalhioon.
When lhe caiegivei has lioulIe selling and nainlaining Iinils, lhe chiIds sIeep onsel is
deIayed as a consequence. Hovevei, vhen such Iinils aie sel consislenlIy, lhe chiId is alIe
lo sIeep quickIy. Many chiIdien have a nixluie of SIeep Onsel Associalion and Linil Selling
lypes. As chiIdien gel oIdei, lhey lypicaIIy have Iess difficuIly vilh SIeep Onsel Associalion
Insonnia as lhey aie lellei alIe lo gel lo sIeep on lheii ovn and ie-cieale lheii sIeep onsel
condilions and ieluin lo sIeep duiing lhe nighl. Duiing lhose sane deveIopnenlaI slages,
hovevei, chiIdien aie voiking lo lecone noie independenl and aie lesling Iinils sel ly
lheii caiegiveis. Oflen lhis can iesuIl in giealei difficuIlies vilh Linil Selling Insonnia vilh
age (Mooie & MeIlzei, 2OO8). Lilhei lype of lehavioiaI insonnia can affecl line lo sIeep
onsel, lhe conlinuily of nighlline sIeep and lhe oveiaII lolaI anounl of sIeep achieved and
lheiefoie, lhe iisk foi dayline liiedness and associaled sequeIae foi allenlion, Ieaining and
lehavioi.
4.3.2 DeIayed SIeep Onset in oIder chiIdren and adoIescents
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As chiIdien nove lovaid adoIescence, lhey lypicaIIy legin lo denonsliale a ciicadian
piefeience foi a Ialei (deIayed) sIeep phase. If lhe piefeience foi Iale sIeep phase lecones
piolIenalic and inleifeies vilh lhe dayline funclioning of lhe chiId oi adoIescenl, il is
iefeiied lo as having deIayed sIeep phase syndione (DSIS). DSIS is connon in
adoIescence vilh an eslinaled pievaIence of 1O (Mooie & MeIlzei, 2OO8). In DSIS, sIeep
onsel and vake lines aie inliaclalIy Ialei lhan sociaIIy acceplalIe (i.e., an adoIescenl vho
faIIs asIeep al 1an, and vakes al 1Oan aIlhough schooI slails al 8an), occui al
appioxinaleIy lhe sane line daiIy, and lheie is IillIe oi no difficuIly nainlaining sIeep aflei
sIeep onsel has occuiied. In DSIS, lhe lining of lhe sIeep-vake cycIe is lhe piolIen ialhei
lhan lhe quaIily of sIeep. Theie aie oflen conpIainls of 'insonnia vhen lhe chiId oi
adoIescenl allenpls lo go lo sIeep al an eaiIy line, hovevei nol vhen allenpling lo sIeep al
a Ialei, desiied line. TypicaIIy lhe chiId oi adoIescenl has a veiy difficuIl line vaking up al
a iequiied line, such as foi schooI, and has decieased aIeilness in lhe noining. This can
Iead lo fiequenl laidiness and/oi alsence fion schooI. The chiId oi adoIescenl fiequenlIy
allenpls lo 'calch-up on Iosl sIeep ly sIeeping in lo lhe Iale noining oi afleinoon on
veekends. DSIS can significanlIy shoilen sIeep duialion, incieasing lhe iisk foi dayline
liiedness and associaled sequeIae.


71
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Iiinaiy oi psychophysioIogicaI insonnia can aIso le iesponsilIe foi sIeep piolIens in
chiIdien and adoIescenls. Insonnia is lioadIy defined as difficuIly vilh onsel, nainlenance
oi non-iesloialive sIeep. The foIIoving consensus slalenenl has leen deveIoped lo noie
specificaIIy define pedialiic insonnia: 'iepealed difficuIly vilh sIeep inilialion, duialion,
consoIidalion oi quaIily lhal occuis despile age-appiopiiale line and oppoilunily foi sIeep
and iesuIls in dayline funclionaI inpaiinenl foi lhe chiId and/oi faniIy (MindeII, 2O1O).
Iiinaiy insonnia is chaiacleiized ly lension and Ieained sIeep-pievenling associalions.
ChiIdien and adoIescenls vilh piinaiy oi psychophysioIogicaI insonnia lend lo iespond lo
sliess vilh sonalic synplons, and vhiIe liying lo dovnpIay lhe sliess, end up incieasing
lhe sliessfuIness of lheii insonnia. Iiinaiy insonnia is iaie in pie-puleilaI chiIdien, lul
has a pievaIence of 9 lo 13 in adoIescenls (MindeII, 2O1O).
4.3.3 PartiaI arousaI parasomnias
IailiaI aiousaI paiasonnias aie lehaviois duiing sIeep lhal occui piinaiiIy ieIaled lo non-
RLM oi sIov vave sIeep. These incIude confusionaI aiousaIs, sIeep vaIking, and sIeep
leiiois. These pailiaI aiousaIs lypicaIIy occui vilhin a fev houis of sIeep onsel and aie
faiiIy connon in chiIdhood, vhen lhe peicenl of non-RLM sIeep is giealei conpaied lo
aduIlhood. IndividuaIs vilh such pailiaI aiousaI paiasonnias do nol iecaII lhe evenls lhal
occui duiing sIeep. IaniIy hisloiy appeais lo inciease lhe IikeIihood foi lolh sIeep vaIking
and sIeep leiiois if olhei faniIy nenleis aIso expeiienced il. ConfusionaI aiousaIs aie
episodes vheie individuaIs aie aioused lul disoiienled and nay nol fuIIy avaken foi up lo
3O ninules. These occui in al Ieasl 17 of chiIdien. SIeep vaIking on a ieguIai lasis is aIso
connon in chiIdhood, olseived in aloul 15 lo 2O. olh confusionaI aiousaIs and sIeep
vaIking lypicaIIy legin in lhe pieschooI yeais. ConfusionaI aiousaIs lend lo dissipale ly
eaiIy adoIescence, vheieas, foi aloul 2O of affecled individuaIs, sIeep vaIking peisisls
inlo aduIlhood. SIeep leiiois aie oflen noie significanl and disliessing lul piinaiiIy lo lhe
olseivei lecause lhe affecled chiId can appeai fiighlened and agilaled. SIeep leiiois occui
in aloul 1 lo 6 of chiIdien, vilh onsel lelveen pieschooI and pieleen yeais and lhey
lypicaIIy sulside ly adoIescence. These paiasonnias can le liiggeied ly inadequale oi
iiieguIai sIeep, iIIness, sliess and olhei sIeep piolIens such as SD oi ILMD. Iaienl and
chiId educalion aloul lhe disoideis, vhal lhey can do lo Iessen lhe iisks foi occuiience and
assuiing safely duiing episodes aie lhe nosl inpoilanl inleivenlions. These lehaviois do
nol disiupl sIeep conlinuily on lheii ovn and lheiefoie, unconpIicaled pailiaI aiousaI
paiasonnias aie nol lypicaIIy associaled vilh dayline lehavioiaI sequeIae Iike ADHD.
Hovevei, a 2OO6 sludy fion Taivan suggesled an associalion lased on paienlaI ialings
(Shui-Ien Cau, 2OO6). In geneiaI, lhe piesence of lhese paiasonnias nighl indicale anolhei
sIeep disoidei lhal has leen ieIaled lo ADHD synplons and nighl le lhe cIue lo Iook
fuilhei foi piolIens such as SD, ILMD, oi inadequale sIeep.
4.3.4 SIeep-reIated Rhythmic Movement Disorder
Rhylhnic novenenl disoidei (RMD) is connon in chiIdhood, usuaIIy having onsel in lhe
fiisl yeai of Iife and vaning ly eaiIy schooI age. This disoidei incIudes vaiious
conlinalions of novenenls of lhe head, Iinls, and liunk iesuIling in head iocking, head oi
lody ioIIing, and head langing, anong olheis and lypicaIIy occui on liansilion lo oi fion


72
sIeep oi duiing sIeep. Il is lypicaI foi lhe novenenls lo have a ieguIai, ihylhnic pallein. To
neel ciileiia foi RMD, lhe lehavioi nusl inleifeie vilh noinaI sIeep, inpaii dayline
funclioning oi cause lodiIy injuiy, and nol le due lo anolhei disoidei oi use of nedicalion.
Mosl individuaIs do nol iequiie liealnenl foi RMD as lhe iisk of injuiy is Iov and il
dissipales vilh age, hovevei, pioleclive suifaces nighl le needed foi noie significanl cases
(Holan, 2OO3). Case sludies have suggesled RMD in chiIdien vilh ADHD and ADHD in
chiIdien vilh RMD lul sludies lo dale aie snaII (WaIleis, 2OO8).
4.3.5 Night-time fears and nightmares
As chiIdien gel oIdei, nighlline feais and nighlnaies lecone noie fiequenl sIeeping
piolIens. Mosl chiIdien have nighlline feais, vilh peak ages fion 3-6 yeais foi lolh sexes,
and in giiIs al schooI-age (Mooie & MeIlzei, 2OO8). Nighlline feais aie usuaIIy shoil-Iived
deveIopnenlaI phenonena and quile lenign. Al lhe peak age of nighlline feais al
pieschooI-age, chiIdien aie leconing noie avaie of lhe consequences of lheii aclions and
lhal lhey can ieaIIy le huil oi affecled ly occuiiences aiound lhen (MindeII, 2O1O). TypicaI
nighlline feais change vilh deveIopnenlaI IeveI, vilh youngei chiIdien leing noie afiaid
of inaginaiy ciealuies such as nonsleis and oIdei chiIdien leing afiaid of noie ieaIislic
dangeis such as a naluiaI disaslei oi a luigIai. Nighlnaies aie aIso connon in chiIdhood,
vilh appioxinaleIy 75 of chiIdien expeiiencing al Ieasl one nighlnaie (Mooie & MeIlzei,
2OO8, MindeII, 2O1O). SiniIai lo nighlline feais, nighlnaies aie a noinaI pail of a chiIds
deveIopnenl, and lhe conlenl lends lo vaiy ly age. Young loddIeis voiiy aloul leing
sepaialed fion lheii paienls, and as chiIdien gel oIdei lhey incoipoiale inaginaiy and lhen
ieaIislic feais inlo lheii nighlnaies. Diffeienl fion nighlline feais, nighlnaies lypicaIIy
occui duiing RLM sIeep (usuaIIy in lhe Iasl lhiid of lhe sIeep peiiod vhen lheie is a giealei
peicenlage of RLM sIeep), and can le liiggeied ly sIeep depiivalion. olh nighlline feais
and nighlnaies can le liiggeied oi exaceilaled ly sliess and anxiely. Consequences of
nighlline feais oi nighlnaies incIude deIayed sIeep onsel and pioIonged nighl avakenings,
iespecliveIy and eilhei affecl lhe degiee lo vhich sIeep is iesloialive foi lhe affecled
individuaI.
4.3.6 Enuresis
SIeep enuiesis is anolhei possilIe cause of sIeep disluilance in chiIdien. UnconpIicaled oi
nonosynplonalic sIeep enuiesis is chaiacleiized ly iecuiienl, invoIunlaiy voiding
occuiiing duiing sIeep. Lnuiesis can occui in any slage of sIeep, aIlhough nosl occui in lhe
fiisl haIf of lhe nighl (MindeII, 2O1O). Il, loo, foIIovs lhe deveIopnenlaI liajecloiy of lhe
chiId, vilh a giealei piopoilion of youngei chiIdien expeiiencing sIeep enuiesis. The
najoiily of sIeep enuiesis episodes aie piinaiy sIeep enuiesis, in vhich lhe chiId has nol yel
deveIoped conlioI ovei voiding al nighl, and has nol had a succession of diy nighls. These
chiIdien lypicaIIy faiI lo iespond lo lhe sensalion of lIaddei fuIIness oi inhilil lIaddei
conliaclions duiing lhe nighl. Sponlaneous ienission of sIeep enuiesis is connon as
chiIdien age, lhe appioxinale ienission iale is 15 of affecled individuaIs pei yeai. The
cuiienl pievaIence eslinales aie 3O in 4-yeai-oIds, 1O of 6-yeai-oIds, 5 of 1O-yeai-oIds
and 3 of 12-yeai-oIds. SIeep enuiesis is lypicaIIy nol diagnosed unliI age 5, and nol liealed
unliI age 7 oi 8 yeais. Iiinaiy enuiesis is noie pievaIenl in chiIdien vilh a faniIy hisloiy of
sIeep enuiesis, and aIso, lhose vilh ADHD. Secondaiy enuiesis, in vhich lhe chiId


73
pieviousIy has had conlioI ovei lheii lIaddei al nighl (and has had a pievious diy peiiod of
al Ieasl 6 nonlhs) and lhen deveIops sIeep enuiesis, does nol occui as a pail of lypicaI
deveIopnenl, and usuaIIy iequiies fuilhei diagnoslic evaIualion. Il can le liiggeied ly
psychosociaI sliessois, nedicaI piolIens such as uiinaiy liacl infeclions, chionic
conslipalion, dialeles neIIilus, a neuioIogic disoidei, oi olhei sIeep disoideis, such as
olsliuclive sIeep apnea oi ILMD. ChiIdien vilh conpIicaled oi non-nonosynplonalic
sIeep enuiesis have day- and nighlline synplons.
5. Consequences of insufficient sIeep
As noled alove foi SD and RLS/ILMD, pooi sIeep can have a gieal inpacl on dayline
funclion of lhe chiId and olhei faniIy nenleis. AduIls vilh pooi sIeep lend lo appeai liied
duiing lhe day, yavning and faIIing asIeep easiIy in inappiopiiale sellings. Hovevei, lhe
synplons of sIeepiness in chiIdien aie oflen 'paiadoxicaI lehavioiaI nanifeslalions such as
enolionaI IaliIily, iiiilaliIily, neuiocognilive deficils and lehavioiaI inhililion. These
difficuIlies can cause piolIens al hone, in schooI and in olhei connunily sellings. MuIlipIe
paienlaI iepoils (and sone leachei iepoils) shov incieased incidence and seveiily of
lehavioiaI difficuIlies in chiIdien vilh sIeep piolIens lhan lhose vilhoul (IaIIone, 2OO2,
Sadeh, 2OO2). Moie seveie lehavioiaI piolIens have leen shovn in chiIdien vilh shoilei
sIeep duialion (IaIIone, 2OO2). Incieased sIeepiness oi decieased sIeep duialion vilhin lhe
pievious day have leen associaled vilh incieased iisk of accidenlaI injuiy in chiIdien fion
pieschooI-aged lhiough adoIescence (IaIIone, 2OO2). Insufficienl sIeep and/oi sIeepiness in
adoIescenls have leen associaled vilh incieased iisk-laking lehaviois (Mooie & MeIlzei,
2OO8). ChiIdien vilh lehavioi piolIens aie aIso noie IikeIy lo have sIeep piolIens ly
paienlaI iepoil (IaIIone, 2OO2). Sludies have shovn inpiovenenl in lhese lehavioiaI
piolIens vilh inpioved sIeep, hovevei, nol acioss aII sellings (IaIIone, 2OO2). Lovei
acadenic achievenenl has aIso leen associaled vilh pooi sIeep in chiIdien, vhen conpaied
lo chiIdien vilh uninpaiied sIeep (IaIIone, 2OO2). AddilionaIIy, adoIescenls vho iepoiled
pooi sIeep veie noie IikeIy lo iepoil sociaI piolIens as veII (Ovens, 2OO8). An associalion
lelveen acule sIeep iesliiclion and pooiei nenoiy oi Iovei IQ has nol leen found (IaIIone,
2OO2, Oiien, 2OO4). Hovevei, Iongei-lein sIeep disluilance has leen Iinked lo inpaiied
nenoiy and inleIIigence (Oiien, 2OO4).
ChiIdiens sIeep piolIens can aIso cause a significanl anounl of disliess in lhe faniIy. The
inpacl of chiIdhood sIeep piolIens is ieIaled lo lhe paienls sIeep, especiaIIy if lhe paienls
pooi sIeep Ieads lo dayline faligue oi nood piolIens (Oiien, 2OO4). AIleinaliveIy,
inpioving lhe chiIds sIeep, and ly exlension lhal of lhe iesl of lhe faniIy, can inpiove lhe
funclioning of aII faniIy nenleis invoIved.
6. SIeep in chiIdren with ADHD
As noled pieviousIy in lhis chaplei, sIeep difficuIlies veie pail of lhe diagnoslic ciileiia foi
ADHD in pievious veisions of lhe Diagnoslic SlalislicaI ManuaI, indicaling a Iong-slanding
leIief lhal sIeep is piolIenalic in chiIdien vilh ADHD. Hovevei, aIlhough lhe ieIalionship
lelveen sIeep and ADHD has leen sludied exlensiveIy ovei lhe pasl fev decades veiy fev
oljeclive diffeiences have leen found lelveen lhe sIeep of chiIdien vilh ADHD and
chiIdien vilhoul ADHD. Yel, nany suljeclive diffeiences have leen uncoveied.


74
6.1 SIeep and ADHD: subjective differences
Theie is IillIe disagieenenl in lhe Iileialuie lhal paienls of chiIdien vilh ADHD iepoil
pooiei sIeep foi lheii chiIdien lhan paienls of chiIdien vilhoul ADHD. Oiien el. aI found
lhal 77 of chiIdien vilh significanl synplons of ADHD, and 7O of chiIdien vilh niId
synplons of ADHD veie iepoiled lo have sIeep disluilances vhiIe onIy 43 of chiIdien
vilhoul ADHD synplons veie iepoiled lo have sIeep piolIens (Oiien, 2OO3). Iaienls of
chiIdien vilh ADHD iepoil noie of lhe foIIoving lhan paienls of chiIdien vilhoul ADHD:
ledline iesislance, sIeep-onsel deIay, anxiely, paiasonnias, nighl vakings, dayline
sIeepiness, and shoilei duialion of sIeep (Ovens, 2OOO, Coikun, 2OO1, Oiien, 2OO3,
SiIveslii el aI., 2OO9, Ciulei, 2OO9). Iaienls aIso iepoil noie snoiing in chiIdien vilh ADHD
conpaied vilh conlioIs (Coilese, 2OO9). ChiIdien vilh and vilhoul ADHD lend lo have
noining aiousaI al lhe sane line, lul chiIdien vilh ADHD have a shoilei iepoiled sIeep
duialion lhoughl lo le due lo deIayed sIeep onsel (Ovens, 2OO5).
Theie aie seveiaI possilIe expIanalions foi lhese incieased suljeclive conpIainls in chiIdien
vilh ADHD. One hypolhesis suggesls lhal sone of lhese aie nol sIeeping piolIens pei se,
ialhei, lehavioiaI piolIens in lhe conlexl of a difficuIl paienl-chiId ieIalionship (Coilese,
2OO9, Coikun, 2OO1). Anolhei hypolhesis is lhal faniIies of chiIdien vilh ADHD aie noie
IikeIy lo have pooi sIeep hygiene (i.e., ledline ioulines, sIeeping enviionnenl), Ieading lo
noie difficuIlies al ledline (Coilese, 2OO9). AIleinaliveIy, chiIdien vilh ADHD nay have
synplons lhioughoul lhe day and evening, vhich cieales ledline difficuIlies even in lhe
appiopiiale enviionnenl (Coilese, 2OO9, Ciulei, 2OO9). Sone chiIdien vilh ADHD nay
have a disoidei of lheii sIeep-vake scheduIe (i.e., deIayed sIeep phase syndione oi olhei
disoidei of ciicadian ihylhn), and aienl alIe lo faII asIeep vhen lhey aie expecled lo,
vhich can Iead lo ledline iesislance (Ciulei, 2OO9). ChiIdien vilh ADHD nay aIso have
co-noilid psychialiic disoideis vhich conliilule lo ledline difficuIlies (see leIov). Ovens
el. aI found lhal paienls of chiIdien vilh ADHD iecognize sIeep-onsel difficuIlies as
diffeienl fion ledline iefusaI. Olhei sludies have diavn siniIai concIusions, paienls aie
alIe lo iecognize lhe diffeience lelveen unviIIingness and inaliIily lo sIeep (Iadei el aI.,
1997). SlinuIanl nedicalion is fiequenlIy used lo lieal ADHD in chiIdien and nay have
effecls on lheii sIeep. This viII le addiessed in a Ialei seclion of lhis chaplei.
6.2 SIeep and ADHD: objective differences
Theie is IillIe agieenenl in lhe Iileialuie iegaiding oljeclive diffeiences in sIeep in chiIdien
vilh ADHD. SIeep in chiIdien vilh ADHD has leen fiequenlIy sludied lul vilh snaII
popuIalions, and vilh confIicling iesuIls. Highei iales of olsliuclive sIeep apnea (highei
apnea-hypopnea index) have leen found in chiIdien vilh ADHD (Oiien, 2OO3, Coilese,
2OO9, CoIan, 2OO4). ChiIdien vilh niId synplons of ADHD aie noie IikeIy lo have
olsliuclive sIeep apnea lhan lhose vilh significanl oi no synplons (Oiien, 2OO3).
ChiIdien vilh ADHD have aIso leen found lo have an incieased RLM Ialency and snaIIei
peicenlage of sIeep spenl in RLM (Oiien, 2OO3, 2OO3, SiIveslii el aI., 2OO9, usly, 1981).
Oiien el aI found a posilive coiieIalion lelveen Ienglh of RLM Ialency and inpuIsivily,
inallenlion, cognilion and hypeiaclive lehaviois, and a negalive coiieIalion lelveen RLM
Ialency and allenlion and execulive funclioning (Oiien, 2OO3). Yel, olhei sludies have
shovn an inciease in peicenlage of RLM sIeep in chiIdien vilh ADHD (CoIan, 2OO4) oi
decieased RLM Ialency (Khan, 1982, Kiiov el aI., 2OO4), and sliII olheis have shovn no
diffeiences in RLM Ialency oi peicenlage (CoIan, 2OO4, Coilese, 2OO9). Incieased peiiodic


75
Iinl novenenls have leen discoveied in chiIdien vilh ADHD (usly, 1981, Oiien, 2OO3,
SiIveslii el aI., 2OO9). Olheis have found decieased sIeep efficiency, incieased aiousaI index
and incieased dayline sIeepiness in chiIdien vilh ADHD (Coiaya el aI., 2OO9, Coilese, 2OO9,
Oiien, 2OO3, SiIveslii el aI., 2OO9, Ciulei, 2OO9, CoIan, 2OO4). The hypeiaclivily in chiIdien
vilh ADHD has leen hypolhesized as a conpensaloiy nechanisn foi lhe incieased
dayline sIeepiness ieIaled lo pooi duialion and/oi quaIily sIeep. Despile lhese nany
sludies, lheie is nuch noie lo le discoveied conceining lhe sIeep of chiIdien vilh ADHD.
One lheoiy vhich addiesses lhese confIicling diffeiences in lhe sIeep of chiIdien vilh
ADHD is lhal lheie aie diffeienl sulsels of ADHD, sone of vhich aie associaled vilh noie
sIeeping piolIens. Oiien el. aI conpaied lhe sIeep of chiIdien vilh ADHD iefeiied lo
lheii sIeep cIinic, chiIdien vilh ADHD synplons fion lhe connunily and chiIdien
vilhoul ADHD, and found lhal vhiIe aII chiIdien vilh ADHD had sone diffeiences
conpaied lo lhe conlioIs, lhe chiIdien vho veie iefeiied aIso had giealei nighlnaies,
enuiesis and vilnessed apneas conpaied lo lhe chiIdien vilh ADHD synplons fion lhe
connunily gioup (Oiien, 2OO3). They pioposed lhal lhe chiIdien vho veie iefeiied
iepiesenl a diffeienl sulsel of chiIdien vilh ADHD. AddilionaIIy, diffeiences have leen
found, in sone cases, lelveen lhe sIeep of chiIdien vilh ADHD inallenlive sullype and
conlined sullype, vilh noie diffeiences in sIeeping palleins found lelveen chiIdien vilh
conlined sullype ADHD and lypicaIIy deveIoping chiIdien (Ciulei, 2OO9, Mayes, 2OO9).
Co-noilid psychialiic disoideis aie connon in chiIdien vilh ADHD, and aie lhoughl lo
conliilule lo piolIens vilh sIeep. ChiIdien vilh ADHD and anxiely oi depiession veie
found lo have noie sIeeping piolIens lhan lhose vilhoul, aIlhough chiIdien vilh co-
noilid opposilionaI defianl disoidei (ODD) veie nol found lo have incieased sIeeping
piolIens (Mayes, 2OO9). SIeep piolIens have leen shovn lo have a veakei ieIalionship
vilh ADHD aflei conlioIIing foi co-noilid anxiely, depiession oi disiuplive lehavioi
disoideis (Mick, 2OOO). Hovevei, sone of lhe sludies pieviousIy discussed in lhis seclion
found diffeiences in sIeep in chiIdien vilh ADHD vilhoul co-noilid psychialiic disoideis
conpaied lo lypicaIIy deveIoping chiIdien.
7. MedicaI treatment for ADHD and sIeep probIems
7.1 PsychostimuIant medications for ADHD and effects on sIeep
IsychoslinuIanl nedicalion, lhe fiisl-Iine liealnenl foi ADHD, has oflen leen ciled as
causing sIeeping disluilances in lhis popuIalion. Hovevei, as discussed in pievious
seclions, lheie is a conpIicaled ieIalionship lelveen ADHD and sIeep. Sone have
suggesled lhal slinuIanl nedicalion causes sIeep disluilances in chiIdien and adoIescenls
vilh ADHD. Sone sludies of slinuIanl nedicalion have suppoiled lhis, lul olheis have
shovn no change oi inpiovenenls in sIeep in chiIdien and adoIescenls liealed vilh
psychoslinuIanl nedicalion, (CaIIand el aI., 2O1O, Mick, 2OOO, aikIey el aI., 199O, Cioidani,
2OO8, Oiien, 2OO3, Kin, 2O1O, CilIin & SlioleI, 2O1O).
Regaiding sludies vheie lhe use of psychoslinuIanl nedicalion has leen associaled vilh
pooi sIeep, in a sludy ly Mick el. aI, lheie vas a liend lovaids chiIdien vilh ADHD having
noie sIeep disoideis and vhen nuIlipIe confounding vaiialIes veie accounled foi, lhey
found a ieIalionship lelveen lhe use of slinuIanl nedicalion and pooi sIeep (Mick, 2OOO).
ChiIdien vilh ADHD liealed vilh psychoslinuIanl nedicalion veie noie IikeIy lhan


76
conlioIs lo le iepoiled as a ieslIess sIeepei, vaking duiing lhe nighl, laIking in lheii sIeep,
afiaid of sIeeping in lhe daik and going lo lhe lalhioon duiing lhe nighl (Mick, 2OOO).
Iaienls have aIso iepoiled noie difficuIly vilh insonnia in chiIdien vilh ADHD liealed
vilh psychoslinuIanls (aikIey el aI., 199O). SeveiaI oljeclive sludies have aIso shovn
changes in sIeep vilh psychoslinuIanl nedicalion. LLC sludies have shovn incieased RLM
onsel Ialency and of slage 1 and 2 sIeep vilh a iesuIlanl deciease in line spenl in RLM and
slage 3 sIeep aflei nocluinaI adninislialion of a psychoslinuIanl (Chalooi, 1983).
IoIysonnogiaphy sludies shoved no significanl diffeience in sIeep lining, duialion oi
efficacy lelveen chiIdien vilh ADHD off of nedicalion foi 48 houis and conlioI chiIdien
(CaIIand el aI., 2O1O). Hovevei, vhen lhe chiIdien vilh ADHD had laken lheii dose of
psychoslinuIanl nedicalion, lhey had a Iongei sIeep Ialency and voke eaiIiei in lhe
noining, iesuIling in a shoilei sIeep duialion in conpaiison lo conlioI chiIdien (CaIIand el
aI., 2O1O). SIeep aichilecluie vas nol aIleied ly lhe nedicalion (CaIIand el aI., 2O1O). CaIIand
el. aI olseived lhal lheii sludy, and olheis lhal had found incieased sIeep onsel Ialency on
psychoslinuIanl liealnenl, veie designed such lhal lhe conpaiisons lelveen
nelhyIphenidale and pIacelo veie vilhin-suljecl. They posluIale lhal lhis nay indicale
lhal lhe individuaI diffeiences of lhe effecls of psychoslinuIanl nedicalion on sIeep nay le
noie inpoilanl lhan Iaigei gioup diffeiences (CaIIand el aI., 2O1O).
Anolhei hypolhesized facloi is lhal lhe incieased iepoiled difficuIlies vilh sIeep in chiIdien
vilh ADHD liealed vilh psychoslinuIanl nedicalion nay le lhe iesuIl of lhe
psychoslinuIanl nedicalion veaiing off and/oi causing a 'ielound effecl. This ielound
effecl can Iead lo an appaienl incieased aiousaI and hypeiaclivily. This Ied lo lhe idea lhal
sone chiIdien nay lenefil fion an addilionaI Iale afleinoon oi eaiIy evening dose of
psychoslinuIanl nedicalion. An addilionaI Iale afleinoon (4pn) dose vas shovn lo
inpiove lehavioi in 12 psychialiicaIIy hospilaIized chiIdien vilh ADHD (Kenl el aI., 1995).
Lov-dose (1Ong) and high-dose (15ng) nelhyIphenidale and pIacelo veie given al 4pn,
vilh IillIe effecl on lhe sIeep onsel in lhe chiIdien (Kenl el aI., 1995). When ieceiving lhe
high-dose nelhyIphenidale, chiIdien did have an incieased sIeep onsel Ialency (Kenl el aI.,
1995). NolalIy, lhe incieased sIeep onsel Ialency in chiIdien on lhe highei dose of
nelhyIphenidale vas siniIai lo lhal of chiIdien on lhe pIacelo (Kenl el aI., 1995). A siniIai
sludy lesled lhe effecl of lvice-daiIy dosing lo lhiice-daiIy dosing of nelhyIphenidale in
chiIdien vilh ADHD, and found lhal lheie veie no diffeiences in sIeep duialion lelveen
lhe lvo dosing ieginens (Slein, 2OO1). Hovevei, lheie vas a liend lovaid decieased sIeep
duialion in lhe lhiice-daiIy dosing conpaied lo pIacelo on paienlaI ialings and acligiaphic
neasuienenls (Slein, 2OO1). SIeep onsel Ialency did nol diffei significanlIy acioss lhe dosing
piolocoIs (incIuding pIacelo) (Slein, 2OO1).
Olhei iecenl sludies, have confiined lhe ieIalionship of ADHD vilh pooi sIeep, lul
denonslialed IillIe associalion psychoslinuIanl nedicalion lo pooiei sIeep in chiIdien vilh
ADHD. ChiIdien vilh ADHD veie found lo have noie sIeep disluilances lhan lhose
vilhoul ADHD, iiiespeclive of lheii nedicalion slalus (Oiien, 2OO3). The use of
psychoslinuIanl nedicalion vas nol found lo have an associalion vilh pooi sIeep (Oiien,
2OO3). ChiIdien vilh ADHD liealed vilh psychoslinuIanl nedicalion lended lo have Iongei
RLM onsel Ialency, hovevei lhis did nol ieach slalislicaI significance (Oiien, 2OO3).
Incieased sIeep disluilances have nol leen found in chiIdien liealed vilh suslained ieIease
piepaialions of psychoslinuIanls (Kin, 2O1O, CilIin & SlioleI, 2O1O). Osnolic-conlioIIed


77
ieIease oiaI deIiveiy syslen (OROS) nelhyIphenidale vas found lo deciease lhe nunlei of
nighl aiousaIs (paiasonnias) in chiIdien vilh ADHD, lul nol aIlei sIeep onsel Ialency on
eilhei suljeclive oi oljeclive neasuies (Kin, 2O1O) . Hovevei, chiIdien vho iepoiled
suljeclive sIeep difficuIlies duiing liealnenl vilh OROS nelhyIphenidale had incieased
sIeep onsel Ialency, sIeep onsel deIay and ledline iesislance vhen conpaied lo lhose
vilhoul suljeclive sIeep conpIainls. This again, nay indicale lhal lhe individuaIs iesponse
lo slinuIanl nedicalion nay le lhe nosl inpoilanl facloi (Kin, 2O1O). Lisdexanfelanine
vas aIso shovn lo deciease nighlline aiousaIs, and did nol negaliveIy inpacl sIeep in
chiIdien vilh ADHD (CilIin & SlioleI 2O1O). The decieased nighlline aiousaIs nay suggesl
noie consoIidaled sIeep in chiIdien liealed vilh psychoslinuIanls.
Theiefoie, lhe use of psychoslinuIanl nedicalions has leen associaled vilh pooi sIeep in
chiIdien vilh ADHD in sone sludies, hovevei lhe exacl ieIalionship ienains uncIeai.
IndividuaIs vilh sIeep conpIainls vhiIe on psychoslinuIanl nedicalions have leen noled
lo have incieased sIeep disluilance. Ieihaps il is lesl lo considei each palienl individuaIIy
vhen assessing foi adveise effecls of liealnenl. Il nay le lhal foi lhe najoiily of palienls,
liealnenl vilh psychoslinuIanl nedicalion does nol inleifeie vilh sIeep, lul in lhose
iepoiling voise sIeep, lhe nedicalion does pIay a ioIe in sIeep disluilances.
7.2 Non-psychostimuIant Medications for ADHD and effects on sIeep
In 2OO2, lhe US Iood & Diug Adninislialion (IDA) appioved lhe non-slinuIanl,
alonoxeline foi use in chiIdien vilh ADHD. Ciealei cIinicaI inpiovenenl is lypicaIIy
allained vilh psychoslinuIanl nedicalion, hovevei alonoxeline can le good aIleinalive
nedicalion lo use vhen a psychoslinuIanl nedicalion is nol loIeialed oi cannol le used
(Nevcoin el aI., 2OO8). When conpaied vilh lhiice-daiIy dosing of nelhyIphenidale, lvice-
daiIy alonoxeline vas found lo have decieased sIeep onsel Ialency, and incieased sIeep
duialion (SangaI, 2OO4). Tiealnenl vilh lvice-daiIy alonoxeline and lhiice-daiIy
nelhyIphenidale iesuIled in decieased inleiiupled sIeep, hovevei, liealnenl vilh
nelhyIphenidale Ied lo a Iaigei deciease in inleiiupled sIeep (SangaI, 2OO4). ChiIdien
iepoiled an easiei line avakening in lhe noinings and faIIing asIeep al nighl vhiIe laking
alonoxeline (SangaI, 2OO4). The nosl connon sIeep-ieIaled adveise effecl iepoiled fion
alonoxeline is sonnoIence (KialochviI el aI., 2O11, Cheng el aI., 2OO7, Nevcoin el aI., 2OO8).
AIpha-agonisls such a cIonidine and guanfacine have leen used lo lieal lolh lhe lehavioiaI
and sIeep piolIens of ADHD. CIonidine has leen heIpfuI in liealing sIeeping piolIens in
chiIdien vilh ADHD (IIizka, 2OO7). TiiaIs of Iong acling cIonidine (vilh and vilhoul lhe use
of psychoslinuIanls) have shovn lhal sonnoIence and/oi faligue aie lhe najoi sIeep-
ieIaled adveise effecl of liealnenl (iedeinan el aI., 2OO8, KoIIins el aI., 2O11). Hovevei,
iedeinan el. aI shoved lhal lhis is usuaIIy a liansienl effecl (iedeinan el aI., 2OO8).
7.3 Medications for sIeep probIems in chiIdren with ADHD
As discussed exlensiveIy in lhis chaplei, sIeeping disluilances aie fiequenlIy associaled
vilh ADHD. Sone of lhese sIeep disluilances can le ieIaled lo analonic disoideis, such as
sIeep-disoideied liealhing oi peihaps an adveise effecl of psychoslinuIanl nedicalion.
Hovevei, in nany cases, a nodifialIe cause is nol idenlified lhal iesuIls in a nedicaI
liealnenl foi lhe sIeep disluilance. In facl, a Iaige NelheiIands sludy of chiIdien vilh


78
ADHD on slinuIanl nedicalion found lhal ovei 1O of lhe chiIdien veie laking neIalonin,
piesunalIy foi sIeep piolIens (Ialei el aI., 2OO6). MeIalonin has leen shovn lo deciease
sIeep onsel Ialency in chiIdien vilh ADHD (nol on nedicalion) vilh chionic sIeep-onsel
insonnia (Van dei Heijden el aI., 2OO6). Despile lhis inpioved sIeep onsel Ialency, lheie vas
nol significanl effecl (posilive oi negalive) on lhe chiIdiens lehavioi, cognilion oi quaIily of
Iife (Van dei Heijden el aI., 2OO6). In foIIov-up of lhis sludy, appioxinaleIy 3 yeais Ialei, lhe
najoiily of chiIdien ienained on neIalonin, and lheii paienls lhoughl il vas an effeclive
liealnenl (Hoeleil el aI., 2OO9). Iaienls iepoiled lhal lhe neIalonin inpioved lheii
chiIdiens dayline lehavioi (Hoeleil el aI., 2OO9). A Iileialuie ieviev confiined lhal
chiIdien vilh ADHD and insonnia shoved inpiovenenl in iegaids lo sIeep onsel Ialency
vhen laking neIalonin (endz & Scales, 2O1O). Hovevei, lhese iesuIls aie Iiniled as lheie
aie fev sludies, and nosl of lhen have snaII sanpIe sizes. ZoIpiden has aIso leen
evaIualed foi liealing sIeep disluilances in chiIdien and adoIescenls vilh ADHD (Iunei el
aI., 2OO9). ZoIpiden did nol deciease sIeep onsel Ialency, noi inpiove sIeep efficiency oi
nocluinaI avakenings (Iunei el aI., 2OO9). Theie vas a liend lovaid inpioving lehavioiaI
synplons, pailicuIaiIy in lhe adoIescenls, hovevei, lhis did nol ieach slalislicaI significance
(Iunei el aI., 2OO9).
8. CIinicaI appIication
In lhis seclion, ve desciile lvo cIinicaI cases exanpIes vheie ADHD evaIualion nighl le
conpIicaled ly sIeep conceins. The puipose is lo highIighl seveiaI concepls iegaiding
deveIopnenl and sIeep.
8.1 Younger chiId
AIex, a 7-yeai-oId loy, piesenled lo his piinaiy caie physicians office vilh his nolhei due
lo piolIenalic lehavioi al schooI. His nolhei noles lhal hes aIvays leen a lusy and aclive
chiId. Ovei lhe pasl fev yeais, shes had sone difficuIly vilh his lehavioi al hone, noling
lhal he had fiequenl lenpei lanliuns as a loddIei and pieschooI-aged chiId, lul lhe paienls
lhoughl his lehavioi vas nanagealIe. Hovevei, Iasl yeai in kindeigailen AIexs leachei
aIso expiessed concein aloul his lehavioi and lhis has incieased vilh his fiisl giade leachei
lhis yeai. He has leen having difficuIly slaying sealed vilh lhe iesl of his cIass duiing sloiy
line and vilh slaying in Iine vilh his cIass vhen lhey Ieave lhe cIassioon. He has aIso
iecenlIy hil a cIassnale ovei a ninoi disagieenenl. He lypicaIIy gels aIong vilh olhei
chiIdien, and nolhei noles lhal he has lvo lesl fiiends, vilh vhon he Iikes lo iide likes.
Theie vas no hisloiy of piolIens al liilh oi vilh deveIopnenl. He has no chionic nedicaI
conceins, has nol had hospilaIizalion oi suigeiy and has nol had significanl injuiies. He is
invoIved in oy Scouls and spoils oulside of schooI.
On ieviev of syslens, AIexs nolhei noles lhal his sIeep scheduIe is lypicaIIy unifoin
lhioughoul lhe veek. He goes lo led aiound 8 IM on veeknighls, and vakes up al 7 AM
foi schooI. On lhe veekends, he lends lo go lo led aiound 8:3O IM, and vakes al 7 AM on
his ovn. He lends lo faII asIeep appioxinaleIy 3O-45 ninules aflei his ledline. He does nol
appeai liied in lhe noining oi lhioughoul lhe day, and does nol nap, noi faII asIeep
uninlenlionaIIy. His nolhei does sliuggIe lo pul hin lo led nosl nighls, noling lhal he
seens lo do anylhing lo avoid sIeeping. He fiequenlIy asks foi anolhei sloiy, and gIass of
valei. AIexs nolhei aIso noles lhal he snoies quile IoudIy, she can heai hin snoiing fion


79
hei ledioon vhen his dooi is cIosed. She hasnl noled any pauses in liealhing. He sveals
duiing sIeep fiequenlIy, iequiiing his nolhei lo change lhe sheels duiing lhe nighl
appioxinaleIy once a veek. He has leen diy al nighl foi lhe pasl lhiee nonlhs, and piioi lo
lhal he had sIeep enuiesis appioxinaleIy once eveiy lvo veeks. AIexs nolhei and oIdei
liolhei have ADHD, and his naleinaI giandfalhei vas iecenlIy diagnosed vilh olsliuclive
sIeep apnea. He does nol have any faniIy hisloiy of Ieaining disaliIily oi nood disoidei.
His physicaI exan vas nolalIe foi noulh liealhing and 3+ lonsiIs.
AIexs sIeep conceins iaise queslions aloul nuIlipIe sIeep piolIens. One such piolIen is
sIeep disoideied liealhing, connon in eaiIy schooI-age chiIdien. AIex is al a peak age foi
incieased Iynphoid hypeiliophy, vhich can cause a ieIalive naiioving of lhe aiivay
duiing sIeep. His ledline iesislance couId suggesl lehavioiaI insonnia of chiIdhood, Iinil
selling lype, vilh inadequale Iinil-selling ly his nolhei oi his negalive lehavioi nay le
lhe iesuIl of liiedness nade voise ly lhe pooi quaIily sIeep due lo sIeep disoideied
liealhing. AIexs duialion of sIeep is IikeIy appiopiiale foi his age, hovevei lhe quaIily is
IikeIy disluiled and affecling his dayline funclioning.
To evaIuale fuilhei, an oveinighl poIysonnogiaphy vas peifoined, vhich denonslialed
olsliuclive sIeep apnea. Conneis ialing scaIes fion lolh paienls and his fiisl giade leachei
endoised piolIens vilh allenlion, hypeiaclivily and inpuIsivily foi age and gendei.
AIex vas evaIualed ly a pedialiic oloIaiyngoIogisl vho ieconnended an adenolonsiIIeclony,
vhich vas sulsequenlIy peifoined. Thiee nonlhs aflei his suigeiy, AIexs nolhei noled
significanl inpiovenenls in his snoiing, nov onIy infiequenlIy and lhal he no Iongei sveals
al nighl, and has ienained diy oveinighl. Hovevei, he has ienained veiy aclive and 'on lhe
go and vhiIe his lehavioi piolIens al schooI had inpioved sonevhal, he conlinued lo have
difficuIlies. His piinaiy physician inilialed a liiaI of shoil-acling slinuIanl nedicalion, lo
vhich AIex iesponded quile veII. AIexs piesenling conceins seened lo le ieIaled lo lolh his
sIeep piolIens and undeiIying ADHD.
8.2 EarIy adoIescent
Susie, a 13-yeai-oId fenaIe, piesenls lo hei piinaiy docloi acconpanied ly hei nolhei foi
conceins iegaiding pooi schooI peifoinance. Molhei slales Susie has had Iongei lein
conceins aloul leing fidgely and disliaclilIe lul had aIvays leen alIe lo keep pace vilh
hei peeis unliI 7lh giade. Theie veie no acadenic conceins in eIenenlaiy schooI and giades
conlinued lo le adequale, aIlhough in ieliospecl, diifled dovnvaid in 6lh giade. In 7lh
giade she had noie lioulIe, she foigol lo luin in assignnenls, seened disoiganized and
didnl foIIov lhiough on diieclions al schooI, as veII as, al hone. In 8lh giade lhis yeai, she
is cIose lo faiIing. Teacheis slale hei lesl peifoinance has leen good, lul lhe fiequenlIy
nissing assignnenls and IillIe engagenenl in cIassioon discussions have puIIed dovn hei
giades. In addilion, lhey iepoil she has leen pione lo napping in lhe fiisl-houi nalh cIass.
Theie is no hisloiy of piolIens al liilh oi vilh deveIopnenl. She has no chionic nedicaI
conceins and has nol had significanl injuiies. She slailed nenses al aloul 1O yeais of age.
She is aclive vilh spoils and nusic foi schooI, pailicipaling in svinning and pIaying ceIIo
lhioughoul lhe yeai. Hei gioup of fiiends has leen slalIe. She desciiles a veiy lusy schooI
scheduIe and lhal she is conceined aloul doing veII.


80
On ieviev of syslens, Susie slales lhal on veekends, she lypicaIIy goes lo sIeep aloul
nidnighl and viII gel up aloul 1O lo 11 AM on hei ovn. Duiing lhe schooI veek, she liies
lo go lo led al 1O IM lul canl gel lo sIeep foi houis. She needs lo le up ly 6 AM foi
schooI. She desciiles feeIing unconfoilalIe al sIeep onsel due lo hei Iegs feeIing ieslIess and
lhinking aloul lhe nexl schooI day. Molhei has nol had conceins aloul Susie snoiing noi
noulh liealhing in lhe pasl. She iecenlIy sIepl in lhe sane ioon on a vacalion and did nol
heai audilIe noulh liealhing lul did nolice lhal Susie seened lo loss a luin quile a lil
duiing sIeep. Susie had occasionaI sIeep vaIking vhen youngei lul nol in lhe Iasl foui
yeais. Susie and hei faniIy aie vegelaiian and she doesnl usuaIIy lake vilanins. IaleinaI
faniIy nenleis have had ADHD and ieslIess Iegs lul no hisloiy of Ieaining disaliIily,
anxiely oi sIeep disoideied liealhing. Theie veie no significanl physicaI exan findings.
Susies sIeep conceins iaise a queslion aloul seveiaI sIeep piolIens. One is deIayed sIeep
phase syndione, a connon lendency anong adoIescenls foi lhe sIeep-vake scheduIe lo
diifl Ialei. Susies Ialei sIeep-vake cycIe, vhen coupIed vilh hei schooI scheduIe, incieases
lhe iisk foi piolIens vilh sIeep inilialion and gelling up in line foi schooI. Hei ieslIessness
al ledline and lhiough lhe nighl, as veII as lhe sensalions al lhe Iovei exlienilies al
ledline suggesl ieslIess Iegs syndione. She is al iisk foi iion deficiency, associaled vilh
RLS/ILMD, due lo lhe Iess dielaiy iion, giovlh due lo adoIescence and Iosses due lo eaiIy
nenaiche. In addilion, Susies voiiies aloul doing veII nay add lo hei iisk foi insonnia.
AIlogelhei, Susies duialion and quaIily of sIeep aie IikeIy disluiled and in luin, affecling
dayline funclioning lhiough polenliaIIy diiecl effecls ieIaled lo RLS and indiieclIy lhiough
chionic sIeep depiivalion. Hei dayline sIeepiness is an indicalion lhal lhe sIeep she is
gelling isnl enough. The paienl has had a Iong-slanding concein aloul sone ADHD
synplons lul lhe onsel is Ialei lhan lypicaI.
To evaIuale Susie fuilhei, a sIeep Iog vas ollained lo assess sIeep duialion and lhe slaliIily
of sIeep-vake pallein. Iion sludies veie ollained and shoved a seiun feiiilin of 1O,
loideiIine Iov seiun iion lul no anenia. Conneis ialing scaIes fion lolh paienls and lvo
leacheis endoised piolIens vilh allenlion and execulive funclioning lul aII olhei scaIes
(incIuding hypeiaclive-inpuIsive donains) veie vilhin noinaI Iinils foi age and gendei.
Susie vas ieconnended lo legin an iion suppIenenl foi lhe niId iion deficiency. In
addilion, Susie voiked vilh lhe docloi lo ieguIaiize hei sIeep-vake scheduIe lelveen
veekday and veekend. Susie aIso adjusled hei dayline scheduIe so lhal she feIl lellei alIe
lo neel hei connilnenls foi schooI, honevoik, piaclice lines and fiiends. Aflei lhiee lo
foui nonlhs, iepeal iion sludies shoved coiieclion of iion slalus and inpioved RLS
synplons. She vas adheiing lo lhe nev scheduIe and gelling lo sIeep noie easiIy. Conneis
ialing scaIes and inleiviev al foIIov up did nol endoise ADHD conceins and leacheis
iepoiled inpioved schooI peifoinance. Taken logelhei, Susies piesenling conceins seened
noie IikeIy ieIaled lo sIeep piolIens lhan ADHD al lhis line, lul Iongei lein foIIov up
vas ieconnended lo assuie she ienained on liack.
9. ConcIusion
In lhis chaplei, ve have ievieved lhe ieIalionship lelveen ADHD and sIeep disoideis vilh
lhe puipose of highIighling lhe inpoilance of evaIualing sIeep piolIens vhen chiIdien and
adoIescenls piesenl foi evaIualion of ADHD. Sludies have suggesled lhal nany


81
piaclilioneis do nol ioulineIy scieen foi sIeep piolIens in geneiaI oi foi specific condilions
Iike SD in pailicuIai (Cheivin, 2OOO, Cheivin, 2OO1, Iunden, 2OO4). In one sludy in a
geneiaI pedialiic cIinic, 83O paienls of chiIdien ages lvo lo lhiileen yeais of age conpIeled
lhe Iedialiic SIeep Queslionnaiie (ISQ), a vaIidaled suivey of a nunlei of nedicaI and
lehavioiaI piolIens of sIeep in chiIdien (Cheivin, 2OOO). The paienls of 86 chiIdien
endoised a sIeep piolIen foi lheii chiId and 44 of lhen (aloul 5 of lhe lolaI nunlei)
endoised synplons of sIeep disoideied liealhing. On a ieliospeclive chail ieviev of lhese
chiIdien, Iess lhan 11 (5 of 44) had docunenlalion lhal lhe synplons veie discussed
(Cheivin, 2OO1). Olhei sludies have aIso caIIed allenlion lo lhe inpoilance of scieening
aloul sIeep piolIens in piinaiy caie sellings (Iunden, 2OO4, IaIIone, 2OO2).

94,,)(3:.3(16044)
;$<= +(*31>
-6044)<*8(,
;?<%$ +(*31>
@,4)(16(2A
;%#<%B +(*31>
1. Cedline
piolIens
Does youi chiId have
any piolIens going lo
led` IaIIing asIeep`
Does youi chiId have any
piolIens al ledline`
(Iaienl) Do you have any
piolIens going lo led`
(ChiId)
Do you have any
piolIens faIIing
asIeep al ledline`
(ChiId)
2. Dxcessive
dayline
sIeepiness
Does youi chiId seen
oveiliied oi sIeepy a Iol
duiing lhe day` Does
she sliII lake naps`
Does youi chiId have
difficuIly vaking in lhe
noining, seen sIeepy
duiing lhe day oi lake
haps` (Iaienl) Do you feeI
liied a Iol` (ChiId)
Do you feeI sIeep a
Iol duiing lhe day`
In schooI` WhiIe
diiving` (ChiId)
3. @vakenings
duiing lhe
nighl
Does youi chiId vake
up a Iol al nighl`
Does youi chiId seen lo
vake up a Iol al nighl`
Any sIeepvaIking oi
nighlnaies` (Iaienl) Do
you vake up a Iol al
nighl` Have lioulIe
gelling lack lo sIeep`
(ChiId)
Do you vake up a
Iol al nighl` Have
lioulIe gelling lack
lo sIeep` (ChiId)
4. EeguIaiily
and duialion
of sIeep
Does youi chiId have a
ieguIai ledline and
vake line` Whal aie
lhey`
Whal line does youi chiId
go lo led and gel up on
schooI days` Weekends`
Do you lhink he/she is
gelling enough sIeep`
(Iaienl)
Whal line do you
usuaIIy go lo led on
schooI nighls`
Weekends` Hov
nuch sIeep do you
usuaIIy gel` (ChiId)
5. -noiing
Does youi chiId snoie a
Iol oi have difficuIly
liealhing al nighl`
Does youi chiId have Ioud
oi nighlIy snoiing oi any
liealhing difficuIlies al
nighl` (Iaienl)
Does youi leenagei
snoie IoudIy oi
nighlIy` (Iaienl)
Souice: Ovens, }. and DaIzeII, V. Use of lhe 'LARS sIeep scieening looI in a pedialiic conlinuily
cIinic: a piIol sludy. !,""- ="4%#%'": 6 (2OO5) 63-69, used vilh peinission
TalIe 1. LARS SIeep Scieening AIgoiilhn


82
A scieening looI, lhe LARS vas deveIoped ly Ovens el. aI., and consisls of five sIeep-
ieIaled aieas lo scieen al piinaiy caie visils. Aflei inpIenenling lhis insliunenl in a
piinaiy caie selling, significanlIy noie sIeep issues veie docunenled and sIeep piolIens
idenlified ly lhe piaclilioneis (Ovens & DaIzeII, 2OO5).
The lein LARS slands foi:
- edline piolIens
L - Lxcessive dayline sIeepiness
A - Avakenings duiing lhe nighl
R - ReguIaiily of sIeep/vake cycIes and aveiage sIeep duialion
S - Snoiing
In concIusion, lhe ieIalionship lelveen ADHD and sIeep disoideis in chiIdien and
adoIescenls can nake evaIualion of ADHD chaIIenging. Hovevei, a nelhodicaI and
lhoiough evaIualion lhal iecognizes expecled and unexpecled deveIopnenlaI fealuies
ieIaled lo sIeep viII heIp lo assuie piopei and lineIy idenlificalion and nanagenenl of lolh
ADHD and disoideis of sIeep.
10. References
2OO4 SIeep in Aneiica IoII Sunnaiy of Iindings. 2OO4. Washinglon DC: NalionaI SIeep
Ioundalion.
2OO6 SIeep in Aneiica IoII, Teens and SIeep, Sunnaiy of Iindings. 2OO6. Washinglon DC:
NalionaI SIeep Ioundalion.
AIIen, R.I., Iichielli, D., Hening, W.A., el aI. 2OO3. ReslIess Iegs syndione: Diagnoslic
ciileiia, speciaI consideialions, and epidenioIogy. A iepoil fion lhe ieslIess Iegs
syndione diagnosis and epidenioIogy voikshop al lhe NalionaI Inslilules of
HeaIlh. !,""- ="4%#%'" 4:1O1-119.
Associalion, Aneiican Isychialiic. 2OOO. *%/>'&5$%# /'4 5$/$%5$%#/, ./'9/, &) ."'$/, 4%5&24"25
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Iicchielli, M. A., Iicchielli, D. L. 2OO8. ReslIess Legs Syndione and Ieiiodic Linl
Movenenl Disoidei in ChiIdien and AdoIescenls. !".%'/25 %' 3"4%/$2%# H"92&,&><
15:91-99.
Iichielli, D.L., el aI. 2OO7. ReslIess Iegs syndione: pievaIence and inpacl in chiIdien and
adoIescenls - lhe Ieds RLST sludy. 3"4%/$2%#5 12O:253-266.
IIizka S and AACAI Woik Cioup on QuaIily Issues. 2OO7. Iiaclice Iaianelei foi lhe
Assessnenl and Tiealnenl of ChiIdien and AdoIescenls vilh Allenlion-
Deficil/Hypeiaclivily Disoidei. F&92'/, &) ?."2%#/' ?#/4".< &) 71%,4 /'4 ?4&,"5#"'$
35<#1%/$2< 46 (7):894-921.
Rajaian, S., WaIleis, A.S., LngIand, S.}., Mehla, D., Nizan, I. 2OO4. Sone chiIdien vilh
gioving pains nay acluaIIy have ieslIess Iegs syndione. !,""- 27:767-773.
Reid, C.}., Hong, R.Y., Wade, T.}. 2OO9. The ieIalion lelveen connon sIeep piolIens and
enolionaI and lehavioiaI piolIens anong 2- and 3-yeai-oIds in lhe conlexl of
knovn iisk faclois foi psychopalhoIogy. F&92'/, &) !,""- J"5"/2#1 18:49-59.
Rosa-Nelo I, Lou HC, Cunning I, Iiyds O, Kaiielaek H, Lunding }, Cjedde A. 2OO5.
MelhyIphenidale-evoked changes in sliialaI dopanine coiieIale vilh inallenlion
and inpuIsivily in adoIescenls vilh allenlion deficil hypeiaclivily disoidei.
H"92&G./>" 25 (3):868-876.
Rulia, K., R. HaIaii, A. M. Mohannad, L. TayIoi, and M. iannei. 2O11. MelhyIphenidale
noinaIizes fionlocinguIale undeiaclivalion duiing eiioi piocessing in allenlion-
deficil/hypeiaclivily disoidei. 0%&, 35<#1%/$2< 7O (3):255-62.
Sadeh, A., Ciulei, R., Raviv, A. 2OO2. SIeep, NeuiolehavioiaI Iunclioning, and ehavioi
IiolIens in SchooI-Age ChiIdien. 71%,4 *"+",&-."'$ 73 (2):4O5-417.


88
SangaI. R.., SangaI, }.M. 2OO4. Raling scaIes foi inallenlion and sIeepiness aie coiieIaled in
aduIls vilh synplons of sIeep disoideied liealhing syndione, lul nol in aduIls
vilh synplons of allenlion-deficil/hypeiaclivily disoidei. !,""- ="4%#%'" 5:133-
135.
Shui-Ien C, S. 2OO6. IievaIence of sIeep piolIens and lheii associalion vilh
inallenlion/hypeiaclivily anong chiIdien aged 6-15 in Taivan. F&92'/, &) !,""-
J"5"/2#1 15:4O3-414.
SiIveslii R, CagIiano A, Aiico I, CaIaiese T, Cedio C, iuni O, Conduiso R, Ceinano L,
Ceivasi C, Siiacusano R, Vila C, ianani I 2OO9. SIeep disoideis in chiIdien vilh
Allenlion-Deficil/Hypeiaclivily Disoidei (ADHD) iecoided oveinighl ly video-
poIysonnogiaphy. !,""- ="4%#%'" 1O (1O):1132-1138.
Sinonds, }.I., Iaiiaga, H. 1984. SIeep ehaviois and Disoideis in ChiIdien and AdoIescenls
LvaIualed al Isychialiic CIinics. *"+",&-."'$/, /'4 0"1/+%&2/, 3"4%/$2%#5 5 (1):6-1O.
Slein, M.A., MendeIsohn, }., Oleineyei, W.H., Anionin, }., enca, R. 2OO1. SIeep and
ehavioi IiolIens in SchooI-Aged ChiIdien. 3"4%/$2%#5 1O7 (4).
Svanson, }.M., IIodnan, I., Kennedy, }., Spence, M.A., Moyzis, R., Schucka, S., Muiias, M.,
Moiiaiily, }., aii, C., Snilh, M., Iosnei, M. 2OOO. Dopanine genes and ADHD.
H"92&5#%"'#" /'4 0%&:"1/+%&2/, J"+%"K5 25:21-25.
Tiipp, C., Wickens, }.R. 2OO9. NeuiolioIogy of ADHD. H"92&-1/2./#&,&>< 57:579-589.
Van Dei Heijden K, Snils MC, Cunning W. 2OO6. SIeep hygiene and acligiaphicaIIy
evaIualed sIeep chaiacleiislics in chiIdien vilh ADHD and chionic sIeep onsel
insonnia. F&92'/, &) !,""- J"5"/2#1 15 (1):55-62.
WaIleis, A.S., Iichielli, D.L., Lhienleig, .L., Wagnei, M.L. 1994. ReslIess Iegs syndione in
chiIdhood and adoIescence. 3"4%/$2%# H"92&,&>< 11:241-245.
WaIleis, A.S., SiIveslii, R., Zucconi, M., Chandiashedaiiah, R., KonofaI, L. 2OO8. Reviev of
lhe possiliIe ieIalionship and hypolhelicaI Iinks lelveen allenlion deficil
hypeiaclivily disoidei (ADHD) and lhe sinpIe sIeep ieIaled novenenl disoideis,
paiasonnias, hypeisonnias, and ciicadian ihylhn disoideis. F&92'/, &) 7,%'%#/,
!,""- ="4%#%'" 4:591-6OO.
Zinnei L 2OO9. Iosilion enission lonogiaphy neuioinaging foi a lellei undeislanding of
lhe lioIogy of ADHD. H"92&-1/2./#&,&>< 57 (7-8):6O1-6O7.
Part 2
PsychopharmacoIogy:
Mechanisms and Effects

5
The NeuropsychopharmacoIogy
of StimuIants: Dopamine and ADHD
IauI L.A. CIasei and Cieg A. Ceihaidl
!"#$%&'#() +, -%"(./0)
!12
1. Introduction
In lhis chaplei ve considei lhe neuiopsychophainacoIogy of ADHD in geneiaI and
dopanine and lhe slinuIanls noie specificaIIy. Allenlion viII le given lo lhe vaiious
neuioliansnillei lheoiies foi ADHD. We viII considei lhe lheoielicaI nechanisns of
aclions foi lhe vaiious nedicines used lo lieal ADHD. We viII Iook al hov lhe slinuIanls,
aIlhough oflen assuned lo le siniIai, acluaIIy shov evidence of diffeienliaI nechanisns of
aclion. We viII Iook al nev dala lhal uliIizes lhe lechnique of ieveise niciodiaIysis lo
denonsliale hov diffeienl lhe dose-iesponse cuives aie foi dopanine ieIease in lhe
sliialun foIIoving IocaI appIicalion of lhe diffeienl slinuIanls.
Thioughoul lhe lexl ve viII use ADHD (Allenlion-Deficil/Hypeiaclivily Disoidei) vilhoul
iefeience lo lhe DSM-IV lype, unIess a specific iefeience peilains lo conlined, inallenlive oi
hypeiaclive sullypes.
2. NeuropsychopharmacoIogy of stimuIants
The slinuIanl nedicalions veie discoveied seiendipilousIy vilh lhe indiiecl olseivalion lhal
anphelanines caIned and focused chiIdien vho veie given lhe nedicine lo liy lo lieal
headache lhal vas caused ly lhe lechnique of pneunoencephaIogiaphy, a IaigeIy ouldaled
pioceduie vheie lhe spinaI fIuid vas diained and iepIaced vilh aii in oidei lo see lhe liain
noie cIeaiIy on X-iay (iadIey, 1937, SliohI, 2O11). The foin of anphelanine used ly iadIey
vas enzediine, lhe iacenic nixluie, oi 5O/5O nixluie of d- and I-anphelanine. ecause of
ieseaich poinling lo lhe dopanine ieIeasing quaIilies of lhe slinuIanls, lhe eaiIiesl lheoiy foi
ADHD vas lhal il iepiesenled a hypodopanineigic slale. This hypodopanineigic slale
lheoielicaIIy Ied lo aIleialions in ievaid sensilivily if il vas in lhe nucIeus accunlens,
hypeiaclivily if Ioveied dopanine vas in lhe sliialun, and decieased inhililoiy conlioI if lhe
Ioveied dopanine vas in lhe fionlaI coilex. AIlhough lhe coIIeclive dala nevei suppoiled
such cIean denaicalions in liain sliucluie and dependence soIeIy on dopanine, lhe
hypodopanineigic lheoiy of ADHD is sliII a popuIai leaching in lhe cIinicaI selling.
2.1 Dopamine and ADHD
Dopanine vas nol aIvays consideied a neuioliansnillei. As delaiIs aloul lhe
neuioliansnilleis veie eneiging dopanine vas noled as lhe penuIlinale noIecuIe in lhe


92
synlhesis of noiepinephiine. The concepl eneiged of lhe nonoanines leing packaged inlo
disciele vesicIes lhal couId le ieIeased vhen an aclion polenliaI lioughl on an infIux of
caIciun. Dopanine vas lianspoiled inlo lhese synaplic vesicIes ly VMAT (VesicuIai
Monoanine Tianspoilei). Then lhe enzyne Dopanine |-HydioxyIase inside lhe vesicIe
conveiled lhe dopanine lo noiepinephiine. Woik ly CaiIsson and olheis in lhe 195Os
shoved lhal sone iegions of lhe liain, pailicuIaiIy lhe lasaI gangIia lhal incIudes lhe
sliialun and nucIeus accunlens, veie eniiched in dopanine and had veiy IillIe
noiepinephiine (Coopei el aI., 2OO3). IoIIoving lhese discoveiies, dopanines inpoilance in
cooidinaling noloi conlioI, Iaikinsons Disease, and ievaid veie eslalIished. Il vas found
lhal foIIoving ieIease of dopanine fion piesynaplic vesicIes lhal dopanine had specific
ieceplois poslsynaplicaIIy lhal couId noduIale lhe neuions funclion (lolh slinuIaloiy and
inhililoiy noduIalion depending on lhe dopanine ieceplois and second nessengei
syslens). Dopanine ieceplois veie aIso found piesynaplicaIIy and lhoughl lo aIIov foi
feedlack nechanisns foi piecise ieguIalion of dopanine ieIease. IinaIIy, dopanines effecls
veie leininaled lolh lhiough ieuplake inlo lhe piesynaplic cylopIasn ly lhe dopanine
lianspoilei (DAT), and ly nelaloIisn eilhei inside lhe neuion ly MAO (nonoanine
oxidase) oi exliaceIIuIaiIy ly COMT (calechoI O-nelhyI liansfeiase) (see Iiguie 1).
As discoveiies aloul dopanine veie evoIving, slinuIanls veie leing used foi nany
puiposes in lhe nid lo Iale 2O
lh
cenluiy. iadIeys olseivalions on anphelanines lenefil
foi chiIdien vilh fealuies of ADHD venl IaigeIy ignoied foi seveiaI decades. The
slinuIanls found use foi lheii aliIily lo keep peopIe avake despile faligue. SeveiaI
niIilaiies in WoiId Wai Tvo used lolh anphelanine and nelhanphelanine foi lhis
puipose, aIlhough il vas soon found lhal soIdieis vouId ciash foIIoving lhis use and
need line lo iecovei. ToIeiance vas aIso noled vilh incieasing doses needed foi effecls such
as euphoiia. Aluse vas iepoiled foi seveiaI decades lefoie lhe IDA lanned enzediine
inhaIeis and Iiniled anphelanines lo piesciiplion use onIy in 1959. Reseaicheis in lhe
197Os and 198Os connecled and cIaiified lhe slinuIanls funclion in incieasing dopanine in
lhe synaplic cIefl, as veII as ils conneclion lo liealing ADHD and lhe ioIe of lolh lonic and
phasic IeveIs of dopanine (Rollins & Sahakian, 1979). Ieihaps due lo lhe ease of
neasuienenl and aludance of dopanine in lhe sliialun and nucIeus accunlens, dopanine
ieseaich piedoninaled ovei noiepinephiine. In liulh, anphelanines exeil nosl of ils CNS
effecls lhiough dopanine and noiephinephiine, vilh veiy IillIe effecls on seiolonin.
MelhyIphenidale is sliongesl al lIocking dopanine and nuch Iess so noiepinephiine, and
even Iess so foi seiolonin (CalIey el aI. 1996). IinaIIy cocaine and nelhanphelanine seen lo
affecl aII lhiee neuioliansnilleis, vilh lheii effecl on seiolonin lheoielicaIIy Ieading lo lhe
giealei euphoiia. When lhis seiolonin funclion is coupIed lo lhe ievaid funclion of
dopanine ieIease in lhe nucIeus accunlens, il lheoielicaIIy nakes nelhanphelanine and
cocaine have giealei oveiaII aluse polenliaI conpaied lo anphelanine and
nelhyIphenidale. To lhis day, slinuIanls aie appioved foi use in ADHD, naicoIepsy, and
seveie olesily, lul vilh sliicl conlioI ly lhe IDA and olhei goveinnenlaI agencies aiound
lhe voiId.
2.2 Other Neurotransmitters and ADHD
As noie inliicacies have leen ieveaIed lhiough aninaI nodeIs of ADHD and hunan
ieseaich, olhei neuioliansnilleis have leen inpIicaled in ADHD. Ieihaps lhe sliongesl
case can le nade foi noiepinephiine. Ainslen and coIIeagues have suggesled lhal

The Neuropsychopharmacology of Stimulants: Dopamine and ADHD

93
noiepinephiine is as inpoilanl as dopanine in allenlion and ADHD. Recenl eIeganl voik
in non-hunan piinales suggesl lhal aIpha-2 adieneigic inpul in lhe fionlaI coilex is ciilicaI
in nainlaining voiking nenoiy in a visuaI allenlion lask consliucled ly Ainslens gioup
(Wang el aI., 2OO7). InleieslingIy, dopanine-1 ieceploi inpul is needed in lhe aieas
suiiounding lhe ciicuiliy of voiking nenoiy lo suppiess aieas of lhe fionlaI coilex lhal
veie nol needed foi lhal specific nenoiy. One nighl say lhal noiepinephiine vas aIIoving
foi saIiency and allenlion, and dopanine foi signaI-lo-noise adjuslnenl oi inhililion of
inappiopiiale infoinalion (Cano el aI., 2O1O).
IniliaIIy one nighl lhink lhal alonoxeline Iends ciedence lo jusl lhe noiepinephiine lheoiies
of ADHD in lhal il is a NLT (noiepinephiine lianspoilei) inhililoi. ul ieseaich has shovn
lhal lhe NLT lianspoils dopanine as veII as NL. Thus alonoxeline iaises NL and DA in lhe
piefionlaI coilex. Since NLT is piinaiiIy piesenl in lhe fionlaI coilex and nol lhe nucIeus
accunlens oi sliialun, lhe neuioliansnillei noduIaling effecls of alonoxeline aie onIy in
lhe fionlaI coilex. This accounls foi ils Iack of alusaliIily, and peihaps lhe facl lhal
alonoxeline oveiaII is a Iess efficacious nedicine foi ADHD conpaied lo anphelanine and
nelhyIphenidale (LiIe el aI., 2OO6). The slinuIanls in lIocking DAT (dopanine lianspoilei)
aIso cieale incieases in lolh DA and NL, since Iike NLT, DAT lianspoils lolh DA and NL.
Olhei neuioliansnilleis inpIicaled in ADHD incIude acelyIchoIine, hislanine, adenosine
ieceplois, and gIulanale. Nicolinic ieceplois aie invoIved in vaiious lasks iequiiing
allenlion and lhis has Ied lo lhe specuIalion lhal lhe high iale of snoking seen in peopIe
vilh ADHD nay le due in pail lo seIf-nedicalion. AIlhough nosl nicolinic nedicalions
have laigeled AIzheineis, lheie use in nenoiy nay piove leneficiaI lo ADHD. SeveiaI
hislanine-3-ieceploi anlagonisls aie in lhe slages of leing lesled foi ADHD and olhei
cognilive disoidei (Sandei el aI., 2OO8). OnIy a fev sludies have leen iepoiled lhus fai and
lheii iesuIls using lhese hislanine noduIaling diugs foi ADHD have leen nixed (iioni el
aI., 2O11). Caffeine, an adenosine ieceploi anlagonisl, can inpiove synplons of ADHD in
sone aninaI nodeIs peihaps lhiough inleiaclions of adenosine ieceplois and dopanine
syslens. Caffeine is pooiIy sludied in ADHD lul appeais lo heIp aIeilness noie lhan acluaI
synplons of ADHD (Snilh 2OO2). CIulanale has iecenlIy leen inpIicaled fion lolh
neuioinaging and neuioscience. One open IaleIed liiaI has shovn lhal gIulanale
noduIaling diugs, such as NMDA anlagonisl nenanline shovs sone efficacy in liealing
ADHD (IindIing el aI., 2OO7). InleieslingIy a iecenl palch cIanp sludy suggesls lhal
alonoxeline is aIso an NMDA anlagonisl al cIinicaI IeveIs (LudoIph el aI., 2O1O).
2.3 Heterogeneity amongst the stimuIants
Reluining lo lhe dopanine nechanisns of aclion invoIved in ADHD Iel us nov focus on
hov lhe sepaiale slinuIanls used in liealing ADHD aie diffeienl fion each olhei.
MelhyIphenidale has leen shovn lo have a nechanisn of aclion siniIai lo cocaine in lhal il
specificaIIy lIocks DAT (see Iiguie 1). D-anphelanine (lhe dexlio-isonei of anphelanine)
has leen shovn lo have lhiee polenliaI nechanisns. The fiisl is diiecl effecl on lhe DAT ly
aIIoving ieveise lianspoil of DA fion lhe cylopIasn piesynaplicaIIy inlo lhe synapse, lhis
is a caIciun-independenl DA ieIease lhal is peihaps coupIed lo oveiaII deciease in DA
uplake. SecondIy d-anphelanine inhilils MAO- (Monoanine oxidase- isofoin) vhich
calaloIizes DA. ThiidIy, d-anphelanine inhilils VMAT (vesicuIai nonoanine lianspoilei)
Ieading lo an inciease in cylopIasnic DA lhal can le ieveise lianspoiled oul ly DAT (see


94
Iiguie 1) (eignan el aI. 1989, Cadoni el aI. 1995). AIlhough il is nol knovn vhich of lhese
lhiee nechanisns is lhe nosl inpoilanl of nole is lhal aII lhiee aie diffeienl lhan
nelhyIphenidale. This agiees vilh lhe cIinicaIIy olseived phenonena lhal iesponses lo
nelhyIphenidale and d-anphelanine aie nol aIvays equaI in palienls. Thus, if a palienl is
nol doing veII on one slinuIanl, say nelhyIphenidale, lhen il is lhe ieconnended slandaid
of caie lo lhen liy an anphelanine piepaialion. Sondeis el aI. (1997) calegoiized
phainacoIogicaI agenls lhal acl on lhe hunan dopanine lianspoilei (hDAT) inlo lvo
gioups: sulsliales foi DAT (incIuding dopanine and anphelanine) and cocaine-Iike
(incIuding cocaine and nelhyIphenidale). Thus, anphelanine can acluaIIy seive as a
sulsliale foi DAT, Iike dopanine ilseIf, vheieas nelhyIphenidale is nol a sulsliale foi
DAT.

Iig. 1. SinpIified ModeI of Dopanine synapse vilh pulalive nechanisns of aclion foi
anphelanine and nelyIphenidale.
ul aie aII anphelanine piepaialions equivaIenl` Whal aloul lhe piepaialions such as
AddeiaII lhal have sone I-anphelanine (lhe opposile sleieo isonei of d-anphelanine). In
lhe 199Os lhe diug AddeiaII vas inlioduced and naikeled as a iolusl liealnenl foi lhe
synplons of ADHD conpaied lo olhei nedicalions (Ioppei 1994, Ialiick el aI. 1997). One
cIinicaI sludy conpaied AddeiaII lo D-anphelanine and found lhal AddeiaII decieased
specific synplons of hypeiaclivily sIighlIy faslei and ovei a Iongei line peiiod lhan D-
anphelanine (}anes el aI. 2OO1), lul lhis vas a ninoi diffeience. Olhei cIinicaI liiaIs
suppoil lhal AddeiaII is noie effeclive lhan innediale-ieIease nelhyIphenidale on
oulcones neasuied 4 lo 5 houis aflei dosing (IeIhan el aI. 1999). A najoiily of dala
suppoils lhal popuIalion conpaiison of efficacy foi slinuIanls in liealing ADHD shov IillIe
diffeience. Il is onIy vhen you gel lo lhe individuaI palienl lhal you find diffeiences in lhe
slinuIanls. Ioi exanpIe, I-anphelanine aIone has leen lesled and shovn in a snaIIei sludy
lo le usefuI foi sone palienls vilh ADHD, even a fev vhich did nol iespond as veII lo d-
anphelanine (SegaI 1974). Moie iecenl conpaiison of conlioIIed-ieIease piepaialions of


95
anphelanines and nelhyIphenidale shov IillIe diffeiences in oveiaII efficacy. Iievious in
vivo voIlanneliy dala in oui Ialoialoiy shoved diffeiences in kinelics lelveen
anphelanine oplicaI isoneis (CIasei el aI. 2OO5). In lhese sludies, piepaialions vilh L-
anphelanine evoked faslei DA iise lines and signaI decay lines conpaied lo D-
anphelanine. AddilionaIIy, dala coIIecled ly oui gioup shoved giealei anpIiludes and
Iongei DA iesponse signaI kinelics foIIoving IocaI appIicalions of AddeiaII in conpaiison
vilh D-anphelanine and D,L-anphelanine (}oyce el aI. 2OO7) suppoiling diffeienl
nechanislic effecls of lhese diugs on DA ieIease.
2.4 Reverse microdiaIysis of stimuIants in the rat striatum: hypothesis
When conpaiing diffeienl slinuIanl nedicalions and lheii effecls on dopanine IeveIs,
seveiaI caveals have Iiniled diiecl conpaiison. Iiisl of aII, slinuIanls aie oflen given ly
inliapeiiloneaI injeclion, due in pail lo ils ease and lhe facl lhal lhe iapid iise in lIood IeveIs
nakes dopanine easiei lo neasuie in liain iegions. Hovevei vaiialiIily in alsoiplion and
fiisl pass effecls of lhe Iivei nake il difficuIl lo conpaie concenlialions lelveen
nedicalions. Cavage oi oiaI deIiveiy of food, vhiIe sinuIaling lhe cIinicaI expeiience foi
ADHD, has even noie phainacokinelic faclois invoIved due lo gul alsoiplion faclois as
veII. IinaIIy, nany injeclion and oiaI slinuIanl sludies have lo use Iaigei, noie aluse
ieIaled dosing, lecause lheie aie oflen IillIe appiecialIe changes in dopanine al diug
dosing siniIai lo lhal used in ADHD, aIlhough a fev sludies have leen alIe lo acconpIish
lhis (eiiidge el aI, 2OO6). In oidei lo ciicunvenl sone of lhese caveals, and yel sliII Iook al
lhe in vivo effecls of lhese diugs and lheii diffeiences on sliialun, ve chose lhe lechnique of
ieveise niciodiaIysis. This lechnoIogy pIaces lhe nedicalion in lhe diaIysale lhal goes
diieclIy lo lhe sliialun and aIIovs foi diiecl and sensilive dose-iesponse cuives foi
slinuIanl-evoked dopanine.
The lechnique of ieveise niciodiaIysis coupIed vilh high peifoinance Iiquid
chionalogiaphy vilh eIecliochenicaI deleclion (HILC-LC) vas used lo sludy IocaI diug-
evoked incieases in exliaceIIuIai dopanine (DA) IeveIs and changes in DA nelaloIiles in
lhe sliialun of aneslhelized ials. Iuidon el aI. (2OO3) shoved dala suppoiling lhal lhe
oidei of adninislialion of diffeienl concenlialions of D-anphelanine significanlIy affecled
DA and DOIAC IeveIs. These iesuIls veie IikeIy alliilulalIe lo changes in lhe suiface
expiession of DAT on DA neive endings and/oi DAT funclion. Olhei in vilio sludies have
shovn sulsliale dependenl liafficking of lhe DAT lo and fion lhe pIasna nenliane and
sulsequenl changes in lhe aliIily lo lianspoil DA (KahIig el aI. 2OO5, }ohnson el aI. 2OO5,
Saundeis el aI. 2OOO, KahIig el aI. 2OO4, KahIig and CaIIi 2OO3). Theiefoie lo have lhe nosl
accuiale dose-iesponse cuives lhe sane aninaI shouId nol le used lo lesl seveiaI doses. Ioi
lhese expeiinenls diug-nave aninaIs veie used lo ciicunvenl issues iegaiding DAT
liafficking and/oi change in funclion foIIoving sulsliale exposuie (KahIig and CaIIi 2OO3,
KahIig el aI. 2OO4, Iuidon el aI. 2OO3). We lesled lhe hypolhesis lhal slinuIanl
concenlialion-iesponse cuives of DA and ils nelaloIiles viII dispIay diffeienliaI palleins of
DA oveifIov lhal coiieIale vilh lheii nechanislic piopeilies al lhe IeveI of DAT funclion. In
addilion, ve lesled a unique foinuIalion of 25 D- and 75L-anphelanine and leined
lhis nixluie Reveise AddeiaII, lo conliasl il vilh AddeiaII lhal is ~75 D- and 25 L-
anphelanine. We hypolhesized lhal lhe Reveise AddeiaII vouId aIso have a diffeienliaI
dose-iesponse cuive lhan lhe olhei anphelanine piepaialions.


96
2.5 Reverse microdiaIysis of stimuIants in the rat striatum: methods
MaIe Iischei 344 (I344) ials (3-6 nonlhs oId) veie aneslhelized vilh uielhane (1.25 g/kg
i.p. in O.9 saIine). Aflei pIacenenl inlo a sleieolaxic fiane (Kopf, Tujunga, CA, USA) vilh
lhe incisoi lai sel al -2.3 nn, lhe ial sliialun vas piepaied foi sludy. ody lenpeialuie
vas nainlained ly use of an isolheinaI healing pad (iainliee Scienlific, iainliee, MA,
USA) al 37 C and peiiodicaIIy noniloied ly a ieclaI lheinonelei. Aflei lhe ieliaclion of
lhe skin and lissue and exposuie of lhe skuII oveiIying lhe sliialun, a snaII cianiolony (2 x
2 nn) vas caiiied oul in lhe iighl henispheie. The niciodiaIysis pioles veie
sleieolaclicaIIy pIaced vilh iespecl lo liegna: +1.O nn AI, 2.2 nn ML, DV -6.O nn)
(Iaxinos and Walson, 1986). The 2-nn Ienglh nenliane pioles (CMA/11, CMA
MiciodiaIysis, SlockhoIn, Sveden) ienained al lhis Iocalion foi lhe duialion of lhe
expeiinenl. AII pioceduies veie peifoined in accoidance vilh lhe NalionaI Inslilules of
HeaIlh CuideIines foi lhe Caie and use of MannaIs in Neuioscience and ehavioiaI
Reseaich (2OO3) and veie appioved ly lhe AninaI Caie and Use Connillee of lhe
Univeisily of Kenlucky.
IIuid fIov lhiough lhe niciodiaIysis pioles vas achieved using a syiinge punp (KDS23O,
KD Scienlific, HoIIislon, MA) filled vilh 1nI gaslighl syiinges (1OO1 LTN, HaniIlon USA,
Reno, NV) conlaining diaIyzing fIuid. DiaIysis pioles veie peifused al a fIov iale of 1
I/nin. Syiinges veie connecled lo a Iiquid svilch (CMA/11O, CMA MiciodiaIysis,
SlockhoIn, Sveden) lhal aIIoved foi aIleinalion lelveen liealnenls: ailificiaI ceieliaI
spinaI fIuid (aCSI) (in nM: NaCI 123, KCI 3, CaCI2 1, MgCI2 1, NaHCO3 25, NaH2IO4 1,
and gIucose 5.9) and aCSI + |diugj. TefIon luling (ILI luling, O.12 nn i.d.) and luling
adapleis (CMA MiciodiaIysis, SlockhoIn, Sveden) veie used lo eslalIish aII conneclions.
SanpIes veie coIIecled al lvenly ninule inleivaIs inlo a O.2 nI niciocenliifuge lule and
nanuaIIy injecled inlo an HILC-LC syslen. The oidei of adninislialion foi each of lhe
diug soIulions lesled vas as foIIovs: sanpIes 1-6 (O-12O ninules, aCSI), sanpIe 7 (12O-14O
ninules, aCSI + slinuIanl diug soIulion), sanpIes 8-12 (16O-24O ninules, aCSI).
Iiole iecoveiies veie coIIecled using a slandaid soIulion vilh knovn concenlialions of
DA, noiepinephiine (NL), seiolonin (5-HT), 3,4-dihydioxphenyIacelic acid (DOIAC),
honovaniIIic Acid (HVA) and 5-hydioxyindoIeacelic acid (5-HIAA). In oidei foi a piole lo
le used in lhese sludies, in vilio iecoveiies of 1O 1 veie iequiied. ased on lhis
exchange iale, seen foi noIecuIes siniIai in size lo anphelanine such as DA, NL, and 5-HT,
ve veie alIe lo noie accuialeIy adjusl lhe effeclive concenlialions of slinuIanl diugs leing
sludied.
SlinuIanl concenlialions used foi ieveise niciodiaIysis sludies veie chosen lo iepiesenl a
iange lhal incIuded cIinicaIIy ieIevanl IeveIs and aluse IeveIs lhal veie noinaIized foi lhe
anounl of D-anphelanine. Oui piioi sludies suppoil lhal D-anphelanine deleinines lhe
anounl of DA ieIeased in lhe piesence of lolh enanlioneis (CIasei el aI. 2OO5). The
foIIoving concenlialions veie used lased on ~1O exchange iale foi lhe niciodiaIysis
pioles: foi D-anphelanine and nelhyIphenidale, O.1 M, O.5 M, 1 M, 5 M, 1O M, 25
M, 5O M, 1OO M, 4OO M veie sludied, foi Reveise AddeiaII, O.1 M, O.5 M, 1 M, 5 M,
1O M, 25 M, 5O M, 1OO M, 4OO M and 533 M, , and foi AddeiaII , O.1 M, O.5 M, 1
M, 5 M, 1O M, 25 M, 5O M, 1OO M, 4OO M and 539 M soIulions veie sludied . Ioi
D,L-anphelanine (noinaIized lo D-anphelanine/2), L-anphelanine, and cocaine, onIy a
concenlialion of 4OO M vas lesled foi naxinun effecl conpaiisons. Iiioi lo each


97
expeiinenl, 2O nM ascoilic acid vas added lo each soIulion and soIulions veie aeialed
vilh 95 O2/5 CO2. SoIulions veie innedialeIy added lo individuaI 1 nI gaslighl
syiinges. IoIIoving each expeiinenl, ials veie inliacaidiaIIy peifused vilh O.9 NaCI
soIulion foIIoved ly a 4 paiafoinaIdehyde soIulion. They veie lhen decapilaled, and
lheii liains veie fiozen, sIiced on a ciyoslal, and seclioned slained vilh ciesyI vioIel lo
veiify piole pIacenenl in lhe sliialun.
High-Ieifoinance Liquid Chionalogiaphy CoupIed vilh LIecliochenicaI Deleclion
(HILC-LC) anaIysis foIIoved lhe nelhods pieviousIy desciiled ly HaII el aI. (1989). The
Iov IeveI deleclions of DOIAC, DA, 5-HT, NL, 5-HIAA, and HVA veie peifoined using an
isocialic HILC syslen (ecknan, Inc., IuIIeilon, CA) coupIed lo a duaI-channeI
eIecliochenicaI aiiay delecloi (nodeI 53OOA, LSA, Inc., CheInsfoid, MA), L1 = +O.35 nV
and L2 = -O.25 nV, vilh an LSA nodeI 5O11A duaI anaIylicaI ceII. The conpounds of
inleiesl veie sepaialed vilh ieveise-phase chionalogiaphy, using a C18 coIunn (4.6 nn x
75 nn, 3 n pailicIe size, Shiseido CapCeII Iak UC12O, Shiseido Co., LTD., Tokyo, }apan)
vilh a pH 4.1 ciliale-acelale noliIe phase, conlaining 4 nelhanoI and O.34 nM 1-oclane-
suIfonic acid deIiveied al a fIov iale of 2.O nI/nin. Ieaks foi lhe anaIyles veie idenlified
ly ielenlion lines fion knovn slandaids.
Dala veie coIIecled fion 5-6 aninaIs pei 1O diug concenlialions (foi AddeiaII, D-
anphelanine, Reveise AddeiaII, and nelhyIphenidale). Dala veie coIIecled foi 5-6 aninaIs
foi lhe highesl diug concenlialion onIy foi L-anphelanine, D,L-anphelanine, and cocaine.
The iav niciodiaIysis vaIues veie expiessed as nM lased on a 1 x 1O-7 M nixed slandaid
of knovn anaIyles and piole iecoveiies of ~ 1O. OulIieis veie excIuded lased on dala
faIIing oulside of 2 slandaid devialions fion lhe nean. Concenlialion-iesponse cuives veie
consliucled lased on lhe nean peak DA oveifIov concenlialion foIIoving lhe lvenly
ninule ieveise niciodiaIysis of each diug concenlialion. CiaphIad Iiisn slalislicaI
anaIysis soflvaie, veision 4.O (Iiisn, San Diego, CA, USA), vas used lo deleinine lhe
appiopiiale nonIineai cuive fil and Log haIf naxinaI effeclive concenlialion (LC5O) of each
diug. An iniliaI one-vay anaIysis of vaiiance vas used lo deleinine significance of DA
oveifIov fion lhe aCSI conlioI. A second one-vay anaIysis of vaiiance vas used foIIoved
ly posl-hoc l-lesls vilh onfeiionis coiieclions lo conpaie DA ieIease pioduced foIIoving
ieveise niciodiaIysis of cIinicaIIy ieIevanl diug concenlialions and naxinun
concenlialions. Iolency neasuies veie defined ly lhe slinuIanl lhal ieached ils haIf-
naxinaI iesponse on lhe concenlialion-iesponse cuive vilh lhe Iovesl effeclive
concenlialion of slinuIanl. Lfficacy neasuies veie defined ly lhe highesl anounl of DA
oveifIov evoked vhen aII slinuIanl concenlialions veie al naxinaI IeveIs. SlalislicaI
significance vas defined as p<O.O5.
2.6 Reverse microdiaIysis of stimuIants in the rat striatum: resuIts
Aveiage laseIine IeveIs of DA (<1O nM) veie neasuied and found lo le siniIai lo
pieviousIy coIIecled dala in lhe sliialun of aneslhelized and avake-lehaving ials (Ceihaidl
and MaIoney 1999, Ieiguson el aI. 2OO3, Caiiis el aI. 1994, Kavagoe el aI. 1992, Iaisons and
}uslice 1992). aseIine DOIAC IeveIs veie deleinined lo le (~8OO-1OOO nM) in lhe ials used
foi lhe D-anphelanine and AddeiaII sludies and aie siniIai lo pieviousIy iepoiled IeveIs
(Ieiguson el aI. 2OO3). The DOIAC dala aie iepoiled as peicenl of laseIine due lo incieased
vaiiance in laseIine sanpIes coIIecled fion lhe ials used foi lhe Reveise AddeiaII and


98
nelhyIphenidale sludies (Iig. 3). LeveIs of lhe DA nelaloIile honovaniIIic acid (HVA), 5-
hydioxyindoIeacelic acid (5-HIAA) and seiolonin (5-HT) IeveIs veie neasuied and
concenlialion-dependenl effecls veie nol delecled (dala nol shovn).
The lvenly ninule IocaI lissue peifusions of diugs induced a concenlialion-dependenl
inciease in DA oveifIov foIIoved ly a 6O ninule line peiiod lo ieluin lo laseIine
suppoiling lhe DAT and DA uplake lIocking effecls of lhe lesled slinuIanls (Wise and
Hoffnan 1992, SuIzei el aI. 1993, Schveii el aI. 1985). The iesuIling DA IeveIs, al lhe highesl
concenlialion of diug, veie siniIai lo pievious niciodiaIysis neasuies of ~15O nM (Seenan
and Madias 2OO2). The neasuies of DA veie seen lo decIine ovei 2 noie fiaclions posl diug
adninislialion. Iuilheinoie, appIicalions of lhe Iovesl slinuIanl concenlialion iesuIled in
DA IeveIs lhal veie nol slalislicaIIy diffeienl fion lhose seen aflei ieveise niciodiaIysis of
lhe ailificiaI ceieliaI spinaI fIuid (aCSI) conlioI.
The iesuIling D-anphelanine concenlialion-iesponse cuive foi exliaceIIuIai DA in ial
sliialun dispIayed an unexpecled doulIe-signoidaI pallein vilh lvo pIaleaus. IIaleaus in
lhe anounl of DA oveifIov occuiied al lhe Iovei concenlialion (1 M D-anphelanine) and
al a highei concenlialion (1OO M D-anphelanine). Al O.1 M D-anphelanine, IillIe oi no

Iig. 2. Dose-Response cuives foi evoked oveifIov of dopanine in lhe ial sliialun ly
vaiious slinuIanls.


99
inciease in DA oveifIov iesuIled in conpaiison lo aCSI conlioI, and no significanl
diffeiences veie found lelveen 1OO M and 4OO M D-anphelanine suppoiling an uppei
pIaleau in DA neasuies (Iiguie 2). Tvo haIf-naxinaI effeclive concenlialion (LC5O) vaIues
aie indicaled foi lhe highei polency (Iovei pIaleau) and Iovei polency (uppei pIaleau)
poilions of lhis concenlialion-iesponse cuive (TalIe 1).

"#$%
&'
()
*"#$%+ ,-.
/0# "1
-2345$5 67890:87
,;-. /0# "1
MelhyIphenidale 1O 138.722.2
AddeiaII 25 184.612.3
D-anphelanine II 5O 144.515.6
Reveise AddeiaII 5O 176.719.1
D-anphelanine I O.5 N/A
TalIe 1. SlinuIanl Iolency and Lfficacy on DA Measuies

Iig. 3. Dose-Response cuives foi oveifIov of dopanine nelaloIile DOIAC in lhe ial
sliialun ly vaiious slinuIanls.


100
The nelhyIphenidale concenlialion-iesponse cuive foi exliaceIIuIai DA in lhe ial sliialun
aIso suppoils a concenlialion-dependenl inciease in DA IeveIs (Iiguie 2). Since
nelhyIphenidale had pieviousIy leen chaiacleiized as a DAT lIockei and nol a sulsliale
lhal undeigoes lianspoil lhiough lhe DAT, ve hypolhesized lhal ve vouId see nuch Iovei
IeveIs of DA ieIease in an aneslhelized ial. Il vas lheiefoie suipiising lo see lhal
appIicalions of O.5-4OO M nelhyIphenidale incieased DA concenlialions significanlIy
giealei lhan aCSI conlioI. Hovevei, in conliasl lo d-anphelanine, O.1 M nelhyIphenidale
did nol cause incieased DA ieIease lhal vas significanlIy diffeienl fion conlioI. The lvo
highesl concenlialions lesled (1OO and 4OO M) veie nol significanlIy diffeienl in lhe
anounl of DA ieIease (Iiguie 2).
The AddeiaII concenlialion-iesponse cuive foi exliaceIIuIai DA neasuied in lhe ial
sliialun denonslialed a siniIai iange of evoked DA oveifIov, aIlhough lhe dose-iesponse
cuive vas cIosei lo a singIe signoidaI cuive (Iiguie 2). An uppei pIaleau in DA IeveIs
occuiied al 1OO M AddeiaII, as 1OO M and 4OO M AddeiaII veie nol significanlIy
diffeienl in iesponse. Al O.1 M, AddeiaII did nol pioduce DA IeveIs lhal veie significanlIy
diffeienl fion IocaI appIicalion of aCSI conlioI.
IinaIIy, lhe Reveise AddeiaII (75 L-anphelanine, 25 D-anphelanine) concenlialion-
iesponse cuive foi exliaceIIuIai DA shoved a concenlialion-dependenl inciease in evoked DA
al aII concenlialions lesled excepl foi O.1 M, vhich vas nol significanlIy diffeienl fion aCSI
conlioI (Iiguie 2). WhiIe Reveise AddeiaII vas piedoninanlIy nade of L-anphelanine, il did
nol inciease DA IeveIs lo lhe exlenl of AddeiaII al sone concenlialions (TalIe 1). The highesl
lvo concenlialions of Reveise AddeiaII lesled veie significanlIy diffeienl suppoiling lhal a
pIaleau of DA neasuies viII IikeIy occui al a highei concenlialion.
Iiguie 3 shovs lhe individuaI liacings of delecled DOIAC IeveIs (iepiesenled as of
laseIine) foIIoving ieveise niciodiaIysis of D-anphelanine al nuIlipIe concenlialions. D-
anphelanine, AddeiaII, and Reveise AddeiaII inhililed DOIAC IeveIs in a siniIai nannei
foIIoving IocaI peifusion of diug al 12O ninules and conlinued lo deciease DOIAC
pioduclion up lo one houi vhen DOIAC IeveIs ieluined lo laseIine. WhiIe nelhyIphenidale
caused incieased DA IeveIs siniIai lo lhe olhei slinuIanls, il did nol affecl DOIAC IeveIs in a
consislenl nannei and vas siniIai in lhis aspecl lo lhe effecls of cocaine. DOIAC pioduclion
vas Iess affecled ly nelhyIphenidale and cocaine in conpaiison lo AddeiaII (p<O.OO1), and D-
anphelanine (p<O.O1, p<O.O5). Reveise AddeiaII, L-anphelanine, and D,L-anphelanine aII
caused significanlIy giealei effecls on DOIAC IeveIs in conpaiison lo cocaine (p<O.OO1). An
iniliaI inciease in DOIAC vas seen foIIoving appIicalion of 1OO M and 4OO M
nelhyIphenidale foIIoved ly a deciease siniIai lo lhal of olhei concenlialions vilhoul a
pionounced concenlialion-dependenl pallein (dala nol shovn).
2.7 Reverse microdiaIysis of stimuIants in the rat striatum: impIications
These dala iepiesenl noveI findings iegaiding lhe effecls of vaiious slinuIanls acioss a
iange of concenlialions on dopanine ieIease in lhe sliialun. The concenlialion-iesponse
cuive foi D-anphelanine dispIayed a doulIe-signoidaI pallein lhal suppoiled duaI-
funclionaIily piopeilies of lhe DAT and/oi diffeienliaI nechanisns ly vhich high and Iov
IeveIs of D-anphelanine affecl DA effIux. In addilion, lhese dala shov foi lhe fiisl line lhal
IocaI appIicalions of nelhyIphenidale incieased DA IeveIs in a concenlialion-dependenl


101
pallein and even denonslialed a giealei LC5O (DA) vhen conpaied lo olhei slinuIanls.
These dala aie in agieenenl vilh oui pievious in vivo high speed chionoanpeioneliic dala
lhal suppoil lhe iolusl IocaI aclivily of AddeiaII conpaied lo olhei ADHD nedicalions
(}oyce el aI. 2OO7). Decieased DA IeveIs caused ly cocaine conpaied lo highei DA IeveIs
aflei IocaI appIicalion of nelhyIphenidale suggesl dissocialion lelveen lhe IocaI effecls of
nelhyIphenidale and cocaine. DOIAC IeveIs in lhese sludies shoved significanl decieases
foIIoving addilions of any of lhe anphelanine piepaialions in a dose- dependenl fashion,
vheieas cocaine and nelhyIphenidale veie Iess effeclive in inhililing DOIAC pioduclion.
The dala shovn heie aie consislenl vilh lhe knovn DA ieIeasing piopeilies of
anphelanine piedoninanlIy due lo DAT ieveisaI of noinaI ieuplake inlo lhe piesynaplic
leininaI (Ciios el aI. 1996). Likevise, anphelanine has leen shovn lo inpaii DA ieuplake,
inhilil MAO aclivily, and affecl vesicuIai condilions lhal Iead lo enplying of vesicuIai
sloies via lhe vesicuIai nonoanine lianspoilei 2 (VMAT2) (Hoin el aI. 1971, SuIzei el aI.
1995, Dulocovich el aI. 1985, HeikkiIa el aI. 1975, Uielsky and Snodgiass 1977, Cieen and LI
Hail 1978, Cadoni el aI 1995). Oui pievious dala suppoil anphelanine enanlioneiic
diffeiences lhal couId nol le accounled foi acioss nuIlipIe concenlialions due lo lechnicaI
Iinilalions, pailicuIaiIy vilh lhe cuiienl difficuIlies of sludying lhe effecls of Iov IeveIs of
lhese diugs on DA ieIease using in vivo eIecliochenicaI nelhods (CIasei el aI., 2OO5). We
chose lo caiiy oul lhese sludies in lhis nannei lased on infoinalion suppoiling lhe
dynanic changes lhal occui in DA neuionaI syslens in iesponse lo DAT sulsliales and
inhililois. Iuidon el aI. (2OO3) shoved dala suppoiling lhal lhe oidei of adninislialion of
diffeienl concenlialions of D-anphelanine significanlIy affecled DA and DOIAC IeveIs.
These iesuIls veie IikeIy alliilulalIe lo changes in lhe suiface expiession of DAT on DA
neive endings and/oi DAT funclion. Olhei in vilio sludies have shovn sulsliale
dependenl liafficking of lhe DAT lo and fion lhe pIasna nenliane and sulsequenl
changes in lhe aliIily lo lianspoil DA (KahIig el aI. 2OO5, }ohnson el aI. 2OO5, Saundeis el aI.
2OOO, KahIig el aI. 2OO4, KahIig and CaIIi 2OO3). Theiefoie ve used slinuIanl-nave aninaIs
foi lhese sludies, an inpoilanl lul oflen negIecled consideialion in nany nechanislic
sludies of slinuIanl nedicalions.
WhiIe ve have desciiled lhe use of voIlanneliic sludies lo invesligale lhe piopeilies of
slinuIanls al Iov IeveIs, il is difficuIl lo accuialeIy piedicl vhal lhe iesuIling effeclive
concenlialions veie in lhese sludies. VoIlanneliy affoids lhe aliIily lo sludy
neuioliansnission vilh high lenpoiaI and spaliaI iesoIulion, hovevei, ve Iose a
nagnilude of sensilivily lhal is avaiIalIe using niciodiaIysis coupIed vilh HILC-LC. Using
HILC-LC lo anaIyze sanpIes coIIecled duiing ieveise niciodiaIysis (IocaI appIicalion) of
slinuIanl diugs aIIovs foi sludies lo le caiiied oul vilh Iovei diug concenlialions. These
sludies veie designed lo conpIenenl oui pievious sludies and ninic Iongei
adninislialion (ovei 2O ninules) in conveise lo lhe iapid piessuie ejeclion used eaiIiei (2O
seconds). As a finaI ialionaIe of lhis voik, ve pioposed lo invesligale conpIele
concenlialion-iesponse sludies using ieveise niciodiaIysis coupIed vilh HILC-LC.
Invesligalions of concenlialion-iesponse palleins veie inlended lo inciease oui
undeislanding of ADHD diug nechanislic aclivily ly Iooking al lheii effecls on DA and
nelaloIile IeveIs.
AIlhough ve did neasuie noiepinephiine (NL) vilh oui HILC nelhods, lhe peak vas nol
consislenlIy neasuialIe due lo ils pioxinily lo lhe soIvenl edge. In addilion, NL is nol a


102
connon neuioliansnillei in lhe sliialun. Theiefoie, one caveal of oui sludy is lhal il does
nol invesligale lhe possiliIily lhal NL eIevalion, and nol DA, in lhe IIC (and nol lhe
sliialun) is nosl inpoilanl foi cIinicaI efficacy in ADHD. This lheoiy goes on fuilhei lo
slale lhal DA is eIevaled in lhe synapse onIy al highei doses of slinuIanls and lhal lhis Ieads
noie lo lhe ievaiding synplons and diug-aluse polenliaI (lhe dovnvaid sIope of lhe
lheoielicaI inveiled-U of slinuIanl aclion). Oui dala vouId suggesl lhal lhis nay le liue foi
nelhyIphenidale, lul lhal d-anphelanine does invoIve appiecialIe DA al Iovei-doses lhal
nay voik in conceil vilh NL in lhe IIC. This vouId aIso give ciedence lo lhe facl lhal lhe
lvo nain slinuIanls aie lolh liied on palienls vilh ADHD lecause sone viII iespond veII
lo one and nol lhe olhei, vheie as olhei palienls iespond lo lolh. OlviousIy, a iepeal of lhis
sludy using niciodiaIysis in lhe IIC and an HILC nelhod lo pick up lhe Iovei IeveIs of
DA and NL in lhe IIC vouId le needed lo ansvei lhis nechanisn of aclion queslion.
One possilIe nechanisn foi lhe D-anphelanine doulIe-signoidaI concenlialion-iesponse
cuive invoIves laigeling of specific DA pooIs and anphelanine concenlialion-dependenl
effecls. Sone dala suppoil conliilulion of lolh cylosoIic and vesicuIai sloies lo lhe ieIeased
DA foIIoving exposuie lo anphelanine (IifI el aI. 1995), vhiIe olhei dala indicale a
piedoninanl vesicuIai DA conliilulion (}ones el aI. 1998). }ones el aI. (1998) neasuied DA
ieIeased foIIoving eIecliicaI slinuIalion and anphelanine peifusion of sliialaI liain sIices
and noliced a deIay in DA ieIease vilh anphelanine, suppoiling lhal DA had lo le
iedisliiluled lo lhe cylosoI piioi lo leing ieIeased fion lhe ceII. ased on lhese diffeienl
conliilulions lo anphelanine-evoked DA incieases, ve suggesl lhal Iovei concenlialions
of D-anphelanine ieIease nevIy synlhesized DA pooIs in lhe cylosoI, and highei
concenlialions conliilule lo lhe enplying of vesicuIai sloies. Togelhei lhis pioduces a
liphasic pallein and a naiked inciease in lhe anounl of DA ieIeased al lhe highei
concenlialions (Seiden el aI. 1993, LangeIoh and TiendeIenluig 1987, SuIzei el aI.
1993,2OO5).
An aIleinalive nechanisn foi lhe D-anphelanine concenlialion-iesponse cuive nighl le
expIained ly an upieguIalion of DAT IeveIs caused ly slinuIalion of D2R auloieceplois
Ieading lo second nessengei ieguIalion. Olheis have iepoiled a Iink lelveen slinuIalion of
D2R auloieceplois and IeveIs of nenliane DATs (Iaisons el aI. 1993, Cass and Ceihaidl
1994, RolhlIal and Schneidei 1997, Dickinson el aI. 1999, Hoffnan el aI. 1999, MayfieId and
Zahnisei 2OO1). Ioi exanpIe, decieased DA cIeaiance in lhe sliialun, piefionlaI coilex, and
nucIeus accunlens aflei adninislialion of lhe D2R agonisl iacIopiide has leen
denonslialed (Cass and Ceihaidl 1994). In addilion, acule anphelanine slinuIalion caused
incieased synaplosonaI DAT suiface expiession lhal occuiied vilhin 3O seconds (}ohnson
el aI. 2OO5) indicaling lhe iapid liafficking of lhe DAT and suppoiling lhal lhese changes
vouId have occuiied duiing lhe line fiane ve veie sanpIing (Saundeis el aI. 2OOO). Due lo
lhe conpaialiveIy incieased sensilivily of D2R auloieceplois, Iov IeveIs of exliaceIIuIai DA
aie sufficienl lo slinuIale lhese auloieceplois lhal vouId iesuIl in incieased DA cIeaiance
(Coopei el aI. 2OO3) (Iig. 4). The snaII anounls of ieIeased DA iequiied lo slinuIale lhese
auloieceplois vouId le laken up quickIy lhiough incieased IeveIs of nenliane DATs,
suppoiling lhe effecls ve see vilh lhe fiisl pIaleau of lhe D-anphelanine concenlialion-
iesponse cuive. Al highei concenlialions of D-anphelanine, incieased DA cIeaiance viII
IikeIy le foIIoved ly auloieceploi desensilizalion caused ly lhe high IeveIs of DA ieIeased
aflei such a iolusl concenlialion of diug (Khoshlouei el aI. 2OO4, CoienlIa and Vaughan


103

Iig. 4. TheoielicaI nodeI of aclivily desciiling lhe doulIe IIaleaus of lhe D-anphelanine
concenlialion-iesponse cuive foi DA: IIaleau I Lov |D-anphelaninej: Lovei
concenlialions of D-anphelanine cause ieveise lianspoil of Iov IeveIs of DA lhiough lhe
DAT. In addilion, DA sensilive D2R auloieceplois aie slinuIaled. Due lo lhe incieased
cIeaiance of DA, lhe iesuIl is lhe fiisl pIaleau of lhe concenlialion-iesponse cuive. IIaleau
II High |D-anphelaninej: Anphelanine has leen shovn lo inleiacl vilh DATs and
faciIilale DA ieIease foIIoved ly DAT inleinaIizalion. Highei concenlialions of D-
anphelanine viII IikeIy cause incieased DA ieIease and DAT inleinaIizalion. D2R
auloieceploi desensilizalion is IikeIy lo occui and inleiiupl DAT expiession. Highei
IeveIs of exliaceIIuIai DA and decieased DA cIeaiance IikeIy cause lhe second pIaleau.
2OO5, Kin el aI. 2OO1, Nankung and SilIey 2OO4, Ieiguson el aI. 1996, Tang el aI. 1994) (Iig.
4). IinaIIy, dala suppoil lhal inleiaclions of anphelanine and lhe DAT Iead lo DAT
inleinaIizalion via phosphoiyIalion of laigel iesidues in lhe C- and N- leinini (Khoshlouei
el aI. 2OO4, KahIig el aI. 2OO6, Iog el aI. 2OO6), lhal nay conliilule lo lhe effecls ve see in lhe
second pIaleau of lhe D-anphelanine concenlialion-iesponse cuive. We piopose lhal lhe
anounl of D-anphelanine in AddeiaII Ieads lo a siniIai lul sIighlIy diffeienl
concenlialion-iesponse cuive. Iievious in vivo eIecliochenicaI dala suppoil lhe faslei
kinelics of lhe effecls of L-anphelanine in conlinalion vilh lhe sIovei kinelics of D-
anphelanine couId aIIosleiicaIIy noduIale DAT liafficking iendeiing a concenlialion-
iesponse vilh Iess appaienl pIaleaus (CIasei el aI. 2OO5, }oyce el aI. 2OO7). Anolhei possilIe
coiieIalion is lhe siniIai LC5O foi lolh lhe second D-anphelanine signoidaI cuive and lhe
DOIAC deciease consislenl vilh MAO inhililion.
WhiIe lhe doulIe pIaleaus ve nole heie aie in iegaids lo incieasing concenlialions of D-
anphelanine, olhei iepoils suggesl liphasic effecls of calechoIanine lianspoileis ovei
diffeienl paianeleis. }ohnson el aI. (2OO5) desciiled lhe effecls of anphelanine on DAT
suiface expiession in ial synaplosones. They desciiled iniliaI anphelanine upieguIalion of
DATs lo lhe pIasna nenliane Ieading lo DA effIux foIIoved ly anphelanine induced
inleinaIizalion of DATs aflei iepealed doses of anphelanine. }ayanlhi el aI. (2OO5) desciiled
nechanisns lhal conliilule lo a liphasic ieguIalion of endogenous seiolonin lianspoileis
(SLRTs) expiessed in pIaleIels. Iiolein Kinase C (IKC) aclivalion in pIaleIels iesuIled in lhe
iniliaI ieduclion of funclionaI SLRTs foIIoved ly enhanced endocylosis of SLRTs.


104
InliapeiiloneaI adninislialion of nelhyIphenidale in fieeIy-noving ial has leen shovn lo
cause incieases in DA IeveIs neasuied in diaIysales and sone aigue lhal lhe giealesl effecls
veie seen in lhe piefionlaI coilex (Huid and Ungeisledl 1989, eiiidge el aI. 2OO6). In
pailicuIai, Huid and Ungeisledl found lhal anphelanine and nelhyIphenidale caused
siniIai incieases in DA IeveIs, hovevei, nelhyIphenidale caused lhese IeveIs ovei a Iongei
line peiiod coiieIaling vilh lhe iolusl effecls of nelhyIphenidale ve piesenl heie. This
sludy aIso iepoiled lhal nelhyIphenidale had Iess of an effecl on decieasing DOIAC IeveIs
conpaied lo lhe noie pionounced deciease caused ly anphelanine (Huid and Ungeisledl
1989). In leins of lehavioiaI effecls, D-anphelanine and nelhyIphenidale have leen shovn
lo induce Ioconoloi aclivily al Iov doses and cause sleieolypies al highei doses (IessIei el aI.
198O, Hughes and Cieig 1976, ScheeI-Kiugei 1971). AddilionaIIy, nelhyIphenidale has aIso
leen found lo le ieinfoicing in iegaids lo diug aluse polenliaI in hunans, and il has leen
seIf-adninisleied in aninaI nodeIs (Sloops el aI. 2OO5, Rush el aI. 2OO1, Risnei and }ones 1975).
In geneiaI, cocaine and nelhyIphenidale aie lhoughl lo voik in a siniIai nannei ly
piedoninanlIy acling as conpelilive inhililois of lhe DAT (Wu el aI. 2OO1) and incieases in
exliaceIIuIai DA iesuIl piedoninanlIy fion lhis lIockade aflei inpuIse-dependenl ieIease
of DA. Hovevei, lhe iolusl exliaceIIuIai effecls of nelhyIphenidale in lhis sludy aigue
againsl lhis concepl as lhe effecls olseived niiioi d-anphelanine and nol cocaine.
WhiIe lhe aigunenl can le nade lhal lhe sludies heiein lhal invoIve IocaI appIicalions of
diugs faiI lo accounl foi phainacokinelic diffeiences lelveen lhese slinuIanls, ve piopose
lhal lhis is a pailicuIai slienglh of oui sludy. Ioi lhese expeiinenls, diugs veie appIied
ovei a iange of IeveIs, incIuding cIinicaIIy ieIevanl concenlialions (1O-5O M) and
polenliaIIy diug aluse IeveIs (>4OO M) (Wesl el aI. 1999, Shadei el aI. 1999, Kuczenski and
SegaI 2OO1, SoIanlo el aI. 2OO1, CiiIIy and LoveIand 2OO1). The Iov concenlialions veie
piojecled lo sinuIale polenliaI IeveIs of diug lhal vouId le piesenl in liain lissue foIIoving
syslenic oi oiaI adninislialion. IinaIIy, adninisleiing lhe diugs via ieveise niciodiaIysis
eIininaled phainacokinelic issues fion lhe sludy aIIoving foi noie of lhe puie effecls of
lhe diugs on DA neive leininaIs.
In sunnaiy, ve have shovn lhal lhe D-anphelanine concenlialion-iesponse cuive of DA
dispIayed a doulIe pIaleau pallein indicaling effecls on DA sloies and/oi iapid ieguIalion
of DAT liafficking and/oi funclion. These dala suppoil lhal nelhyIphenidale nay cause
DA ieIease in addilion lo acling as a DA uplake inhililoi. Taken logelhei, lhese dala expIain
lhe effecls of cIinicaIIy avaiIalIe slinuIanls on DA IeveIs ovei a iange of concenlialions and
confiin lhal nelhyIphenidale, d-anphelanine, and conlinalions of anphelanine isoneis
have polenl, yel diffeienl, effecls on dopanine in lhe sliialun.
2.8 Future directions in the neuropsychopharmacoIogy of ADHD
The dala piesenled heiein denonsliales lhe liansIalionaI aspecl of hov lhe cuiienlIy
avaiIalIe slinuIanls aie diffeienl fion each olhei, and lheiefoie lacks up lhe cuiienl
piaclice of liying diffeienl slinuIanls on palienls lo naxinize efficacy and nininize side
effecls. Il is aIso suggesls lhal olhei peicenlages of I-anphelanine nay le usefuI lo lesl in
lhe fuluie foi sone palienls vilh ADHD nay iespond lellei lo lhen. Yel, lhis dala does
IillIe lo addiess sone of lhe Iaigei piolIens lhal face us in undeislanding ADHD and in
finding supeiioi liealnenls foi ADHD. Sone nighl aigue lhal lhe slinuIanls aie IaigeIy
effeclive and safe aIieady. ul vilh lhe iisk of aluse and diveision, lhe facl lhal nany


105
adoIescenls and aduIls do nol Iike hov lhey feeI on lhen and nany olhei faclois such as
vhelhei oi nol lhey liuIy deciease a peisons sulsequenl iisk foi sulslance aluse, lheie is sliII
ioon foi inpioved nedicalions. Ieihaps one goaI nay le lo find a nedicalion lhal liuIy heIps
onIy lhose vilh ADHD, since slinuIanls acluaIIy can le peifoinance enhancing diugs lhal
can give peopIe such as coIIege sludenls vilhoul ADHD lenefils in sludying oi laking lesls
vilh IillIe knovIedge of lheii possilIe dangeis oi elhicaI inpIicalions.
In lhe fuluie il viII le usefuI lo noie fuIIy undeisland nol onIy lhe neuioliansnilleis invoIved
in lhe vaiious aspecls of ADHD, lul lhe vay lhal ciicuiliy and liain iegion inleiacl lo Iead lo
dysfunclion. Neuioinaging nay conliilule giealIy lo lhis as il ollains giealei iesoIulion and
vays lo neasuie sepaiale neuioliansnillei syslens. Oui Ial and olheis have legun lo use
neuioliansnillei specific pioles lo neasuie noie accuialeIy second ly second changes in
neuioliansnilleis. We aie finding lhe niIieu is nuch noie heleiogeneous lhan pieviousIy
undeislandalIe ly niciodiaIysis. As nicioeIecliode lechnoIogy inpioves and gels noie
conpacl, ieaI-line iecoidings of nuIlipIe liain aieas vhiIe lhe aninaI is avake viII ansvei
noie queslions and aIIov foi noie piecise diug deveIopnenl. IinaIIy, phainacogenonics is
slailing lo yieId sone lenefil and nay heIp in noie laigeled use of lhe iighl slinuIanls foi lhe
iighl palienl inslead of lhe liiaI and eiioi nelhod nov enpIoyed.
3. ConcIusion
In lhis chaplei ve have ievieved lhe case foi dopanines ioIe in ADHD especiaIIy as il
peilains lo lhe nechanisns of aclion of lhe slinuIanls nelhyIphenidale and lhe vaiious
anphelanines. We have aIso shovn hov nany olhei neuioliansnilleis aie invoIved in
ADHD and aIleinalive nedicalions foi ADHD. No doull as lhe neuiopsychophainacoIogy
of ADHD evoIves, ve viII discovei noie inliicale delaiIs aloul lhe ieIalive conliilulions of
lhe neuioliansnilleis and hov lhey ieIale lo lhe genelic and neuiociicuiliy IeveIs of oui
undeislanding. The uIlinale goaI of lhis knovIedge is lo inpiove liealnenl and naxinize
safely foi peopIe of aII ages vilh ADHD.
4. AcknowIedgment
SpeciaI lhanks lo . Mallhev }oyce, Ih.D., Caiielson D. LppeiIy, M.S., Theiesa Cuiiiei
Thonas, Ih.D foi lheii conliilulions in conducling lhe expeiinenls in lhis chaplei. These
sludies veie suppoiled ly USIHS gianls MHO66393, MHO1245, DA14944, and NS39787. Iuie
sulslance AddeiaII vas piovided ly Shiie IhainaceulicaIs, Hanpshiie, Chinehan, LngIand.
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(2OO1). DoulIe-lIind, pIacelo-conlioIIed sludy of singIe-dose anphelanine
foinuIalions in ADHD. 3+.&"68 +, (5% 27%&#/6" 2/6C%7) +, B5#8C 6"C 2C+8%'/%"(
4')/5#6(&), VoI. 4O, No. 11, (Novenlei 2OO1), pp. 1268-1276.
}ayanlhi S., Deng X., Ladenhein ., McCoy MT., CIuslei A., Cai NS., Cadel }L. (2OO5).
CaIcineuiin/NIAT-induced up-ieguIalion of lhe Ias Iigand/Ias dealh palhvay is
invoIved in nelhanphelanine-induced neuionaI apoplosis. 4&+/ @6(8 2/6C 1/#
!12, VoI. 1O2, No. 3, (}anuaiy 2OO5), pp.868-73.
}ohnson LA., Iuinan CA., Zhang M., Cuplaioy ., & Cnegy ML. (2OO5). Rapid deIiveiy of
lhe dopanine lianspoilei lo lhe pIasnaIennaI nenliane upon anphelanine
slinuIalion. @%.&+;56&76/+8+A)= VoI. 49, No. 6, (Novenlei 2OO5), pp.75O-758.


108
}ones SR., Caineldinov RR., Wighlnan RM., & Caion MC. (1998). Mechanisns of
anphelanine aclion ieveaIed in nice Iacking lhe dopanine lianspoilei. 3 @%.&+'/#,
VoI. 18, No. 6, (Maich 1998), pp.1979-1986.
}oyce M., CIasei ILA., & Ceihaidl CA. (2OO7). AddeiaII pioduces incieased sliialaI
dopanine ieIease and a pioIonged line couise conpaied lo anphelanine isoneis.
4')/5+;56&76/+8+A) H>%&8I, VoI. 191, No.3, (ApiiI 2OO7), pp. 669-677.
KahIig KM., & CaIIi A. (2OO3). ReguIalion of dopanine lianspoilei funclion and pIasna
nenliane expiession ly dopanine, anphelanine, and cocaine? 9.&+;%6" 3+.&"68
+, 456&76/+8+A), VoI. 479, (Oclolei 2OO3), pp.153-158.
KahIig KM., }avilch }A., & CaIIi A. (2OO4). Anphelanine ieguIalion of dopanine lianspoil-
conlined neasuienenls of lianspoilei cuiienls and lianspoilei inaging suppoil
lhe endocylosis of an aclive caiiiei. 3+.&"68 +, >#+8+A#/68 B5%7#'(&), VoI. 279, No.1O,
(Maich 2OO4),pp. 8966-8975.
KahIig KM., inda I., Khoshlouei H., IakeIy RD., McMahon DC., }avilch }A., & CaIIi A.
(2OO5). Anphelanine induces dopanine effIux lhiough a dopanine lianspoilei
channeI. 4&+/ @6(8 2/6C 1/# !12, VoI. 1O2, No. 9, (Maich 2OO5), pp.3495-35OO.
KahIig KM., Lule }., Wei Y., LoIand C}., Celhei U., }avilch }A., CaIIi A. (2OO6). ReguIalion
of dopanine lianspoilei liafficking ly inliaceIIuIai anphelanine. L+8 456&76/+8,
VoI. 7O, No. 2, (Augusl 2OO6), pp.542-8.
Kavagoe KT., Caiiis IA., Wiedenann D}., Wighlnan RM. (1992). ReguIalion of liansienl
dopanine concenlialion giadienls in lhe nicioenviionnenl suiiounding neive
leininaIs in lhe ial sliialun. @%.&+'/#%"/%, VoI. 51, No.1, (Novenlei 1992), pp.55-64.
Khoshlouei H., Sen N., Cuplaioy ., }ohnson L., Lund D., Cnegy ML., CaIIi A., }avilch }A.
(2OO4). N-leininaI phosphoiyIalion of lhe dopanine lianspoilei is iequiied foi
anphelanine-induced effIux. 4D+1 >#+8, VoI. 2, No.3, (Maich 2OO4). pp.387-93.
Kin KM., VaIenzano K}., Rolinson SR., Yao WD., aiak LS., Caion MC. (2OO1). DiffeienliaI
ieguIalion of lhe dopanine D2 and D3 ieceplois ly C piolein-coupIed ieceploi
kinases and lela-aiieslins. 3 >#+8 B5%7, VoI. 276, No. 4O, (Oclolei 2OO1), pp.374O9-14.
Kuczenski R., SegaI DS. (2OO1). Loconoloi effecls of acule and iepealed lhieshoId doses of
anphelanine and nelhyIphenidale: ieIalive ioIes of dopanine and
noiepinephiine. 3 456&76/+8 9:; <5%&, VoI. 296, No. 3, (Maich 2OO1), pp.876-83.
LangeIoh A., & TiendeIenluig U. (1987). The nechanisn of lhe 3H-noiadienaIine ieIeasing
effecl of vaiious sulsliales of uplake 1: ioIe of nonoanine oxidase and of
vesicuIaiIy sloied 3H-noiadienaIine. @6.")" 1/57#%C%N%&A' 2&/5 456&76/+8, VoI.
336, No. 6, (Decenlei 1987), pp. 6O2-61O.
LiIe }A., Sloops WW., DuieII TM., CIasei IL., & Rush CR. (2OO6). Disciininalive-slinuIus, seIf-
iepoiled, peifoinance, and caidiovascuIai effecls of alonoxeline in nelhyIphenidale-
liained hunans. 9:; B8#" 4')/5+;56&76/+8, VoI. 14, No.2 (May 2OO6), pp. 136-47.
LudoIph AC., Udvaidi IT., Schaz U., Henes C., AdoIph O., Weigl HU., Iegeil }M., oeckeis
TM., & Ihi K}. (2O1O). Alonoxeline acls as an NMDA ieceploi lIockei in cIinicaIIy
ieIevanl concenlialions. >& 3 456&76/+8. VoI. 16O, No. 2 (May 2O1O), pp. 283-91.
Nankung Y., SilIey DR. (2OO4). Iiolein kinase C nediales phosphoiyIalion, desensilizalion,
and liafficking of lhe D2 dopanine ieceploi. 3 >#+8 B5%7, VoI. 279, No. 47,
(Novenlei 2OO4), pp. 49533-41.
MayfieId RD., Zahnisei NR. (2OO1). Dopanine D2 ieceploi ieguIalion of lhe dopanine
lianspoilei expiessed in Xenopus Iaevis oocyles is voIlage-independenl. L+8
456&76/+8, VoI. 59, No. 1, (}anuaiy 2OO1), pp.113-21.


109
Iaisons LH., }uslice } }i. (1992). LxliaceIIuIai concenlialion and in vivo iecoveiy of
dopanine in lhe nucIeus accunlens using niciodiaIysis. 3 @%.&+/5%7, VoI.58, No.1,
(}anuaiy 1992), pp.212-8.
Iaisons LH., Schad CA., }uslice } }i. (1993). Co-adninislialion of lhe D2 anlagonisl
pinozide inhilils up-ieguIalion of dopanine ieIease and uplake induced ly
iepealed cocaine. 3 @%.&+/5%7, VoI.6O, No.1, (}anuaiy 1993), pp.376-9.
Ialiick KS., & Maikovilz }S. (1997). IhainacoIogy of nelhyIphenidale, anphelanine
enanlioneis and penoIine in allenlion-deficil hypeiaclivily disoidei. F.76"
4')/5+;56&76/+8+A)J B8#"#/68 6"C 9:;%&#7%"(68, VoI. 12, No. 6, (Novenlei/Decenlei
1997), pp.527-546.
Iaxinos C., & Walson C. (1986). <5% &6( N&6#" #" '(%&%+(6:#/ /++&C#"6(%' (2
nd
ed.), Acadenic,
Sydney.
IeIhan WL., Cnagy LM., Chionis AM., uiiovs-MacLean L., Ialiano CA., Onyango AN.,
Meichenlaun DL., WiIIians A., Aionoff HR., & Sleinei RL. (1999). A conpaiison of
noining-onIy and noining/Iale afleinoon AddeiaII lo noining-onIy, lvice-daiIy, and
lhiee lines-daiIy nelhyIphenidale in chiIdien vilh allenlion-deficil/hypeiaclivily
disoidei. 4%C#6(&#/', VoI. 1O4, No.6, (Decenlei 1999), pp. 13OO-1311.
IifI C., Diolny H., Reilhei H., & Hoinykievicz OLAS. (1995). Mechanisns of lhe dopanine-
ieIeasing aclions of anphelanine and cocaine: pIasnaIennaI dopanine
lianspoilei veisus vesicuIai nonoanine lianspoilei? L+8 456&76/+8, VoI.47, No. 2,
(Ieliuaiy 1995), pp. 368-373.
Ioppei CW. (1994). The sloiy of foui saIls. 3 B5#8C 2C+8%'/ 4')/5+;56&76/+8, VoI. 4, pp. 217-223.
Iuidon MS., Slanfoid }A., Cuiiiei TD., & Ceihaidl CA. (2OO3). MiciodiaIysis sludies of D-
anphelanine-evoked sliialaI dopanine oveifIov in young veisus aged I344 ials:
effecls of concenlialion and oidei of adninislialion. >&6#" E%'%6&/5, VoI. 979, No.1-
2, (}uIy 2OO3), pp. 2O3-2O9.
Risnei ML., }ones L. (1975). SeIf-adninislialion of CNS slinuIanls ly dog.
4')/5+;56&76/+8+A#6, VoI. 43, No. 3, (Seplenlei 1975), pp.2O7-13.
Rollins TW., & Sahakian }. (1979). "IaiadoxicaI" effecls of psychonoloi slinuIanl diugs in
hypeiaclive chiIdien fion lhe slandpoinl of lehaviouiaI phainacoIogy.
@%.&+;56&76/+8+A), VoI. 18, No. 12, (Decenlei 1979), pp. 931-95O.
RolhlIal DS., Schneidei }S. (1997). RegionaIIy specific effecls of haIopeiidoI and cIozapine on
dopanine ieuplake in lhe sliialun. @%.&+'/# D%((, VoI. 228, No. 2, (}une 1997), pp.119-22.
Rush CR., Lssnan WD., Sinpson CA., akei RW. (2OO1). Reinfoicing and suljecl-ialed
effecls of nelhyIphenidale and d-anphelanine in non-diug-alusing hunans. 3
B8#" 4')/5+;56&76/+8, VoI. 21, No. 3, (}une 2OO1), pp.273-86.
Sandei K., Kollke T., & Slaik H. (2OO8). Hislanine H3 Receploi Anlagonisls Co lo CIinics.
>#+8? 456&7? >.88= VoI. 31, No. 12, (Decenlei 2OO8), pp. 2163~2181.
Saundeis C., Ieiiei }V., Shi L., Chen }Y., MeiiiII C., Lanl ML., Leel-Lundleig LMI.,
CaiveIIi L., & }avilch }A, CaIIi A. (2OOO). Anphelanine-induced Ioss of hunan
dopanine lianspoilei aclivily: an inleinaIizalion- dependenl and cocaine-sensilive
nechanisn. 4&+/ @6(8 2/6C 1/# !12. VoI. 97, No.12, (}une 2OOO), pp. 685O-6855.
ScheeI-Kiugei }. (1971). Conpaialive sludies of vaiious anphelanine anaIogues
denonslialing diffeienl inleiaclions vilh lhe nelaloIisn of lhe calechoIanines in
lhe liain. 9.& 3 456&76/+8, VoI. 14, No.1, pp. 47-59.
Schveii MM., SkoInick I., Raffeily MI., Rice KC., }anovsky A}., IauI SM. (1985).
|3HjThieo-(+/-)-nelhyIphenidale linding lo 3,4-dihydioxyphenyIelhyIanine
uplake siles in coipus sliialun: coiieIalion vilh lhe slinuIanl piopeilies of iilaIinic
acid esleis? 3 @%.&+/5%7, VoI.45, No.4, (Oclolei 1985), pp.1O62-7O.


110
Seenan I., Madias . (2OO2). MelhyIphenidale eIevales iesling dopanine vhich Ioveis lhe
inpuIse-liiggeied ieIease of dopanine: a hypolhesis. >%56$ >&6#" E%', VoI.13O,
No.1, (Maich 2OO2), pp.79-83.
Seiden LS., & SaloI KL. (1993). Anphelanine-effecls on calechoIanine syslens and
lehavioi. 2"". E%$ 456&76/+8 <+:#/+8, VoI. 33, pp.639-677.
SegaI DS. (1974). ehavioiaI chaiacleiizalion of d- and I- anphelanine: neuiochenicaI
inpIicalions. 1/#%"/%, VoI. 19O, (Oclolei 1974), pp. 475-477.
Shadei RI., Hainalz }S., OesleiheId }R., IaineIee DX., SaIIee IR., CieenlIall D}. IopuIalion
phainacokinelics of nelhyIphenidale in chiIdien vilh allenlion-deficil
hypeiaclivily disoidei. 3 B8#" 456&76/+8, VoI. 39, No. 8, (Augusl 1999), pp.775-85.
Snilh A. (2OO2). Lffecls of caffeine on hunan lehavioi. O++C B5%7 <+:#/+8. VoI. 4O, No. 9,
(Seplenlei 2OO2), pp. 1243-55.
SoIanlo MV., Ainslen AIT., & CasleIIanos IX. (2OO1) 1(#7.86"( C&.A' 6"C 2PFPQ N6'#/ 6"C
/8#"#/68 "%.&+'/#%"/%, Oxfoid Univeisily Iiess, Nev Yoik.
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conduclances of lhe hunan dopanine lianspoilei: lhe aclions of dopanine and
psychoslinuIanls. 3 @%.&+'/#= VoI. 17, No. 3, (Ieliuaiy 1997), pp. 96O-974.
Sloops WW., LiIe }A., IiIInoie MT., CIasei IL., Rush CR. (2OO5). Reinfoicing effecls of
nelhyIphenidale: infIuence of dose and lehavioiaI denands foIIoving diug
adninislialion. 4')/5+;56&76/+8+A) H>%&8I, VoI. 177, No. 3, (}anuaiy 2OO5), pp.349-55.
SliohI MI. (2O11). iadIey's enzediine sludies on chiIdien vilh lehavioiaI disoideis. R68% 3
>#+8 L%C, VoI. 84, No. 1, (Maich 2O11), pp. 27-33.
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pionole ieveise lianspoil of dopanine in venliaI nidliain neuions? 3 @%.&+/5%7 ,
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SuIzei D., Chen TK., Lau YY., Kiislensen H., Raypoil S., Lving A. (1995). Anphelanine
iedisliilules dopanine fion synaplic vesicIes lo lhe cylosoI and pionoles ieveise
lianspoil. 3 @%.&+'/#, VoI. 15, No.5, (May 1995), pp.41O2-8.
SuIzei D., Sondeis MS., IouIsen NW., & CaIIi A. (2OO5). Mechanisns of neuioliansnillei
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2OO5), pp. 4O6- 433.
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synlhesis ly anphelanine in sliialaI sIices? 3 456&76/ 9:; <5%&, VoI. 2O2, No.3,
(Seplenlei 1977), pp.565-58O.
Wang M., Ranos I., IaspaIas CD., Shu Y., Sinen A., Duque A., Vijayiaghavan S., iennan
A., DudIey A., Nou L., Mazei }A., McCoinick DA., Ainslen AI. (2OO7). AIpha2A-
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inlo nucIeus accunlens coie and sheII suliegions of ials diffeienliaIIy sensilive lo
dopanineigic diugs. >%56$ >&6#" E%', VoI. 98, No. 1, (}anuaiy 1999), pp.155-65.
Wise RA., Hoffnan DC. (1992). LocaIizalion of diug ievaid nechanisns ly inliacianiaI
injeclions. 1)"6;'%, VoI. 1O, No.3, (Maich 1992), pp.247-63.
Wu Q., Reilh ML., Kuhai M}., CaiioII II., & Caiiis IA. (2OO1). IiefeienliaI incieases in
nucIeus accunlens dopanine aflei syslenic cocaine adninislialion aie caused ly
unique chaiacleiislics of dopanine neuioliansnission. 3 @%.&+'/= VoI. 21, No. 16,
(Augusl 2OO1), pp. 6338-6347.
6
Trends in the Prescribing and Adverse Drug
Reactions Patterns of PsychostimuIants Among
Danish ChiIdren and AdoIescents
Lise Aagaaid and Llla HoIne Hansen
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1. Introduction
The use of psychoslinuIanls, pailicuIaiIy nelhyIphenidale, lo lieal Allenlion
Deficil/Hypeiaclivily Disoidei (ADHD) synplons in chiIdien and adoIescenls has
incieased iapidIy since lhe 199Os (Schuleil el aI. 2O1O). In lhe 2OOOs seiious iepoils on
caidiovascuIai adveise diug ieaclions (ADRs), sudden dealhs and psychialiic disoideis
have Ied lhe ieguIaloiy agencies in Luiope and lhe Uniled Slales (US) lo vain againsl use of
psychoslinuIanls in lhe paedialiic popuIalion (Schuleil el aI., 2O1O). In }uIy 2OO7, cIass
IaleIs veie inpIenenled in lhe pioducl infoinalion lo iefIecl noie specific infoinalion
aloul caidiovascuIai and psychialiic adveise evenls and Iong-lein suppiession of giovlh
(Luiopean Medicines Agency, 2OO7, US Iood and Diug Adninislialion, 2OO7). Despile lhese
vainings, lhe nunlei of chiIdien liealed as veII as lhe anounl of psychoslinuIanls
piesciiled pei chiId has sleadiIy incieased (KaIveidijk el aI., 2OO8).
Sludies have shovn lhal lhe use of psychoslinuIanls in chiIdien in lhe NelheiIands
incieased 8 lines fion 1996 lo 2OO6 (Tiip el aI., 2OO9) and in Ceinany vilh 96 fion 2OOO lo
2OO7 (Schuleil el aI., 2O1O). Iion 1994 lo 2OO4 lhe use of psychoslinuIanls in chiIdien
incieased 5 lines in Noivay (Ashein el aI., 2OO7), and fion 1987 lo 1996 lhe use of
psychoslinuIanls incieased 1O lines anong US chiIdien (Zuvekas el aI., 2OO6).
Infoinalion aloul ADRs fion psychoslinuIanls has leen iepoiled in seveiaI cIinicaI sludies
of shoil duialion, piinaiiIy conducled in 6 lo 12-yeai oIds loys, pailicuIaiIy in lhe US
(Ioch el aI., 2OO9). The najoiily of ADRs iepoiled in lhese sludies veie of lhe lype
0$;&%*5(&";&5($/ 25;*%2"%; as veII as ("%A*>;- and #;1.-5$&%5. disoideis, and onIy fev seiious
ADRs veie iepoiled (Ioch el aI., 2OO9). In spile of phainacoIogicaI liealnenl of chiIdien
vilh ADHD leing connon, lhis piaclice has leen highIy delaled anong heaIlh caie
piofessionaIs due lo lhe diIenna of liealing chiIdien vilh sulslances polenliaI foi aluse,
vheie infoinalion aloul Iong-lein safely aspecls is veiy Iiniled (Ioch el aI., 2OO9). The


112
conceins aloul safely issues fion use of psychoslinuIanls in lhe paedialiic popuIalion aie
aIso due lo lhe nany anecdolaI iepoils of seiious psychialiic ADRs and sudden dealhs lhal
have leen sulnilled lo lhe ieguIaloiy agencies ovei iecenl yeais (Iiingshein & Sleeves,
2O11). Syslenalic anaIyses of ADRs iepoiled lo nalionaI dalalases aie necessaiy, as lhese
dalalases conslilule an inpoilanl, lhough undeieslinaled, souice of dala, especiaIIy aloul
nev, seiious and iaieIy occuiiing ADRs (Hansen, 1992, Aagaaid & Hansen, 2OO9a). We did
nol Iocale any sludies vhich syslenalicaIIy have anaIysed sponlaneous iepoils foi
psychoslinuIanls sulnilled lo nalionaI dalalases conpaied lo dala on nedicine use in lhe
paedialiic popuIalion.
The oljeclive of lhis chaplei vas lo 1) desciile liends in piesciiling of psychoslinuIanls in
lhe Danish paedialiic popuIalion and 2) chaiacleiise sponlaneous ADR iepoils sulnilled lo
lhe Danish Medicines Agency (DKMA) ovei a decade vilh iespecl lo occuiience,
seiiousness, lype and age and gendei of lhe chiId, iepoiled foi psychoslinuIanls.
2. Methods
2.1 Design
We conducled a ieliospeclive anaIysis of aII sponlaneous ADR iepoils foi O-17-yeai oId
chiIdien fion 2OOO lo 2OO9. Dala veie ollained fion lhe Danish ADR dalalase and pIaced
al lhe disposaI of lhis sludy in anonynous foin vilh enciypled peison idenlificalion. The
unil of anaIysis vas one ADR. Dala on nedicine use fion each of lhe slinuIanls veie
exliacled on individuaI IeveI fion lhe nalionaI Danish nedicines iegisliy as defined daiIy
doses (DDD) pei 1OOO inhalilanls pei day and useis (nunlei of liealed peisons pei 1OOO
inhalilanls).
2.2 Setting
2.2.1 Danish registry of medicine use
In onIy a fev counliies infoinalion aloul nedicine use al lhe individuaI IeveI is avaiIalIe,
Dennaik leing one of lhese counliies. The Regisliy of MedicinaI Iioducl Slalislics is a
nalionaI dalalase coveiing aII oulpalienl phainacy-dispensed piesciiplions in Dennaik.
The iegisliy vas eslalIished in 1994 lo piovide conpIele slalislics on lhe use of nedicines in
Dennaik. Dala on piesciiplions aie iegisleied foi each palienl via lhe civiI iegislialion
nunlei. Lach piesciiplion iecoid conlains lhe dale of puichase, lhe dispensing phainacy,
lhe piesciiling physician and delaiIed infoinalion on lhe diug dispensed, incIuding
pioducl nane, analonicaI lheiapeulic cIassificalion (ATC) syslen nane, dosage, package
size and foinuIalion. Medicine use is iecoided in diffeienl vays. In lhis sludy ve appIy lhe
defined daiIy doses (DDD) pei 1OOO inhalilanls and nunlei of useis pei 1OOO inhalilanls
foi oui anaIysis. The DDD is defined al lhe assuned aveiage nainlenance dose pei day foi
a diug used foi ils nain indicalion in aduIls (WHO, 2O11).
2.2.2 Definition of psychostimuIants
A psychoslinuIanls is an agenl lhal causes an inciease in funclionaI aclivily, usuaIIy of lhe
cenliaI neivous syslen (Hovaid el aI., 2O1O). LxanpIes of lhese kinds of effecls nay
Trends in the Prescribing and Adverse
Drug Reactions Patterns of Psychostimulants Among Danish Children and Adolescents

113
incIude enhanced aIeilness, vakefuIness, and Ioconolion, anong olheis. Due lo lheii effecls
lypicaIIy having an "up" quaIily lo lhen, slinuIanls aie aIso occasionaIIy iefeiied lo as
"uppeis". SlinuIanls (anaIeplics) pioduce a vaiiely of diffeienl kinds of effecls ly enhancing
lhe aclivily of lhe cenliaI and peiipheiaI neivous syslens (Hovaid el aI, 2O1O).
In lhis sludy ve focus on lhe lype of slinuIanls nosl fiequenlIy piesciiled in Dennaik, i.e.
nelhyIphenidale, aloxoneline, nodafiniI and anphelanine deiivales in lhe paedialiic
popuIalion. Accoiding lo lhe officiaI sunnaiy of pioducl infoinalion nelhyIphenidale and
alonoxeline aie Iicensed foi liealnenl of ADHD in chiIdien and adoIescenls fion 6 and 8
yeais of age iespecliveIy. ModafiniI and anphelanine deiivales aie nol Iicensed foi use in
chiIdien (Danish Medicines Agency, 2O11).
2.2.3 ADR reporting system
The iepoiling of ADRs has leen olIigaloiy in Dennaik since 1 May 1968. IniliaIIy, onIy
physicians veie coveied ly lhe olIigalion, hovevei, in 1972, denlisls and veleiinaiy
suigeons veie aIso iequiied lo iepoil ADRs (Aagaaid el aI., 2OO8l). Since 1995, diug
nanufacluieis have leen olIiged lo keep iegisleis of suspecled and denonslialed ADRs
and lo nake lhese avaiIalIe lo lhe ieguIaloiy aulhoiilies. Since }uIy 2OO3, consuneis and
olhei heaIlh caie piofessionaIs have leen alIe lo iepoil ADRs diieclIy lo lhe aulhoiilies
(Aagaaid el aI., 2OO8l). An ADR iepoil is defined ly lhe foIIoving foui ciileiia, vhich nusl
le incIuded in aII iepoils: (i) infoinalion aloul lhe palienl, (ii) lhe suspecled nedicine(s),
(iii) lhe piesuned ADR(s), and (iv) infoinalion aloul lhe peison naking lhe iepoil. An
ADR iepoil nay conlain one oi noie ADR leins (Aagaaid el aI., 2OO8l).
Aflei ieceiving lhe ADR iepoils, piofessionaI slaff al lhe DKMA code and calegoiize lhe
ADRs ly degiee of seiiousness and lype of ieaclion accoiding lo lhe MedicaI Diclionaiy foi
ReguIaloiy Aclivilies (MedDRA) leininoIogy (Aagaaid el aI., 2OO8l).
ADR iepoils aie foivaided eIeclionicaIIy lo lhe iespeclive phainaceulicaI conpanies,
vhich peiiodicaIIy assess lhe ADR iepoils ieceived. The iesuIls of lheii assessnenls aie
iepoiled lo lhe DKMA via peiiodic safely updale iepoils (ISURs). The Danish ADR
dalalase conlains aII sponlaneous ADR iepoils in Dennaik, incIuding lhose iepoiled
diieclIy lo lhe phainaceulicaI conpanies (Aagaaid el aI., 2OO8l).
2.2.4 Adverse drug reaction (ADR)
An ADR is defined as any noxious and uninlended iesponse lo nedicines lhal occuis al
doses noinaIIy used in hunans foi lhe piophyIaxis, diagnosis oi lheiapy of diseases
(VoIune 9, 2OO9).
2.2.5 Criteria for seriousness
Seveiily of iepoiled ADRs vas cIassified accoiding lo lhe ciileiia defined in voIune 9 of lhe
iuIes goveining nedicinaI pioducls in lhe Luiopean Union guideIine (VoIune 9, 2OO9).
Heie seiious ADRs aie divided inlo: iesuIling in dealh, Iife-lhiealening, iequiiing
hospilaIizalion oi pioIongalion of exisling hospilaIizalion, iesuIling in peisislenl oi


114
significanl disaliIily/incapacily in lhe iepoileis opinion, a congenilaI anonaIy/liilh defecl
and olhei nedicaIIy inpoilanl condilions (VoIune 9, 2OO9).
Olhei ieaclions veie cIassified as leing non-seiious.
2.2.6 AnatomicaI therapeutic chemicaI (ATC) cIassification groups
The ATC syslen cIassifies nedicinaI pioducls accoiding lo lhe piinaiy consliluenl, oigan
oi syslen on vhich lhey acl and lheii chenicaI, phainacoIogicaI and lheiapeulic piopeilies.
Medicines aie divided inlo 14 nain gioups (fiisl IeveI), vilh one lheiapeulic sulgioup
(second IeveI). The lhiid and fouilh IeveIs aie chenicaI/phainacoIogicaI/lheiapeulic
sulgioups and lhe fiflh IeveI is lhe chenicaI sulslance (WHO ATC index, 2O11).
The exliacl fion lhe ADR dalalase onIy piovides infoinalion accoiding lo lhe liade nane of
lhose nedicinaI pioducls lhal have leen iepoiled as causing ADRs. Theiefoie il vas necessaiy
lo liansIale nanuaIIy liade nanes inlo geneiic nanes al ATC IeveI 5 in lhe nalionaI nedicines
iegislei, and lhen iun lhe geneiic foin of lhe nedicine nane againsl lhe ADRs iepoiled.
2.3 Data extraction
Iiesciiplion dala veie exliacled fion lhe Danish iegisliy of dispensed nedicine. We
exliacled infoinalion aloul DDDs pei 1OOO inhalilanls pei day and nunlei of peisons pei
1OOO inhalilanls piesciiled foi psychoslinuIanls anong chiIdien fion O lo 17-yeais of age.
Infoinalion aloul gendei vas aIso exliacled fion lhe iegisliy. ADR iepoils sulnilled lo
lhe DKMA veie pIaced al lhe disposaI of lhis sludy in anonynous foin vilh enciypled
idenlificalion of lhe nedicine usei. Dala veie exliacled fion lhe ADR dalalase on
Miciosofl LxceI fiIes and lhe naleiiaI conpiised aII ADR iepoils on chiIdien fion liilh lo
17 yeais of age iepoiled lo lhe Danish Medicines Agency fion 2OOO lo 2OO9 foi lhe
psychoslinuIanls. The unil of anaIysis vas one ADR.
The Danish ADR dalalase defines five calegoiies of peisons vho nay sulnil dala lo lhe
dalalase. This ailicIe appIies lhis officiaI designalion foi calegoiy of peison sulnilling iepoils:
Lavyei: palienl injuiy insuieis and/oi Iav fiins
Ihainacisl: connunily oi hospilaI phainacisls
Ihysician: geneiaI piaclilioneis, physicians and denlisls
Olhei heaIlh caie piofessionaI: nuises, phainaceulicaI conpanies, sociaI and heaIlh
caie assislanls
Consuneis: palienls, palienls ieIalives, olhei nenleis of lhe pulIic
ecause consuneis have had lhe oppoilunily lo iepoil ADRs in Dennaik since 2OO3, iesuIls
fion lhis calegoiy onIy covei dala fion lhe Iasl 6.5 yeais of lhe sludy peiiod.
3. ResuIts
3.1 Prescribed psychostimuIants, 2000-2009
Iiguie 1 dispIays lhe annuaI nunlei of DDD/1OOO inhalilanl/day and no. of peisons/1OOO
inhalilanls/day foi aII lypes of psychoslinuIanls piesciiled foi chiIdien fion O lo 17-yeais
of age.

115
Iion 2OOO lo 2OO9 lhe nunlei of piesciiled DDDs/1OOO inhalilanls/day incieased vilh 1629
(fion 1O.87 lo 187.97 DDD/1OOO/inhalilanls/day) and lhe nunlei of liealed peisons/1OOO
inhalilanls/day incieased vilh 775 (fion 21 lo 183.67 DDD/1OOO/inhalilanls/day).
Iion 2OOO lo 2OO4 lhe IeveI of piesciiling vas ialhei conslanl, hovevei fion 2OO5 and
onvaids Iaige incieases in lhe piesciiling of psychoslinuIanls veie olseived.
0
20
40
60
80
100
120
140
160
180
200
2
0
0
0
2
0
0
1
2
0
0
2
2
0
0
3
2
0
0
4
2
0
0
5
2
0
0
6
2
0
0
7
2
0
0
8
2
0
0
9
Year
N
u
m
b
e
r
DDD/1000
inhabitants/day
Persons/1000
inhabitants/day

Iig. 1. AnnuaI nunlei of DDDs/1OOO inhalilanls/day and nunlei of peisons/1OOO
inhalilanls/day foi psychoslinuIanls foi chiIdien fion O lo 17-yeais of age, (2OOO-2OO9)
TalIe 1 dispIays DDDs pei 1OOO inhalilanl/yeai pei calegoiy of psychoslinuIanl nedicalions
fion 2OOO lo 2OO9. MelhyIphenidale vas lhe doninanl piesciiled psychoslinuIanl foIIoved
ly alonoxeline. OnIy fev chiIdien and adoIescenls veie piesciiled pioducls conlaining
anphelanine deiivales and nodafiniI.
Iion 2OOO lo 2OO9 lhe nunlei of piesciiled DDDs/1OOO inhalilanls/day incieased vilh
1557 foi nelhyIphenidale (fion 1O.69 lo 177.16 DDD/1OOO/inhalilanls/day), and foi
alonoxeline an inciease in DDDs of 1274 vas olseived (fion O.74 lo 1O.17 DDD/1OOO/
inhalilanls/day).

"#$% &''' &''( &''& &'') &''* &''+ &'', &''- &''. &''/
Anphelanine
deiivales
O.17 O.18 O.15 O.18 O.3 O.3 O.36 O.44 O.41 O.3
Alonoxeline O O O O O O O.74 4.O3 7.17 1O.17
MelhyIphenidale 1O.69 12.79 16.73 2O.79 31.O9 44.89 61.97 75.77 122.46 177.16
ModafiniI O O.O6 O.22 O.32 O.33 O.25 O.18 O.24 O.31 O.25
TalIe 1. AnnuaI nunlei of DDD/1OOO inhalilanls/day ly psychoslinuIanls foi chiIdien
fion O lo 17-yeais of age, (2OOO-2OO9)


116
Iiguie 2 dispIays lhe annuaI disliilulion of piesciiled DDDs/1OOO inhalilanls/day foi
nelhyIphenidale ly gendei. The najoiily, 8O of DDDs veie piesciiled in loys.
Iion 2OOO lo 2OO9 lhe use of psychoslinuIanls in loys incieased vilh a facloi 16 (fion 18.92
lo 294.45) and in giiIs vilh a facloi 32 (fion 2.39 lo 76.O3 DDD/1OOO inhalilanls/day).

O
5O
1OO
15O
2OO
25O
3OO
35O
2OOO 2OO1 2OO2 2OO3 2OO4 2OO5 2OO6 2OO7 2OO8 2OO9
Yeai
D
D
D
/
1
O
O
O

i
n
h
a
l
i
l
a
n
l
s
/
d
a
y
MaIe
IenaIe

Iig. 2. AnnuaI disliilulion of DDDs/1OOO inhalilanls/day foi nelhyIphenidale ly gendei,
2OOO - 2OO9.

O
1O
2O
3O
4O
5O
6O
7O
8O
2OOO 2OO1 2OO2 2OO3 2OO4 2OO5 2OO6 2OO7 2OO8 2OO9
Yeai
N
o

o
f

A
d
v
e
i
s
e

d
i
u
g

i
e
a
c
l
i
o
n
s
Anphelanine deiivales
Alonoxeline
MelhyIphenidale
ModafiniI

Iig. 3. AnnuaI nunlei of adveise diug ieaclions (ADRs) iepoiled foi psychoslinuIanls in
chiIdien, 2OOO -2OO9

117
3.2 Reported adverse drug reactions for psychostimuIants, 2000-2009
Iion 2OOO lo 2OO9 a lolaI of 13O ADR iepoils incIuding 329 ADRs veie iepoiled foi
psychoslinuIanls foi individuaIs fion liilh lo 17 yeais of age. One haIf of ADRs veie
seiious (N = 165), and no falaI cases veie iepoiled.
Iiguie 3 dispIays lhe annuaI nunlei of iepoiled ADRs ly lype of psychoslinuIanl. The
najoiily of lhe ADRs veie iepoiled foi nelhyIphenidale (N = 251) and alonoxeline (N = 69).
OnIy fev ADRs veie iepoiled foi anphelanine deiivales (N = 2) and nodafiniI (N = 7).
3.2.1 Adverse drug reactions by type of reporter
The disliilulion of ADRs iepoiled foi psychoslinuIanls ly seiiousness and lype of iepoilei
is dispIayed in lalIe 2.
Sevenly-six peicenl of ADRs veie iepoiled ly physicians, 13 of ADRs ly consuneis and
1O of ADRs veie iepoiled ly olhei heaIlh caie piofessionaIs.

012# 34 %#23%5#% 67189:9$; <=>6? >3;8@A#% 035$B
Anphelanine deiivales 2(1) O O 2(1)
Alonoxeline 68(31) O 1(O) 69(31)
MelhyIphenidale 19O(71) 31(25) 3O(3O) 251(126)
ModafiniI 7(7) O O 7(7)
TolaI 267(11O) 31(25) 31(3O) 329(165)
*: OHCI: olhei heaIlh caie piofessionaIs
TalIe 2. TolaI nunlei of adveise diug ieaclions (ADRs) disliiluled ly lype of iepoilei,
nedicalion and ciileiia of seiiousness (in paienlheses), 2OOO-2OO9
3.2.2 Adverse drug reactions by age and gender
TalIe 3 shovs lhe disliilulion of ADRs iepoiled foi psychoslinuIanls ly age, gendei and
seiiousness in lhe paedialiic popuIalion, 2OOO-2OO9.
TolaIIy, 8O of ADRs veie iepoiled foi loys and 2O of ADRs foi giiIs.
The Iaigesl nunlei of ADRs (N = 75) veie iepoiled in 9 lo 1O-yeai-oIds, foIIoved ly 16 lo
17-yeai oIds ( N = 33) and 15 lo 16-yeai oIds (N = 32). Less lhan one peicenl of ADRs vas
iepoiled in chiIdien up lo 4 yeais of age.
The Iaigesl nunlei of ADRs vas iepoiled in 9 lo 1O-yeai oId loys (N = 68). In 16-17 -yeai
oIds giiIs, a Iaigei nunlei of ADRs (N = 2O) veie iepoiled lhan in loys. In lhe age gioup a
nunlei of ADR iepoils veie sulnilled vilhoul infoinalion aloul gendei.
AppioxinaleIy 5O of ADRs iepoiled foi lolh loys and giiIs veie seiious, hovevei Iaige
vaiialions veie olseived vilhin age gioups.
TalIe 4 shovs lhe disliilulion of iepoiled ADRs ly gendei and lype of psychoslinuIanl.


118
CD# D%3@28 E"F G318 H9%B8 IC? 035$B
<1 O O O O
1<2 O O O O
2<3 O O O O
3<4 O O O O
4<5 1(O) O O 1(O)
5<6 6(2) O O 6(2)
6<7 18(13) O O 18(13)
7<8 1O(5) 4(O) 3(O) 17(5)
8<9 21(7) 4(3) O 25(1O)
9<1O 68(42) 7(O) O 75(42)
1O<11 14(1) O O 14(1)
11<12 2O(6) 1(O) O 21(6)
12<13 19(9) 1(O) O 2O(9)
13<14 23(16) 3(O) O 26(16)
14<15 16(5) 5(3) O 21(8)
15<16 24(1O) 8(6) O 32(16)
16<17 13(8) 2O(15) O 33(23)
17<18 18(1O) 2(O) O 2O(1O)
TolaI 271(134) 55(31) 3(O) 329(165)
*: ADR iepoils vilhoul infoinalion aloul gendei.
TalIe 3. TolaI nunlei of iepoiled ADRs ly age gioup and gendei, seiious ADRs in
paienlheses, 2OOO - 2OO9

J#K9:9;#8 G318 H9%B8 IC 035$B
Anphelanine deiivales 1(1) 1 O 2(1)
Alonoxeline 48(22) 21(9) O 69(31)
MelhyIphenidale 221(11O) 34(23) 3(O) 258(133)
ModafiniI 7(7) O O O
TolaI 271(134) 55(31) 3(O) 329(165)
TalIe 4. Disliilulion of lolaI nunlei of iepoiled ADRs (N) ly gendei and nedicalion
(nunleis of seiious ADRs in paienlheses), 2OOO - 2OO9
AppioxinaleIy 85 of ADRs veie iepoiled in loys, lhe najoiily foi nelhyIphenidale and
alonoxeline. AII ADRs iepoiled foi nodafiniI occuiied in loys and lhey veie aII seiious.
Ioi anphenine deiivales one oul of 2 iepoiled ADRs occuiied in loys.
AppioxinaleIy 45 of ADRs occuiiing in loys iepoiled foi alonoxeline and
nelhyIphenidale veie seiious.

119
3.2.3 Adverse drug reactions by type and seriousness
TalIe 5 dispIays lhe chaiacleiislics of ADRs iepoiled foi psychoslinuIanls ly lype, syslen
oigan cIass, seiiousness and nedicalion.
The Iaigesl shaie of iepoiled ADRs vas of lhe lype psychialiic disoideis (21 of lolaI
ADRs) foIIoved ly lhe SOCs geneiaI disoideis (19 of lolaI ADRs) and neivous syslen
disoideis (16 of lolaI ADRs).
Ioi ADRs of lhe lype neivous- and psychialiic disoideis lhe shaie of seiious ADRs ianged
fion appioxinaleIy 5O lo 7O of lolaI ADRs. Ioi lhe nedicalions alonoxeline and
nelhyIphenidale appioxinaleIy 45 of aII iepoiled ADRs veie seiious, and foi nodafiniI
aII iepoiled ADRs veie seiious.

L185#A <%D$; >B$88 EL<>F
E$B27$M#59:$B 3%K#%F
CA27#5$A9;#
K#%9N$5#8
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Iood and Iynphalic syslen
disoideis
O 2(2) O O 2(1)
Caidiac disoideis O 11(4) 6(3) O 17(7)
CongenilaI, faniIiaI and genelic
disoideis
O O 1(1) O 1(1)
Lai and Ialyiinlh disoideis O 1 O O 1(O)
Lndociine disoideis O O 2(2) O 2(2)
Lye disoideis O 6 O O 6(O)
CaslioinleslinaI disoideis 1 22(12) 1O(2) 1(1) 34(15)
CeneiaI disoideis O 55(15) 5(2) O 6O(17)
Infeclions and infeslalions O O 1(1) O 1(1)
Invesligalions O 13(1O) 7(3) O 2O(13)
MelaloIisn and nuliilion disoideis O 7(1) 3 O 1O(1)
MuscuIoskeIelaI disoideis O 6(3) 1 O 7(3)
Neivous syslen disoideis O 48(33) 4(3) 3(3) 55(39)
Isychialiic disoideis 1(1) 48(32) 21(12) 3(3) 73(48)
RenaI and uiinaiy disoideis O 3(1) 1 O 4(1)
Repioduclive syslen and lieasl
disoideis
O 1 O O 1(O)
Respiialoiy disoideis O 4(2) 1 O 5(2)
Skin and sulculaneous lissue
disoideis
O 19(5) 3(1) O 22(6)
SuigicaI and nedicaI pioceduies O O 1 O 1(O)
VascuIai disoideis O 5(2) 2(1) O 7(3)
TolaI 2(1) 251(126) 69(31) 7(7) 329(165)
TalIe 5. TolaI nunlei of iepoiled ADRs (N) foi chiIdien disliiluled ly Syslen Oigan CIass
(SOC), nedicalion (seiious ADRs in paienlheses), 2OOO-2OO9


120
TalIe 6 shovs chaiacleiislics of ADRs iepoiled foi lhe SOC psychialiic disoideis ly lype
of nedicalion and seiiousness.

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Affecl IaliIily O 3(3) O O 3(3)
Agilalion O 2(1) O O 2(1)
Aggiession O 1 2 1(1) 4(1)
Angei O O 2(1) O 2(1)
AninaI pholia O 1(1) O O 1(1)
Anxiely O 6(2) 2(2) O 8(4)
AsociaI lehavioui O 1 O O 1
Connunicalion disoidei O 1(1) O O 1(1)
ConfusionaI slale O 2(1) O O 2(1)
Depiession O 4(3) 4(1) O 8(4)
Diug aluse O 2(2) O O 2(2)
LnolionaI disoidei O 1 O O 1
Luphoiic nood O 2(2) O O 2(2)
Iood aveision O O 1(1) O 1(1)
HaIIucinalion O 2(2) O 1(1) 3(3)
InpuIse-conlioI disoidei O O 1 O 1
Insonnia O 3(2) O O 3(2)
InlenlionaI seIf-injuiy O O 1(1) O 1(1)
Mood svings O O 1(1) O 1(1)
Nighlnaie O O 1 1(1) 2(1)
Olsessive lhoughls O O 1(1) O 1(1)
Isycholic disoidei 1(1) O 1(1) O 2(2)
IeisonaIily change O 1(1) O O 1(1)
ReslIessness O 1(1) O O 1(1)
SIeep disoidei O 7(5) 1(1) O 8(6)
SociaI avoidanl lehavioui O 3(3) O O 3(3)
SuicidaI idealion O 1(1) 3(2) O 4(3)
Tic O 2 O O 2
TolaI 1(1) 46(33) 21(12) 3(3) 73(48)
TalIe 6. TolaI nunlei of iepoiled ADRs of lhe lype psychialiic disoideis ly nedicalion,
and seiiousness (in paienlheses), 2OOO-2OO9.
Tvo-lhiid of ADRs vas iepoiled foi anphelanine deiivales and nelhyIphenidale, and lhe
nosl fiequenlIy iepoiled ADRs veie anxiely, depiession, and sIeep disoideis.
TalIe 7 dispIays lhe chaiacleiislics of ADRs iepoiled foi lhe SOC neivous syslen
disoideis ly lype of nedicalion and seiiousness.
Wilhin lhis SOC appioxinaleIy 9O of ADRs veie iepoiled foi nelhyIphenidale, lhe
najoiily of ieaclions leing dizziness, headache and dyskinesia.

121
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Akalhisia O 1(1) O O 1(1)
AlypicaI lenign pailiaI epiIepsy O O 1(1) O 1(1)
uining sensalion O 2 O O 2
CalapIexy O O O 1(1) 1(1)
Ciying O 2(1) O O 1(1)
DenyeIinalion O 2(2) O O 2(2)
Disluilance in allenlion O 1(1) O O 1(1)
Dizziness O 8(5) 1(1) 1(1) 1O(7)
Dyskinesia O 2(2) O O 2(2)
Dyslonia O 1(1) O O 1(1)
LpiIepsy O 2(1) O O 2(1)
Headache O 12(9) 2(1) O 14(1O)
Henipaiesis O 2(2) O O 2(2)
Hypoaeslhesia O 3(2) O O 3(2)
Hypolonia O O O 1(1) 1(1)
Loss of consciousness O 2(1) O O 2(1)
Nyslagnus O 1 O O 1
Isychonoloi hypeiaclivily O 2(1) O O 2(1)
ReslIess Iegs syndione O 1 O O 1
SonnoIence O 1(1) O O 1(1)
Speech disoidei O 2(2) O O 2(2)
Syncope O 1(1) O O 1(1)
TolaI O 48(33) 4(3) 3(3) 55(39)
TalIe 7. TolaI iepoiled ADRs of lhe lype neivous syslen disoideis ly nedicalion, and
seiiousness (in paienlheses), 2OOO-2OO9.
TalIe 8 shovs lhe chaiacleiislics of ADRs iepoiled foi lhe SOC geneiaI disoideis and
adninislialion sile condilions ly lype of nedicalion and seiiousness.
Wilhin lhis SOC aInosl aII ADRs veie iepoiled foi anphelanine deiivales, and no ADRs
veie iepoiled foi alonoxeline and nodafiniI. Many ADRs ieIaling lo lhe efficacy of lhe
nedicalions veie iepoiled.
A Iaige nunlei of ADRs vilhin lhe SOC gaslioinleslinaI disoideis veie aIso iepoiled
(see lalIe 5). These ieaclions veie piedoninanlIy iepoiled foi nelhyIphenidale, and veie
of lhe lypes aldoninaI pain, diaiihoea and diy noulh (dala nol shovn).
4. Discussion
This is lhe fiisl sludy fion a nalionaI ADR dalalase lhal has exanined lhe chaiacleiislics
and occuiience of ADRs fion use of psychoslinuIanls in lhe paedialiic popuIalion. The
sludy shoved lhal ovei a decade lhe piesciiling of psychoslinuIanls in lhe Danish
paedialiic popuIalion has incieased dianalicaIIy, and lhal nelhyIphenidale vas lhe
piedoninanl psychoslinuIanl. Tvo lhiid of ADRs veie iepoiled ly physicians, and
appioxinaleIy 8O of aII ADRs veie iepoiled foi loys fion alove 5 yeais of age. The


122
CKN#%8# K%@D %#$:593; ECPQF CA27#5$A9;#
K#%9N$5#8
J#571B27#;9K$5# C53A3O#59;# J3K$49;9B 035$B
Aslhenia O 2(2) O O 2(2)
Chesl pain O 5(2) O O 5(2)
ChiIIs O 1 O O 1
Diug effecl decieased O 17(1) O O 19(1)
Diug effecl incieased O 1 O O 1
Diug ineffeclive O 14(2) O O 14(2)
Diug inleiaclion O 1(1) 1(1) O 2(2)
Iace oedena O 1 O O 1
IeeIing hol O 1 O O 1
Ialigue O 7(6) 3(1) O 1O(7)
IiiilaliIily O O 1 O 1
Iain O 1(1) O O 1(1)
Iyiexia O 1 O O 1
Theiapeulic iesponse unexpecled
vilh diug sulslilulion
O 3 O O 3(O)
TolaI O 55(15) 5(2) O 6O(17)
TalIe 8. TolaI nunlei of iepoiled adveise diug ieaclions of lhe lype geneiaI disoideis and
adninislialion sile condilions ly nedicalion, and seiiousness (in paienlheses), 2OOO-2OO9.
Iaigesl shaies of iepoiled ADRs vas of lhe lype geneiaI disoideis and adninislialion
condilions, psychialiic and neivous syslen disoideis.
Iion 2OOO lo 2OO9 Iaige incieases in nunlei of piesciiled dosages and useis veie olseived,
and lhese findings veie in Iine vilh iesuIls fion olhei counliies (Ashein el aI. 2OO7,
KaIveidijk el aI., 2OO8, Tiip el aI., 2OO9, Schuleil el aI, 2O1O, Zuvekas el aI., 2OO6). The najoiily
of useis veie loys, lul ve found a Iaige inciease in use of psychoslinuIanls anong giiIs, and
lhis pallein vas expecled (Hodgkins el aI, 2O11). Iion 2OOO lo 2OO4 lhe use of
psychoslinuIanls veie al a slalIe IeveI, hovevei fion 2OO5 lhe use has incieased dianalicaIIy.
LxpIanalions of lhis inciease couId le lhe naikeling piessuie, change in diagnoslic ciileiia
and lhe deveIopnenl of nev lypes of psychoslinuIanls such as alonoxeline and nodafiniI foi
liealnenl of ADHD. In lhe sane peiiod of line lhe phainaceulicaI conpanies have naikeled
Iong-lein ieIease foinuIalions of nelhyIphenidale foi schooI use (van den an el aI, 2O1O).
Use of psychoslinuIanls in Danish chiIdien has incieased noie ovei lhe Iasl decade lhan in
olhei counliies, hovevei lhis nay le expIained ly lhe facl lhal use of psychoslinuIanls in
Dennaik vas Iovei al lhe leginning of lhe peiiod lhan in olhei counliies.
This is a desciiplive sludy, and lheiefoie ve cannol concIude vhelhei ADRs aie iepoiled
noie connonIy foi nelhyIphenidale lhan lhe olhei pioducls, neilhei vhelhei giiIs
expeiience noie ADRs lhan loys. The nunlei of ADR iepoils does nol iefIecl lhe use of
psychoslinuIanls, and lhe queslion is vheie in lhe IifecycIe of nedicinaI pioducls ADRs aie
iepoiled. Hovevei, since lhe issue is Iong-lein liealnenl of chiIdien and adoIescenls ADR
signaIs aie exlieneIy inpoilanl. A high nunlei of iepoils on decieased diug effecl and/oi
ineffeclive diugs fion use of nelhyIphenidale veie iepoiled. Whelhei lhis signaI is due lo
piolIens vilh lhe quaIily of geneiic pioducls oi lhal ieaI Iife is diffeienl fion lhe lesling
condilions (Hansen, 1992).
The najoiily of iepoils veie sulnilled ly physicians, hovevei, ve vouId aIso have expecled
a Iaigei nunlei of iepoils fion paienls, as lhey shouId le conceined aloul adninislialion

123
nedicalions lo lheii chiIdien, especiaIIy nedicalions foi Iong-lein use, vheie infoinalion
aloul Iong-lein effecls aie Iiniled. The expIanalion of lhe Iaige nunlei of iepoils fion
physicians couId le lhal lhe paienls have lecone avaie of lhe ADRs, and asked lheii
physician lo iepoil lhen. To inciease knovIedge aloul ADRs fion Iong lein use of
psychoslinuIanls lhe nunlei of iepoils sulnilled lo lhe Danish Medicines Agency and
piolalIy olhei nedicines agencies shouId le incieased and lhe ieguIaloiy aulhoiilies nusl
focus on incieasing ADR iepoiling iales fion lolh heaIlh caie piofessionaIs and consuneis.
An enpiiicaI sludy shoved lhal lhe Iicensing naleiiaI foi nelhyIphenidale piovided
nininaI evidence on efficacy and safely in chiIdien (Aagaaid el aI. 2OO9l), and no
infoinalion aloul Iong-lein safely aspecls vas iepoiled. Sponlaneous iepoils aie an
inpoilanl souice of infoinalion aloul nev and pieviousIy uniecognized ADRs, and lhe
vaIue of sponlaneous iepoiling schenes Iies in lheii aliIily lo acl as hypolhesis-geneialing
signaIs. Due lo lhe Iov nunlei of ADRs iepoiled foi psychoslinuIanls in Dennaik il is
necessaiy lo conducl fuilhei sludies lo expIoie dala aloul iaie and seiious ADRs in Iaigei
dalalases, such as lhe LU dalalase LudiaVigiIance and lhe inleinalionaI WHO-ADR
dalalase Vigilase (Aagaaid el aI, 2O1O). These dalalases conlain Iaige anounls of dala
sulnilled fion Luiopean and gIolaI popuIalions, and aie lheiefoie suilalIe foi sludying
specific ADRs oi nev signaIs.
The slienglh of oui sludy is lhal dala conpiised psychoslinuIanl piesciiplions and aII
ADRs iepoiled in one counliy ovei a decade. The puipose vas lo anaIyse infoinalion
iepoiled lo lhe Danish ADR dalalase on ADRs in lhe paedialiic popuIalion fion use of
psychoslinuIanls in lhe liealnenl of ADHD, and nol lo caIcuIale lhe incidence of ADRs in
lhis popuIalion as lhis is nol feasilIe in naleiiaI lased on sponlaneous iepoiling.
A najoi Iinilalion lo lhis sludy is lhal ve do nol knov lo vhich exlenl lhe causaIily of lhese
ADRs can le confiined, and lhis has inpIicalions foi lhe inleipielalion of lhe iesuIls.
Sponlaneous iepoiling syslens suffei fion diffeienl laiiieis, such as inconpIele
iecognilion of ADRs, adninislialive laiiieis lo iepoiling, and Iov dala quaIily, aII of vhich
nay iesuIl in lhe undeiiepoiling of inpoilanl seiious and iaie evenls. NonelheIess, lhe
sludy piovides infoinalion on iepoiled ADRs, and lhis infoinalion conliilules lo
lioadening lhe knovIedge lase on psychoslinuIanls safely.
5. ConcIusion
In Dennaik, a Iaige inciease in lhe use of psychoslinuIanls in lhe paedialiic popuIalion has
leen olseived. The Iaige nunlei of seiious iepoiled ADRs indicale lhal psychoslinuIanls
shouId le piesciiled vilh caulion of lhal giealei caie is needed in ieIalion lo piesciiling lhese
nedicalions foi chiIdien. The Danish Medicines Agency shouId noniloi piesciiling palleins
noie lighlIy lo idenlify polenliaI iisks in lhe paedialiic popuIalion in ieIalion lo lhe evoIving
uliIisalion of use of psychoslinuIanls anong chiIdien and adoIescenls and ieIaled iisks.
6. References
Aagaaid, L., Slenvei, DI., Hansen, LH. (2OO8l). Sliucluies and piocesses in sponlaneous
iepoiling syslens: a conpaialive sludy of AusliaIia and Dennaik. ,-$%'$.1 I*%/2
$(2 4.5"(.", VoI. 3O, pp. 563-7O.


124
Aagaaid, L., Hansen, LH. (2OO9a). Infoinalion aloul ADRs expIoied ly phainacovigiIance
appioaches: a quaIilalive ieviev of sludies on anliliolics, SSRIs and NSAIDs. J?<
</5(5.$/ ,-$%'$.*/*01, VoI. 3, No. 9: pp. 4.
Aagaaid, L., Thiisliup, S., Hansen, LH. (2OO9l). Opening lhe vhile loxes: lhe Iicensing
docunenlalion of efficacy and safely of psycholiopic nedicines foi chiIdien.
,-$%'$.*"#52"'5*/*01 $(2 !%>0 4$+"&13 VoI.18, pp. 4O1-411.
Aagaaid L, Chiislensen A, Hansen LH. (2O1O). Infoinalion aloul adveise diug ieaclions
iepoiled in chiIdien: a quaIilalive ieviev of enpiiicaI sludies. J%5&5;- K*>%($/ *+
</5(5.$/ ,-$%'$.*/*013 VoI. 7O, pp. 481-491.
Ashein, H. , NiIsen, K , }ohansen, } , Iuiu, K. (2OO7). Iiesciiling of slinuIanls foi ADHD
In NoidIand Counly. L52;;H%5+& +*% 2"( E*%;H" 8$"0"+*%"(5(0, VoI. 127, pp. 236O-2362.
|In Noivegianj
Ioch, MH., Ianza, KL., Landeios-Weisenleigei, A., Lecknan, }I. (2OO9). Mela-
anaIysis:liealnenl of allenlion-deficil/hypeiaclivily disoidei in chiIdien vilh
conoilid lic disoideis. K*>%($/ *+ D'"%5.$( D2*/";."(& ,;1.-5$&%1, VoI. 48, pp. 884-893.
Luiopean Medicines Agency. Meeling highIiglhs fion lhe Connillee foi MedicinaI
Iioducls foi Hunan Use, Ref. LMLA/4314O7/2OO7 London, (2OO7).
Iood and Diug Adninislialion. RilaIin-RilaIin SR. (2OO7).
Hansen, LH. (1992). TechnoIogy assessnenl in a usei peispeclive - expeiiences vilh diug
lechnoIogy. M(&"%($&5*($/ K*>%($/ *+ L".-(*/*01 D;;";;'"(& 5( N"$/&- <$%", VoI. 8, pp.
15O-165.
Hodgkins, I., Sasane, R., Meijei, WM. (2O11). IhainacoIogic liealnenl of allenlion-
deficil/hypeiaclivily disoidei in chiIdien: incidence, pievaIence, and liealnenl
palleins in lhe NelheiIands. </5(5.$/ L-"%$#">&5.;, VoI. 33, pp. 188-2O3.
Hovaid, I., Shuslei, }., Tvycioss, R., MihaIyo, M., WiIcock, A. (2O1O). IsychoslinuIanls.
K*>%($/ *+ ,$5( $(2 41'#&*'$&5. ?$($0"'"(&. VoI. 4O, pp. 789-795.
KaIveidijk, L}., Toli, H., van den eig, I., uiskooI, }., Wagenaai, L., Mindeiaa, R., de
}ong-van den eig, LT. (2OO8). Use of anlipsycholic diugs anong Dulch youlhs
lelveen 1997 and 2OO5. ,;1.-5$&%5. 4"%A5.";, VoI. 59, pp. 554-56O.
Iiingshein, T., Sleeves, T. (2O11). IhainacoIogicaI liealnenl foi Allenlion Deficil
Hypeiaclivily Disoidei (ADHD) in chiIdien vilh conoilid lic disoideis. <*.-%$("
!$&$O$;" 41;&"'$&5. :"A5"P;, VoI. 13, CDOO799O.
Schuleil, I. , Kslei, I. , LehnkuhI, C. (2O1O). The changing pievaIence of allenlion-
deficil/hypeiaclivily disoidei and nelhyIphenidale piesciiplions. !">&;.-";
Q%&R"O/$&& M(&"%($&5*($/, VoI. 1O7, pp. 615-621.
Tiip, A-M., Vissei, ST., KaIveidijk, L., de }ong-van den eig, LTW. (2OO9). Laige inciease of
lhe use of psycho-slinuIanls anong youlh in lhe NelheiIands lelveen 1996 and
2OO6. J%5&5;- K*>%($/ *+ </5(5.$/ ,-$%'$.*/*01, VoI. 67, pp. 466-468.
Van den an, L., Souveiein, IC., Svaal, H., van LngeIand, H., Lgleils, TC., Heeidink, LR.
(2O1O). Less disconlinualion of ADHD diug use since lhe avaiIaliIily of Iong-acling
ADHD nedicalion in chiIdien, adoIescenls, and aduIls undei lhe age of 45 in lhe
NelheiIands. D&&"(&5*( !"+5.5& N1#"%$.&5A5&1 !5;*%2"%, VoI. 2, pp. 213-22O.
WoiId HeaIlh Oiganizalion (WHO) CoIIaloialing Cenlie foi Diug Slalislics MelhodoIogy,
2O11. VoIune 9: ICH guideIine foi nedicinaI pioducls foi hunan use and
veleiinaiy pioducls (2OO9).
Zuvekas, SH. , VilieIIo, . , Noiquisl, CS. (2OO6). Recenl liends in slinuIanl nedicalion use
anong U.S. chiIdien. D'"%5.$( K*>%($/ *+ ,;1.-5$&%1, VoI. 163, pp.579-585.
7
Do StimuIant Medications for
Attention-Deficit/Hyperactivity Disorder (ADHD)
Enhance Cognition?
CIaiie Advokal and Chiisline Vinci
|cuisiana S|a|c Unitcrsi|q,
USA
1. Introduction
Chaiacleiislic synplons of Allenlion-Deficil/Hypeiaclivily Disoidei (ADHD) have leen
iecognized in lhe nedicaI Iileialuie foi ovei 2OO yeais. The eaiIiesl knovn cIinicaI
desciiplion is found in lhe look ly lhe Scollish physician Sii AIexandei Ciichlon, enlilIed
An |nquirq in|c |nc Na|urc and Origins cf Mcn|a| Dcrangcncn| (Ciichlon, 1798, as ciled in
auneislei el aI., 2O11). In lhe chaplei, Allenlion, and ils Diseases (p. 254), Ciichlon noles
lhal lhese condilions nake peopIe incapalIe of allending vilh conslancy lo any one oljecl
of educalion (p. 271), cause nenlaI ieslIessness, vaIking up and dovn, and lhe
fidgels (p. 272). AIlhough Ciichlon vas cIeaiIy desciiling disoideis of allenlion, Ceoige
SliII, a iilish pedialiician, is usuaIIy ciediled vilh leing lhe fiisl peison lo desciile lhe
syndione lhal has since leen iecognized as ADHD. Di. SliII gave a seiies of Iecluies on
Scnc Aoncrna| Psqcnica| Ccndi|icns in Cni|drcn in 19O2, in vhich he noled lhal even sone
chiIdien vilh noinaI inleIIigence nay exhilil a Iack of allenlion vhich is veiy
nolicealIe.|and vhichj no doull accounls lo a consideialIe exlenl foi lackvaidness in
schooI acquiienenls (SliII, 19O2l, p. 1O81 as ciled in auneislei el aI., 2O11).
Since lhose oiiginaI desciiplions, lhe diagnoslic chaiacleiizalion of ADHD has leen ievised
nuneious lines. The lhiee coie synplons aie piesenlIy consideied lo le Inallenlion,
InpuIsivily and Hypeiaclivily (auneislei el aI., 2O11, iedeinan & Iaiaone, 2OO5,
Davidson, 2OO8). Cuiienl pievaIence eslinales in lhe Uniled Slales aie 6-9 foi chiIdien and
adoIescenls and 3-5 in aduIls (Dopheide & IIizka, 2OO9). In lhe nosl iecenl NalionaI
Conoilidily Suivey, in vhich neaiIy 32OO aduIls, 19 lo 44 yeais of age, veie scieened, lhe
pievaIence vas 4.4 (KessIei el aI., 2OO6).
UnIike lhe chiIdhood piesenlalion, synplons of hypeiaclivily and inpuIsivily aie Iess
pioninenl in ADHD-diagnosed aduIls lhan piolIens iesuIling fion inallenlion,
disliacliliIily and disoiganizalion (Dopheide & IIizka, 2OO9). The psychosociaI difficuIlies
caused ly lhese synplons have leen veII-docunenled, incIuding naiilaI and ieIalionship
piolIens, pooi jol peifoinance and enpIoynenl hisloiies, and Iovei socioecononic slalus
(iedeinan el aI., 2O11a, Iischei el aI., 199O, Hechlnan el aI., 1984, Hechlnan & CieenfieId,
2OO3, Ingian el aI., 1999, Mannuzza el aI., 1993, Spencei el aI., 2OO7). Many aduIls vilh
ADHD iepoil fiequenl enpIoynenl changes, difficuIly in oiganizing finances, and


126
househoId and paienlaI nanagenenl iesponsiliIilies, dangeious diiving, and unslalIe
sociaI ieIalionships oi sociaI isoIalion (Weiss & Muiiay, 2OO3). AduIls vilh ADHD aie Iess
IikeIy lo allain lhe sane educalionaI (and occupalionaI) IeveI as lhose vilhoul lhe diagnosis
ieIalive lo vhal vouId le piedicled lased on lheii IQ, even vilh phainacolheiapy
(iedeinan el aI., 2OO6, iedeinan el aI., 2OO8a, Mannuzza el aI., 1993). Moieovei, cognilive
deficils of aduIls vilh ADHD, ieIalive lo aduIls vilhoul lhe diagnosis, do nol change acioss
lhe Iifespan (iedeinan el aI, 2O1O). Ioi exanpIe, aIlhough 84 of ADHD-diagnosed aduIls
veie slalislicaIIy expecled lo le coIIege giaduales, onIy 5O ieached lhis IeveI of educalion
(iedeinan el aI., 2OO8a).
In aduIls, as vilh youlh, fiisl-Iine liealnenl oplions incIude lhe slinuIanl diugs, usuaIIy
one of lhe nany foinuIalions of eilhei nelhyIphenidale (MIH) oi anphelanine (AMIH)
(AdIei el aI., 2OO7, einan el aI., 2OO9, Dopheide & IIizka, 2OO9, Dodson, 2OO5, Iaiaone el
aI., 2OO4, Ialeison el aI., 1999, Wendei el aI., 2O11). These agenls aie lhe nosl efficacious
diug liealnenls foi ADHD, vilh Iaige effecl sizes, as neasuied ly slandaidized ialing
scaIes in cIinicaI liiaIs. MelhyIphenidale and anphelanine foinuIalions aie consideied
siniIai in efficacy, vilh lelveen 55 - 75 of diug-liealed palienls (conpaied vilh 4 - 3O
of pIacelo - liealed palienls) shoving cIinicaIIy significanl inpiovenenl foi up lo 4 lo 6
veeks (einan el aI., 2OO9, Dopheide & IIizka, 2OO9). AvaiIalIe infoinalion indicales lhal
on slandaid efficacy neasuies, anphelanine is al Ieasl equivaIenl nay le supeiioi lo
nelhyIphenidale, and, lhal individuaIs vilh ADHD vho donl iespond lo nelhyIphenidale
viII shov significanl inpiovenenl on anphelanine (einan el aI., 2OO9). When lolh diugs
aie liied, iesponse iales nay le as high as 85 (Dopheide & IIizka, 2OO9).
Civen lheii sulslanliaI and ieIialIe cIinicaI lenefil foi liealnenl of allenlion disoideis, il is
nol suipiising lhal piesciiplions foi slinuIanls have incieased dianalicaIIy in lhe Iasl fev
yeais. elveen 1998 and 2OO5, lheie vas a 133 inciease in anphelanine pioducl
piesciiplions and a 52 inciease in nelhyIphenidale pioducls, foi leenageis and
pieleenageis in lhe US (SelIik el aI., 2OO9). Accoiding lo US goveinnenl dala, fion 1998 lo
2OO7, lolaI anphelanine piesciiplions incieased ly aloul 11.7 niIIion, oi 463 (Slix, 2OO9).
The inciease in slinuIanl piesciiplions has iesuIled in a coiiesponding escaIalion of iIIicil
use, pailicuIaiIy in coIIege sludenls, confiined ly nuneious suivey iesuIls (Advokal el aI.,
2OO8, Aiiia & DuIonl, 2O1O, HaII el aI., 2OO5, McCale el aI., 2OO5, Ralinei el aI., 2OO8, 2OO9a,
2OO9l, Ralinei el aI., 2O1O, Telei el aI., 2OO3, Telei el aI., 2OO5, Telei el aI., 2OO6, Weyandl el
aI., 2OO9, While el aI., 2OO6, WiIens el aI., 2OO8). WiIens and coIIeagues (2OO8) iepoil Iifeline
iales of diveision ianging fion 16 lo 29, vilh nedicaI piesciiplions leing given, soId oi
liaded ly sludenls. Sludies consislenlIy shov lhal nosl sludenls iepoil using slinuIanl
nedicalions, IegaIIy oi iIIicilIy, lo inpiove acadenic peifoinance, specificaIIy lo inciease
concenlialion, oiganizalion, and lhe aliIily lo slay up Iongei and sludy. ecause lhe
ialionaIe foi iIIicil slinuIanl use in undeigiaduales is usuaIIy slaled lo le inpiovenenl of
acadenic peifoinance, ialhei lhan ieciealionaI, il is nol aIvays consideied lo le as
piolIenalic as olhei lypes of diug aluse. UnfoilunaleIy, lhis is nol necessaiiIy lhe case, and
lhe nedicaI and IegaI consequences of iIIicil slinuIanl use nay le undeiappiecialed (Aiiia
& DuIonl, 2O1O, Aiiia el aI., 2OO8, Aiiia el aI., 2O11).
The cuiienl escaIalion in slinuIanl diveision and nisuse has inilialed delale aloul lhe
noiaI inpIicalions of using diugs lo inpiove acadenic peifoinance. LlhicaI discussions
aloul laking diugs foi 'cognilive enhancenenl, have leen lhe suljecl of seveiaI ediloiiaIs

Do Stimulant Medications for Attention-Deficit/Hyperactivity Disorder (ADHD) Enhance Cognition?

127
and connenlaiies (Iaiah el aI., 2OO4, CieeIy el aI., 2OO8, Haiiis, 2OO9, Monasleisky, 2OO8),
vhich confiined lhe videspiead use of lhese agenls, especiaIIy anong coIIege sludenls,
piofessionaIs and acadenics. Oflen lhe lein is used veiy lioadIy lo incIude diugs .lhal
inpiove nenoiy, concenlialion, pIanning and ieduce inpuIsive lehavioi and iisky
decision-naking.(Sahakian & Moiein-Zanii, 2OO7, p. 1157). ThoughlfuI pioposaIs foi lhe
'iesponsilIe use of cognilive-enhancing diugs aie espoused, caIIing foi lhe scienlific sludy
of lhe expecled iisks and lhe lenefils lo le gained as veII as lhe noiaI consequences of
aIIoving lioad access lo phainacoIogicaI enhancenenl of nenlaI capacilies.
These deveIopnenls Ied lhe Llhics, Lav and Hunanilies Connillee of lhe Aneiican
Acadeny of NeuioIogy (AAN) lo ieIease a speciaI iepoil, "Responding lo iequesls fion
aduIl palienls foi neuioenhancenenls," (Laiiivieie el aI., 2OO9). Accoiding lo Iead aulhoi,
Dan Laiiivieie, "A gioving nunlei of palienls vilhoul iIIness leIieve lhey can inpiove
lheii nenoiy, cognilive focus and allenlion span ly laking neuioenhancenenl diugs and
aie asking foi piesciiplions." Ioi lhe nosl pail, lhese 'neuioenhanceis consisl of slinuIanl
diugs. The diugs nosl connonIy used foi cognilive enhancenenl al piesenl aie
slinuIanls, naneIy RilaIin (nelhyIphenidale) and AddeiaII (nixed anphelanine saIls), and
aie piesciiled nainIy foi lhe liealnenl of allenlion deficil hypeiaclivily disoidei (ADHD).
One of lhe sliongesl endoisenenls vas expiessed al lhe 6O
lh
AnnuaI Confeience of lhe
Canadian Isychialiic Associalion in 2O1O ly Di. Deiiyck Snilh vho piesenled a voikshop
on lhe suljecl and slaled lhal psychialiisls shouId nol hesilale lo piesciile slinuIanls foi
neuioenhancenenl, if lhey vish. We knov lhey voik..I lhink lhe effecls of lhese
nedicalions aie lhe sane vhelhei you have a nedicaI diagnosis oi nol - lhey nake
eveiylody lellei (}ohnson, 2O1O).
These deveIopnenls iIIusliale lhe facl lhal, lecause slinuIanls have leen used effecliveIy
foi decades lo ieduce hypeiaclivily, inpuIsivily and inallenlion in chiIdien, and nov
aduIls, vilh ADHD, il has undeislandalIy leen assuned lhal lhe diugs enhance Iong-lein
inleIIecluaI peifoinance. AIlhough lhal vouId seen lo le a ieasonalIe concIusion, il luins
oul lhal lhe scienlific evidence foi lhis concIusion is Iess lhan conpeIIing. Recenl ievievs
(Advokal, 2O1O, de }ongh el aI., 2OO8, Repanlis el aI., 2O1O, Snilh & Iaiah, 2O11) piovide
veiy IillIe expeiinenlaI suppoil foi slinuIanl-induced cognilive enhancenenl. de}ongh
(2OO8) ciles a fev ieseaich sludies lhal found sone inpiovenenl in acule nenoiy lask
peifoinance vilh anphelanine in individuaIs vilh a Iov nenoiy laseIine, .vhiIe high-
|nenoiyjspan suljecls aie eilhei nol affecled oi gel voise (p. 763). SiniIai iesuIls veie
sunnaiized foi nelhyIphenidale, Wilh iegaid lo MIH |nelhyIphenidalej, ve veie nol
alIe lo piovide sufficienl evidence of posilive effecls in heaIlhy individuaIs fion oljeclive
lesls (Repanlis el aI., 2O1O, p. 2O4). A noie delaiIed anaIysis of lhe scienlific ieseaich on
slinuIanl-induced cognilive effecls in aduIls vilh and vilhoul ADHD (Advokal, 2O1O) aIso
found IillIe suppoil foi 'cognilive neuioenhancenenl vilh lhese diugs. And iecenl ailicIes
in lhe Nev Yoikei (TaIlol, 2OO9) and Scienlific Aneiican (Slix, 2OO9), desciiling lhe cuiienl
iesuigence of lhese agenls confiin lhe nodesl inleIIecluaI lenefil deiived fion lheii use in
lhe 'ieaI voiId.
AccoidingIy, lhis seIeclive ieviev viII discuss lhe evidence iegaiding cognilive effecls of
lhe lvo najoi slinuIanl nedicalions, anphelanine (AMIH) and nelhyIphenidale (MIH).
We viII enphasize infoinalion ieIaled lo acadenic oulcones, incoipoialing sone iesuIls of
oui ovn ieseaich on lhe neuiopsychoIogicaI and cognilive effecls of slinuIanl nedicalions


128
in coIIege undeigiaduales, vhich shov lhal lhese diugs do nol ieduce lhe acadenic
dispaiily lelveen ADHD-diagnosed and nonADHD-diagnosed sludenls. We viII discuss
expIanalions pioposed lo accounl foi lhe Iack of cognilive inpiovenenl vilh slinuIanl
diugs. Oui goaI is lo shed sone Iighl on lhe appaienl paiadox of slinuIanl nedicalions,
naneIy: Why do diugs lhal aculeIy inciease allenlion and concenlialion pioduce so IillIe
Iong-lein inleIIecluaI lenefil`
2. Academic achievement of chiIdren and adoIescents with ADHD
The leneficiaI effecl of slinuIanl diugs foi cIassioon nanagealiIily of lehavioi-disoideied
chiIdien vas fiisl iepoiled ly iadIey !"#$%). Duiing shoil, veekIy, liealnenl peiiods he
desciiled incieased pioduclivily, conpiehension and accuiacy of lhe chiIdien, pailicuIaiIy
in oulpul of aiilhnelic piolIens. Since lhen, a vasl Iileialuie has confiined siniIai shoil-
lein lenefils. These nedicalions have leen shovn lo aculeIy inciease lhe quaIily of nole-
laking, scoies on quizzes and voiksheels, viiling oulpul and honevoik conpIelion. The
diugs. ieduce oveiaclivily, ieslIessness and disliacliliIily, enhance allenlion span oi
concenlialion and ieduce inpuIsivily in iesponding lo vaiious lasks. Since a chiId vho is
allenlive and lellei alIe lo concenliale vouId piesunalIy Ieain noie fion his cIassioon
expeiiences, il shouId foIIov lhal lhese slinuIanl diugs vouId faciIilale lhe schoIaslic
peifoinance of hypeikinelic chiIdien (aikIey & Cunninghan, 1978, p. 85). NeveilheIess, il
has leen iecognized foi ovei 3O yeais lhal lheie is IillIe evidence lhal lhese diugs inpiove
lhe Iong-lein acadenic achievenenl of ADHD diagnosed chiIdien.
aikIey and Cunninghan (1978) iepoiled in lhe fiisl ieviev of lhe lopic, lhal in Iong lein
sludies Iasling al Ieasl one yeai (and as Iong as 5 lo 1O yeais) lhe diugs had IillIe inpacl on
acadenic oulcone. A sulslanliaI piopoilion of ADHD-diagnosed chiIdien veie in speciaI
schooIs oi cIasses, had faiIed one oi noie giades, had ieading oi aiilhnelic difficuIly and
veie having piolIens silling sliII and sludying. The aulhois concIuded lhal, in spile of
vaiious pioceduiaI diffeiences anong lhe pulIished sludies, lhe oulcones veie lhe sane -
slinuIanl diugs had IillIe inpacl on lhe .|cng-|crn acadcnic cu|ccnc cr adjus|ncn| cf
nqpcr|inc|ic cni|drcn. |f |nc drugs ccn|riou|c pcsi|itc|q, |ncq appcar |c rcducc disrup|itc ocnaticr
ra|ncr |nan inprctc acadcnic pcrfcrnancc (p. 89-9O, ilaIics added). The sane concIusion vas
ieached in a sulsequenl ieviev ly Cadov (1983) and aInosl 8 yeais Ialei, anolhei gioup
(Svanson el aI., 1991) acknovIedged lhal Lven lhough il has leen eslalIished lhal
slinuIanls do inpiove prcduc|iti|q, il is sliII uncIeai vhelhei slinuIanls aIone inpiove Iong-
lein acadenic acnictcncn|, and, lhal. vhelhei lhis videspiead cIinicaI piaclice has a Iong
lein leneficiaI effecl on Ieaining oi acadenic achievenenl is sliII an open queslion (p. 22O).
CaiIson and unnei (1993), incoipoialing lhe sludies pieviousIy discussed ly Cadov and
Svanson concuiied lhal slinuIanls faciIilaled acule acadenic pcrfcrnancc of chiIdien vilh
ADHD, lul lhal Iong lein liealnenl did nol inpiove oulcones neasuied ly lhe Wide
Range Achievenenl Tesl (WRAT), lhe Iealody IndividuaI Achievenenl Tesl (IIAT), lhe
Slanfoid Achievenenl Tesl (SAT), and faiIed giades.
Theie is nov sulslanliaI evidence foi peisislenl acadenic undeiachievenenl and pooi
educalionaI oulcone in chiIdien and adoIescenls diagnosed vilh ADHD (Loe & IeIdnan,
2OO7). ChiIdien vilh ADHD have a consislenlIy Iovei fuII-scaIe IQ lhan noinaI conlioIs.
They scoie significanlIy Iovei on ieading and aiilhnelic achievenenl lesls, use noie
ienediaI acadenic seivices, aie noie IikeIy lo le pIaced in speciaI educalion cIasses, noie


129
IikeIy lo le expeIIed, suspended oi iepeal a giade, conpaied vilh conlioIs. y lhe line lhey
ieach adoIescence, individuaIs vilh ADHD faiI noie giades have Iovei iepoil caid scoies,
Iovei cIass iankings, and voise scoies on slandaidized achievenenl lesls lhan nalched
noinaI conlioIs. They lake noie yeais lo conpIele high schooI, and have Iovei iales of
coIIege allendance and giadualion. Sulsequenl invesligalions of Iong-lein oulcones of
chiIdien vilh ADHD have onIy confiined lhese concIusions and veiified lhe nodesl
acadenic inpacl of slinuIanl nedicalions (Advokal, 2OO9, ailaiesi el aI., 2OO7a, 2OO7l,
CaIeia el aI., 2OO9, ScheffIei el aI., 2OO9, Van dei Ooid el aI., 2OO8).
Many invesligalois have consideied possilIe ieasons foi lhis negalive iesuIl, incIuding lhe
possiliIily lhal lhe slinuIanls nighl nol affecl lhe undeiIying cause of lhe acadenic
dysfunclion (aikIey & Cunninghan, 1978). Cadov (1983) iaised seveiaI issues in iegaid lo
lhe cIinicaI use of lhe diugs. He discussed lhe possiliIily lhal doses iequiied foi lehavioiaI
conlioI nighl le giealei lhan needed lo inpiove (and nighl acluaIIy voisen) cognilion. He
suggesled lhal shoil-acling agenls nighl veai off duiing a lypicaI schooI day, such lhal
infoinalion piesenled in lhe noining vouId le expeiienced vhiIe lhe chiId vas undei lhe
infIuence of nedicalion, vhiIe naleiiaI piesenled in lhe afleinoon nighl nol le. He noled
lhal lhe duialion of liealnenl nighl nol have leen Iong enough lo piovide lenefil foi
peifoinance on achievenenl lesls, lecause such lesls assess concepls laughl ovei seveiaI
giade IeveIs. He poinled oul lhal pievious sludies did nol lake inlo accounl lhe conliilulion
of co-noilid diagnoses, especiaIIy Ieaining disaliIilies, lhe incIusion of diffeienl ADHD
sullypes, oi of non-iespondeis. (Hovevei, as noled alove, nosl palienls do iespond lo
slinuIanl nedicalions if effoils aie nade lo deleinine vhich diug vouId le nosl effeclive.
A nela-anaIysis of lhe five sludies in chiIdien lhal conpaied MIH lo AMIH in lIind
ciossovei condilions found lhal aloul 37 of palienls had a cIeaiIy lellei oulcone on an
anphelanine piepaialion, and 26 had a cIeaiIy lellei iesponse lo nelhyIphenidale. The
olhei 37 of slinuIanl iespondeis couId use eilhei noIecuIe vilh equaI lenefil, CieenhiII el
aI., 1996).
3. Academic achievement of coIIege students with ADHD
Duiing lhe Iasl 3O yeais, speciaI educalion and disaliIily Iavs have leen passed enalIing a
vaiiely of quaIified sludenls vilh disaliIilies lo giaduale fion coIIege piepaialoiy
piogians in high schooIs and enlei coIIeges and univeisilies. SpecificaIIy, lhe Aneiicans
vilh DisaliIilies Acl (199O), lhe IndividuaIs vilh DisaliIilies Lducalion Acl (1975) and
Seclion 5O4 of lhe RehaliIilalion Acl (1973) nandaled educalionaI acconnodalion foi
sludenls vilh disaliIilies, and noie sludenls vilh disaliIilies aie nov successfuIIy
conpIeling high schooI and allending coIIege. Sludenls vilh hidden disaliIilies, vhich
incIudes ADHD, have iepiesenled lhe giealesl inciease. ecause lhese sludenls donl have
lo iepoil lo disaliIily offices il is difficuIl lo deleinine lhe pievaIence of ADHD, lul lhe lesl
eslinale is lhal 25 of sludenls gelling disaliIily seivices do so lecause of ADHD and lhal
2 lo 8 of lhe undeigiaduale popuIalion seIf-iepoil ADHD synplons (Weyandl &
DuIauI, 2OO6, WoIf, 2OO1).
ecause nosl ADHD-diagnosed aduIls do nol ollain a coIIege degiee, il is possilIe lhal
lhose vho do successfuIIy piogiess lhiough a coIIege cuiiicuIun nighl diffei fion lhose
vho do nol allend, oi do nol conpIele coIIege. In olhei voids, aduIls vilh ADHD vho
neel adnission ciileiia foi poslsecondaiy educalion nighl le Iess cogniliveIy inpaiied


130
lhan lhose vho donl. As noled ly Iiaziei el aI., (2OO7&' nol aII ADHD-diagnosed
individuaIs have acadenic deficils. Moieovei, coIIege sludenls vilh ADHD nighl have
noie inleIIecluaI aliIily, lellei acadenic piepaialion and le alIe lo conpensale lellei
lhan lheii non-coIIegiale cohoil (Iiaziei el aI., 2OO7)( Such sludenls nighl have deveIoped
a vay lo use slinuIanl nedicalions noie effecliveIy, oi lo appIy successfuI Ieaining
slialegies, oi lolh. If lhese individuaIs veie alIe lo lenefil acadenicaIIy fion slinuIanls
il vouId le inpoilanl lo knov hov lhey did il. On lhe olhei hand, if lhe diugs aie no
noie effeclive foi lhis popuIalion lhan lhey veie foi eIenenlaiy and high schooI
sludenls, il vouId le inpoilanl lo liy lo undeisland vhy lhey donl piovide lhe expecled
inleIIecluaI advanlage.
Moieovei, lhe undeigiaduale popuIalion piovides an exceIIenl oppoilunily lo evaIuale
sone of lhe phainacoIogicaI expIanalions offeied, in lhe pasl, foi vhy slinuIanls did nol
inpiove acadenic oulcone in chiIdien and adoIescenls. As noled alove, one hypolhesis
vas lhal lhe slinuIanl doses iequiied lo conlioI lhe hypeiaclivily of ADHD-diagnosed
chiIdien nighl le giealei lhan doses lhal aie nosl effeclive foi inpioving cognilion.
Hovevei, unIike chiIdien, coIIege sludenls aie Iess IikeIy lo le chaiacleiized as hypeiaclive,
and noie connonIy diagnosed vilh, oi lo seIf-iepoil, lhe synplon of inallenlion !Iiaziei
el aI., 2OO7) NoivaIk el aI., 2OO9, Ralinei el aI., 2OO8, Schvanz el aI., 2OO7) even vilhoul a
specific diagnosis of ADHD (Levandovski el aI., 2OO8). Theiefoie, undeigiaduales shouId
le alIe lo deleinine lhe anounl of slinuIanl nedicalion lhal vouId piesunalIy inpiove
lheii allenlion and concenlialion vilhoul having lo conlioI hypeiaclivily as veII.
Iievious ievievs of chiIdien had aIso specuIaled lhal peihaps lhe shoil-acling agenls didnl
piovide sufficienl coveiage duiing a slandaid schooI day, and lhal daiIy vaiialiIily in lIood
IeveIs nade il difficuIl lo lenefil fion lhe inleIIecluaI advanlages of lhe diugs. ul duialion
of coveiage is aIso Iess of a piolIen in undeigiaduale popuIalions since Iong-acling
foinuIalions aie nov avaiIalIe, and iegaidIess, coIIege cIasses aie usuaIIy nol scheduIed aII
day Iong. These consideialions nake aigunenls aloul dosage and vaiialiIily of lIood IeveIs
Iess peisuasive, and vouId piedicl giealei efficacy in lhe coIIege popuIalion.
Iuilheinoie, lheiapeulic use of slinuIanls in chiIdien usuaIIy invoIves adninislialion
piinaiiIy duiing lhe schooI day, so lhal diug effecls veai off in lhe evening, peihaps vhiIe
honevoik is leing done, lo aIIov foi sufficienl sIeep. This is nol necessaiiIy hov coIIege
sludenls, oi olhei aduIls, ioulineIy use slinuIanls. Suiveys iepoil lhal undeigiaduales oflen
use lhe diugs lo slay up al nighl lo sludy oi conpIele olhei piojecls. Thal is, aduIls aie alIe
lo choose vhen lhey lake lhe diugs, vhich nighl aIso pionole noie effeclive cognilive
oulcones.
The fiisl ieviev lo desciile lhe geneiaI acadenic funclioning of coIIege sludenls vilh
ADHD appeaied onIy a fev yeais ago and sunnaiized iesuIls fion 23 sludies (Weyandl &
DuIauI, 2OO6). They found lhal ADHD-diagnosed coIIege sludenls did nol diffei in IQ fion
lhose vilhoul ADHD, and veie alIe lo neel lhe denands of coIIege couises. NeveilheIess,
lhey had significanlIy Iovei giade poinl aveiages (CIAs), iepoiled noie acadenic
piolIens, and veie Iess IikeIy lo giaduale fion coIIege. Sludenls vho seIf-iepoiled high
IeveIs of ADHD synplons used significanlIy fevei coping slialegies conpaied vilh lhose
vho did nol (see aIso Reasei el aI., 2OO7). They veie Iess oiganized and 'nelhodicaI, lhey
had Iess seIf-conlioI and discipIine, and lhey piociaslinaled noie. On Ialoialoiy


131
adninisleied neuiopsychoIogicaI lesls lhey shoved significanl deficils in allenlion, lul
veie nol diffeienl fion noinaI sludenls on olhei neasuies, such as lhe aliIily lo le fIexilIe
and lo nainlain peifoinance as lask denands veie vaiied. Theie vas aIso no diffeience
lelveen lhose vilh and vilhoul ADHD on conpuleiized lasks lhal assessed divided
allenlion. Hovevei, lhe ioIe of nedicalions in lhese oulcones vas nol deleinined .il is
uncIeai vhal effecls nedicalions have on acadenic, inleipeisonaI and psychoIogicaI
oulcones anong coIIege sludenls (Weyandl & DuIauI, 2OO6, p. 14).
Since lhal ieviev, nuneious sludies have ieached siniIai concIusions. Sone (Advokal el aI.,
2OO8, Advokal el aI., 2O11, Iase el aI., 2OO9) have found significanlIy Iovei CIAs in ADHD-
diagnosed coIIege sludenls ieIalive lo non-ADHD conlioIs. Nol suipiisingIy, highei IeveIs
of ADHD synplonaloIogy aie consislenlIy associaled vilh pooi sludy halils, skiIIs and
acadenic adjuslnenl, and giealei seIf-iepoils of allenlion deficils (NoivaIk el aI., 2OO9,
Schvanz el aI., 2OO7). Recenl suiveys (Ralinei el aI., 2OO8, 2OO9a, 2OO9l) shov no diffeience
lelveen lhe ADHD-diagnosed undeigiaduales vho used slinuIanl nedicalions and lhose
vho didnl, in iegaid lo seIf-iepoiled conceins vilh lheii acadenic peifoinance, piolIens
of inallenliveness, hypeiaclivily, depiession oi lheii sociaI Iife. In olhei voids nedicalion
had no disceinilIe effecl in lhe liansilion lo coIIege of sludenls vilh ADHD (Iase el aI.,
2OO9).
Ioi lhe Iasl seveiaI yeais, oui Ialoialoiy has leen conducling ieseaich in undeigiaduales
vilh ADHD lo liy lo undeisland lhe cognilive effecls of slinuIanl nedicalions (Advokal el
aI., 2OO7, Advokal el aI., 2OO8, Advokal el aI., 2O11, Advokal & Luo, unpulIished, aiiiIIeaux
& Advokal, 2OO9). Civen evidence lhal suggesls lheie is a posilive ieIalionship lelveen lhe
Ciade Ioinl Aveiage of undeigiaduales and lheii voiking nenoiy (Cioppei & Tannock,
2OO9) oui effoils lo cIaiify lhe cognilive aclions of lhese diugs incIude sludies of lolh,
neuiopsychoIogicaI and acadenic peifoinance of aduIl ADHD-diagnosed undeigiaduales.
3.1 NeuropsychoIogicaI assessment of ADHD-diagnosed coIIege students
ecause inallenlion is a coie synplon of ADHD, aiiiIIeaux and Advokal (2OO9) lesled lhe
effecl of slinuIanl nedicalions on allenlion vilh a iepealed neasuies design, using lhe
conpuleiized, Slandaid veision of lhe Conneis Conlinuous Ieifoinance Tesl (CIT). In
lhis veision, Ielleis of lhe aIphalel aie piesenled one al a line foi 25O ns and lhe
iespondenl is insliucled lo piess lhe space lai foi eveiy Iellei cxccp| lhe Iellei X. ADHD-
diagnosed undeigiaduales (n = 13), and lhose vilhoul ADHD (n = 17), veie lesled lvice on
lhe CIT. Ioi lhe ADHD-diagnosed pailicipanls one lesl vas adninisleied aflei lhey had
laken lheii nedicalion and lhe olhei vhen lhey veie nol on lheii nedicalion.
The iesuIls aie sunnaiized in Iiguie 1, vhich shovs lhe aveiage nunlei of connission
eiiois, lhal is, iesponses nade vhen lhey shouId nol have leen (vhen lhe Iellei X
appeaied). This kind of nislake is oflen vieved as a neasuie of inpuIsivily. The Iefl side of
lhe figuie shovs lhe nean nunlei of connission eiiois foi lhe ConlioI Cioup, on lhe fiisl
session (open lai), second session (daik lai) and lhe aveiage of lhe lvo sessions (Iighl lai).
The iighl side of lhe figuie shovs lhe nean nunlei of connission eiiois foi lhe ADHD
Cioup vhen lhey veie Medicaled (daik lai) and Non-Medicaled (Iighl lai). Non-
nedicaled ADHD-diagnosed aduIls nade significanlIy noie connission eiiois lhan


132
Commission Errors
0
5
10
15
20
ControI ADHD *
M
e
a
n

Session 1
Session 2
Average
Med
Non-Med

Iig. 1. Mean nunlei of Connission Liiois of Non-ADHD (ConlioI) and ADHD-diagnosed
undeigiaduales on lhe Conlinuous Ieifoinance Tesl (CIT).
conlioIs, vhen nedicaled, lhey peifoined as veII as conlioIs and significanlIy lellei lhan
vhen lhey veie unnedicaled. These dala iIIusliale lhe lypicaI, cIassic inpaiinenl of
allenlion found in nuneious sludies of ADHD diagnosed individuaIs, and lhe
inpiovenenl pioduced ly slinuIanl nedicalions.
In sulsequenl sludies ve assessed lhe effecl of slinuIanl nedicalions on seveiaI olhei
neuiopsychoIogicaI lesls. UnIike lhe CIT, peifoinance on lhese lasks is infIuenced ly
piaclice, lheiefoie, aII of oui olhei sludies used a lelveen-suljecl pioceduie. Thal is, in each
expeiinenl, lhiee gioups of undeigiaduale sludenls veie lesled, one gioup vilhoul an
ADHD diagnosis (ConlioI), one gioup of ADHD-diagnosed sludenls lesled vilhoul
nedicalion (Off Meds) and one gioup of ADHD-diagnosed sludenls lesled vhiIe on lheii
nedicalion (On Meds). SeveiaI lypes of lesls veie adninisleied, ianging fion assessnenls
of noloi dexleiily, veilaI fIuency, acquisilion and ielenlion of void Iisls, disliacliliIily and
piolIen-soIving.
Moloi dexleiily vas lesled vilh a niiioi-liacing lask. Lach pailicipanl vas asked lo liace
lhe oulIine of a slai shape, vhich vas piesenled on a conpulei scieen. Tiacing diieclion
vas sel lo niiioi-ieveised, such lhal lhe pailicipanl had lo nove lhe cuisoi in lhe opposile
diieclion lo lhal of lhe pallein Iines in oidei lo liace lhe pallein. Thal is, lhe pailicipanls had
lo Ieain ovei successive liiaIs lo liace lhe slai shape as if il vas leing shovn in a niiioi.
The iesuIls, sunnaiized in Iiguie 2 leIov, shoved no oveiaII diffeience in Ialency anong
lhe lhiee gioups, aII pailicipanls conpIeled lhe lask in lhe sane anounl of line. Hovevei,
vhiIe lhe conlioI gioup shoved a significanl deciease in Ialency acioss lhe five liiaIs
(p = .OO2) lhe lvo ADHD gioups did nol (Advokal & Vinci, unpulIished dala). Thal is,
unIike nonADHD sludenls, lhe peifoinance of ADHD-diagnosed sludenls did nol inpiove
significanlIy iegaidIess of vhelhei oi nol lhey veie on slinuIanl nedicalion.


133

Iig. 2. Median Ialency of niiioi-liacing acioss 5 successive liiaIs, in 3 gioups of coIIege
sludenls: nonADHD (ConlioIs) (n = 19), ADHD-diagnosed sludenls, lesled vilhoul
nedicalion (Off Meds, n = 22) and ADHD-diagnosed sludenls lesled vhen on lheii
nedicalion (On Meds, n = 22).
Oui iesuIl is ieniniscenl of a iepoil ly Tucha & Lange (2OO4) lhal nedicalion voisened
sone aspecls of handviiling in ADHD-diagnosed chiIdien. In lhal silualion, lhe
handviiling inpaiinenl vas alliiluled lo a diug-induced cnnanccncn| of allenlion. Thal is,
lhe iesuIls veie inleipieled lo nean lhal, vhen lhey veie on lheii nedicalion, chiIdien
vilh ADHD paid so nuch allenlion lo lhe viiling piocess lhal il inpaiied lhe fIuency of
lheii handviiling novenenls. Il is lenpling lo specuIale lhal a siniIai phenonenon
occuiied in oui ADHD-diagnosed undeigiaduales.
These olseivalions shov lhal aIlhough a deciease in lehavioiaI aclivily is lhe nosl ieIialIe
effecl of slinuIanl nedicalions in ADHD, aII lypes of lehavioiaI aclivily aie nol ieduced oi
inpioved ly lhese diugs. ADHD-diagnosed chiIdien oflen shov inpaiinenl in
iudinenloiy noloi funclion, incIuding posluiaI slaliIily (}acoli-IoIishook el aI., 2OO9), gail
(Leilnei el aI., 2OO7), noloi lining (Rulia el aI., 2OO3) and olhei neuioIogicaI iefIexes !Sliay
el aI., 2OO9), vhich is geneiaIIy aIIevialed ly slinuIanls. Hovevei, inpiovenenl is nol
aIvays conpIele, oi evidenl undei aII condilions. Ioi exanpIe, IeIhan el aI., (199O)
evaIualed nelhyIphenidale in loys vilh ADHD vhiIe lhey veie pIaying a seiies of sofllaII
ganes. AIlhough lhe diug inpioved lhe chiIdiens allenlion duiing lhe ganes, il did nol
affecl lheii acluaI peifoinance oi skiII.
Theie is a vasl Iileialuie desciiling expeiinenlaI effoils lo deleinine lhe neuiocognilive
deficils associaled vilh ADHD, and hov lhey nighl le affecled ly slinuIanl diugs. WhiIe
lhe lechnoIogy and lhe concepluaI nodeIs have lecone noie sophislicaled, piogiess has
leen nodesl. Recenl anaIyses of slinuIanl effecls on neuiocognilive inpaiinenls in ADHD
chiIdien (DoyIe, 2OO6, CuaIlieii & }ohnson, 2OO8, Svanson el aI., 2O11) have essenliaIIy
confiined eaiIy olseivalions (Rollins & Sahakian, 1979): slinuIanls aie nosl IikeIy lo
inpiove peifoinance of ADHD diagnosed individuaIs in lhe donains of ieaclion line and
piocessing speed, ialhei lhan in noie conpIex funclions iequiiing .inhililion, voiking
nenoiy, slialegy foinalion, pIanning and sel-shifling (Svanson el aI., 2O11, p. 211).
SeveiaI ievievs have assessed neuiopsychoIogicaI funclions in lhe aduIl popuIalion vilh
ADHD (Iiaziei el aI., 2OO4, Heivey el aI., 2OO4, SchoechIin & LngeI, 2OO5, Woods el aI., 2OO2)


134
and shovn nodesl, lul inconsislenl inpaiinenl. Iuilheinoie, lhese deficils aie aIso nol
aIvays eIininaled ly slinuIanl diugs. Tuinei el aI., (2OO5) lesled ADHD aduIls, lefoie and
aflei nelhyIphenidale, on allenlion lesls and one nenoiy lask, and did nol find
inpiovenenl. MIIei el aI., (2OO7& iepoiled lhal nedicaled ADHD aduIls veie sliII
inpaiied, ieIalive lo conlioIs, on seveiaI neuiopsychoIogicaI neasuies such as lhe Tovei of
London lesl of 'pIanning aliIily, and lhe Slioop lesl of 'disliacliliIily. Kuischeidl el aI.,
(2OO8) iepoiled ieliospeclive iesuIls of 34 palienls on chionic nelhyIphenidale. Conpaied
lo laseIine, lhe diug significanlIy inpioved allenlion and 'veilaI nenoiy peifoinance
aflei nonlhs of liealnenl - vhiIe olhei lasks veie nol affecled. Tucha el aI., (2O11) iepoiled
diffeiences lelveen nonADHD and ADHD-diagnosed aduIls on lhe Tovei of London lask
and one lhal neasuied veilaI fIuency. In lhis case, MIH did inpiove peifoinance of
ADHD aduIls on lhe Tovei of London, lul nol on lhe veilaI fIuency lask. iedeinan el aI.,
(2OO8l& adninisleied a lalleiy of lesls lo non-ADHD suljecls and sepaiale gioups of
ADHD palienls vho veie eilhei on oi off nedicalion. They found lhe Iaigesl leneficiaI
effecls on suslained allenlion (vigiIance) and veilaI Ieaining, vheieas slinuIanls did nol
significanlIy inpiove neasuies of inleifeience (i.e. disliacliliIily) oi piocessing speed (on
lhe Slioop lesl).
We iecenlIy conducled a sludy of lhe nosl connonIy used neuiopsychoIogicaI lasks in oui
undeigiaduale popuIalion, incIuding a veilaI fIuency neasuie, lhe Tovei of London
pIanning lask and lhe 'disliacliliIily lask, lhe Slioop lesl. The onIy significanl diffeience
anong lhe gioups vas on lhe Slioop lesl. This lesl invoIved lhiee sels of slinuIi, piesenled
on a conpulei scieen. The void ieading slinuIi consisled of lhiee coIoi voids (lIue, ied,
and gieen) in lIack ink, vhich lhe pailicipanl iead aIoud. In lhe coIoi naning lesl, lhe
slinuIi veie a seiies of five Xs (i.e., XXXXX) in aII lIue, aII ied, oi aII gieen ink, and lhe
pailicipanl iead aIoud lhe ink coIoi. IinaIIy, in lhe incongiuenl coIoi naning slinuIus sel
(inleifeience condilion), slinuIi consisled of lhe coIoi voids lIue, ied, and gieen piinled in
an incongiuenl coIoi. The pailicipanl had lo nane lhe coIoi of lhe in| in vhich lhe void is
piinled, nol lhe void coIoi.
We found nodesl, lul slalislicaIIy significanl diffeiences on lvo neasuies of lhe Slioop lesl.
As shovn in lhe lop haIf of Iiguie 3, leIov, on lhe Slioop Inleifeience lesl, lhe ConlioI
(n=35) and ADHD (On Med) gioups (n=36) ieacled significanlIy faslei lhan lhe ADHD (Off
Med) gioup (n=33). Iail shovs lhal lhe ConlioI gioup nade sIighlIy, lul significanlIy,
fevei nislakes (vas noie accuiale) lhan lhe ADHD (Off Med) gioup, vhiIe lhe ADHD (On
Med) gioup did nol diffei fion lhe olhei lvo gioups.
These dala aie consislenl vilh olhei sludies shoving fiisl, lhal aduIls (}ohnson el aI., 2OO1,
King el aI., 2OO7, Muiphy el aI., 2OO1, Rappoil el aI., 2OO1& as veII as chiIdien vilh ADHD
(edaid el aI., 2OO2, Iiehn-Kiislensen el aI., 2O11), aie inpaiied on lhe Slioop inleifeience
neasuie conpaied lo conlioI popuIalions. Second, iedeinan el aI., (2OO8l) shoved lhal
nedicalion did nol noinaIize Slioop inleifeience conlioI in young aduIls vilh ADHD. In
oui sludy, lhe Inleifeience RT of lhe On Med gioup uas noinaIized. Yel, lhe Inleifeience
accuracq of lhe On Med gioup, aIlhough inpioved, vas sliII nol significanlIy diffeienl fion
eilhei of lhe olhei lvo gioups. Consideiing lhe snaII alsoIule diffeience in nagnilude, il is
suipiising lhal lhe diugs did nol fuIIy eIininale lhe accuiacy deficil aIong vilh lhe RT
deficil. One possiliIily is lhal lhe ieduclion in RT incieased inpuIsivily, vhich nighl have
inpaiied a coiiesponding inpiovenenl in accuiacy.


135

GROUP
ControI ADHD Off ADHD On
I
n
t
e
r
f
e
r
e
n
c
e

R
T

(
m
s
)
600
650
700
750
800

GROUP
ControI ADHD Off ADHD On
I
n
t
e
r
f
e
r
e
n
c
e

A
c
c
u
r
a
c
y

(
%
)
97
98
99
100

Iig. 3. Top: Slioop Inleifeience Reaclion Tine (RT - niIIiseconds). The ConlioI gioup
(n=35) and ADHD (On Med) gioup (n=36) ieacled faslei lhan lhe ADHD Off Med gioup,
p<O.O5 (n=33). ollon: Slioop Inleifeience Accuiacy. The ConlioI gioup nade fevei
nislakes lhan lhe ADHD (Off Med) gioup in inleifeience, p<O.O5, and lhe ADHD On Med
gioup did nol diffei fion lhe olhei lvo gioups. ais iepiesenl slandaid eiioi of lhe nean.
In liief, oui iesuIls shoved lhal undeigiaduale sludenls vilh ADHD did nol shov
significanl deficils in veilaI fIuency oi pIanning aliIily, conpaied lo noinaI sludenls. The
onIy slalislicaI effecls occuiied in lhe Slioop lesl, and lhe alsoIule diffeiences veie
exlieneIy snaII. Lven so, vhiIe nedicalions inpioved lhe peifoinance of ADHD sludenls
lhey did nol eIininale lhe deficil, noi did lhey heIp ADHD sludenls peifoin lellei lhan
noinaI sludenls in donains of funclions vheie no deficils veie found. Il is possilIe lhal
noie diffeiences nighl have leen seen in neasuies olhei lhan lhe Slioop lesl, if lhe gioups
veie Iaigei. Hovevei, oui gioup sizes veie conpaialIe lo lhose lypicaIIy used. A noie
IikeIy possiliIily is lhal oui ADHD popuIalion nay have had Iess seveie synplonaloIogy
lhan pailicipanls in olhei sludies, ciled alove, vho appeaied lo le cIinic palienls.


136
AIlhough ieseaich shovs piaclicaIIy no cognilive lenefil of eilhei nelhyIphenidale oi
anphelanine on acquisilion (Advokal, 2O1O), lheie is sone evidence lhal slinuIanls nighl
inpiove rc|cn|icn of pieviousIy acquiied infoinalion !Izquieido el aI., 2OO8, Soelens el aI.,
1993, 1995, Zeeuvs & Soelens, 2OO7). In a seiies of expeiinenls ly Soelens and coIIeagues,
nonADHD aduIl naIes ieceived pIacelo and anphelanine, in a vilhin-suljecl
expeiinenlaI pioceduie. Aflei each diug, pailicipanls veie asked lo sludy void Iisls and
veie lesled al vaiious lines afleivaid lo assess hov nany voids lhey couId iecaII. The fiisl
lesl look pIace innedialeIy aflei piesenlalion of each of 1O void Iisls, lhe nexl lesl vas
given al lhe end of each daiIy session (aflei aII lhe Iisls), and olhei lesls veie given aflei 1
houi, aflei 1 day, and aflei 3 days.
Theie vas no diug effecl aflei innediale iecaII oi al lhe end of lhe daiIy session, lhal is, no
effecl of anphelanine on acquisi|icn of lhe voids. ul lheie vas a significanl effecl of
anphelanine on iecaII 1 houi aflei lhe end of lhe session, and al 1 and 3 days Ialei. These
iesuIls veie inleipieled lo nean lhal aIlhough anphelanine did nol inpiove Ieaining
(acquisilion), il faciIilaled lhe ccnsc|ida|icn of infoinalion lhal had aIieady leen Ieained, and
lhal lhe leneficiaI effecl on consoIidalion vas iesponsilIe foi lhe inpioved ielenlion of lhe
voids al 1 houi and 1 and 3 days Ialei. The lein 'consoIidalion iefeis lo lhe piocess ly vhich
nenoiy undeigoes a change fion lhe shoil-lein, IaliIe, foin lo a Iong-lein, slalIe foin.
We allenpled lo iepIicale lhis phenonenon in oui undeigiaduales. AIlhough ve couId nol
adninislei slinuIanl diugs lo nonADHD pailicipanls, il vas possilIe lhal ADHD sludenls
nighl have a nenoiy inpaiinenl lhal couId le ieduced ly slinuIanls. In oui sludy,
pailicipanls fion each of lhe lhiee expeiinenlaI gioups vieved five sels of len voids. Aflei
each Iisl of 1O voids lhe pailicipanls veie asked lo viile dovn as nany voids as lhey couId
ienenlei (Tesl 1). Aflei lhe fiflh sel of voids vas piesenled, pailicipanls veie 'disliacled ly
peifoining a second lehavioiaI lask (lhe niiioi liacing lask, discussed alove). IoIIoving lhe
niiioi liacing lask, pailicipanls veie asked lo viile dovn as nany of lhe 5O voids as lhey
couId ienenlei (Tesl 2). Lasl, pailicipanls veie conlacled on lhe nexl day and asked a lhiid
line lo iecaII as nany voids as lhey couId ienenlei fion lhe void Iisls (Tesl 3). As shovn in
Iiguie 4, leIov, lheie vas no diffeience anong lhe gioups. ADHD sludenls did nol diffei
fion nonADHD sludenls in iegaid lo acquisilion oi ielenlion of lhe void Iisls al any line
poinl, iegaidIess of vhelhei oi nol lhey veie on nedicalion duiing lhe lesl.
In sunnaiy, oui assessnenl of neuiopsychoIogicaI funclion in undeigiaduales vilh ADHD
shoved lhe expecled inpaiinenl on lhe cIassic, CIT lesl of allenlion, vhich vas noinaIized
vilh slinuIanls. We aIso olseived a pieviousIy uniepoiled noloi deficil (on lhe niiioi
liacing lask), vhich vas nol inpioved ly slinuIanls. We sav lvo lypes of deficil in lhe Slioop
lesl of 'disliacliliIily, naneIy, a sIovei ieaclion line, coiiecled ly slinuIanls, and a veiy
sIighl inpaiinenl in accuiacy, vhich vas nol eIininaled ly slinuIanls. These iesuIls aie
consislenl vilh lhe Iileialuie, and iIIusliale lhe counleiinluilive naluie of slinuIanl effecls in
ADHD. Thal is, aIlhough cognilive piocessing speed and lasic aspecls of allenlion aie
noinaIized, even sIighl deficils in 'disliacliliIily aie nol eIininaled. IinaIIy, aIlhough ve did
nol iepIicale lhe nenoiy inpiovenenl lhal had leen shovn in nonADHD aduIls vilh
anphelanine, ve aIso did nol see any deficils in lhal lask in oui ADHD sludenls. Il is
appiecialed lhal lecause lhey veie coIIege sludenls, oui ADHD popuIalion nighl have had
veiy niId synplons and veie peihaps nol iepiesenlalive of lhe lypicaI ADHD aduIl. We
couId nol confiin lheii diagnoses. Hovevei, if lhal vas lhe case, ve vouId nol expecl lhen lo


137

Iig. 4. Relenlion of void Iisls in nonADHD sludenls (ConlioI), ADHD sludenls, vho veie
lesled vhen lhey veie nol on nedicalion (Off Meds) and ADHD sludenls vho veie lesled
vhen lhey veie on lheii nedicalion (On Meds). Relenlion vas lesled innedialeIy aflei
each Iisl of 1O voids (Tesl 1), aloul 2O ninules aflei lhe 5 Iisls (Tesl 2) and 1 day aflei lhe 5
Iisls (Tesl 3). Theie vas no diffeience anong lhe gioups in lhe nunlei of voids iecaIIed on
any lesl.
le acadenicaIIy inpaiied, ieIalive lo lheii nonADHD counleipails, especiaIIy consideiing lhal
lhe slinuIanls exeil lhe sane lypes of effecls in lhose vilh oi vilhoul lhe diagnosis. The dala
ollained iegaiding acadenic peifoinance, discussed leIov, shov lhal lhal is nol lhe case.
3.2 Academic performance of ADHD-diagnosed coIIege students
The ADHD-diagnosed undeigiaduales ve lesled shoved veiy IillIe neuiocognilive
inpaiinenl. Ieihaps lhe facl lhal lhey had successfuIIy enleied coIIege neanl eilhei lhal
lhey had Iess seveie synplonaloIogy oi lhal lhey veie alIe lo gain sone acadenic lenefil
fion lhe slinuIanls (oi lolh). If lhe Iallei, il vouId le inpoilanl lo find oul hov, so lhal
lheii slialegies couId le lioadIy inpIenenled. On lhe olhei hand, in viev of gioving
conceins aloul escaIaling aluse and diveision of slinuIanl diugs, il vouId le equaIIy
inpoilanl lo knov if lhese nedicalions did nol piovide any acadenic advanlage foi
ADHD-diagnosed undeigiaduales.
In lhese invesligalions ve conpaied lhe seIf-iepoiled diug use (lolh Iicil and iIIicil), sludy
halils and slialegies of ADHD-diagnosed and non-diagnosed undeigiaduales. We
adninisleied queslionnaiies lo find oul if lheie vas a sulslanliaI diffeience in hov lhese
lvo gioups appioached lheii schooIvoik, and, if lheie vas any coiiesponding diffeience in
lheii iespeclive Ciade Ioinl Aveiages (CIA) and olhei neasuies of acadenic achievenenl.
In lhe fiisl sludy (Advokal el aI., 2OO8) ve asked aloul lhe IegaI use of piesciiplion
slinuIanls ly undeigiaduales diagnosed vilh ADHD, and conpaied lhal vilh iIIicil use ly
sludenls vilhoul lhe diagnosis.
A lolaI of 155O undeigiaduale sludenls conpIeled al Ieasl pail of lhe suivey, vilh 163
(1O.5) of lhese sludenls iepoiling a diagnosis of ADHD (lhe ADHD Cioup). Anong lhe
ienaining 1387 iespondenls, 591 (43) iepoiled lhal lhey used slinuIanl nedicalions
vilhoul a piesciiplion (lhe No ADHD, IIIicil Use gioup) vhiIe 794 (57) slaled lhey did nol
use slinuIanl nedicalions iIIicilIy (lhe No ADHD, No IIIicil Use gioup).


138
As shovn in Iiguie 5, lhe lhiee gioups diffeied significanlIy in iesponse lo lhe queslion:
Do ADHD nedicalions heIp acadenic peifoinance, in lhal a significanlIy giealei
piopoilion of lhe ADHD, and No ADHD IIIicil Use gioups, endoised lhis slalenenl
conpaied vilh lhe No ADHD No IIIicil Use gioup. The facl lhal a najoiily of iIIicil useis
endoised lhis slalenenl suppoils lhe concIusion lhal lhe diugs veie piinaiiIy used as
sludy aids. Ioi lhal nallei, a suipiising 12 of iIIicil useis in lhal sludy iepoiled lhal lhey
leIieved lhey aIso had ADHD. Thal nighl even le liue, lul ve have no vay of veiifying
lhal assunplion.

Iig. 5. Ieicenl of undeigiaduales vho agieed vilh lhe slalenenl Do ADHD Medicalions
HeIp Acadenic Ieifoinance. *SignificanlIy fevei sludenls in lhe No ADHD No IIIicil Use
gioup endoised lhis slalenenl conpaied lo each of lhe olhei lvo gioups.
Iiguie 6 shovs lhal lhe sane gioups aIso diffeied significanlIy in CIA, in lhal lhe CIA of
lhe ADHD gioup (3.O5, oul of a possilIe 4.O) vas significanlIy Iovei lhan lhal of lhe No
ADHD IIIicil Use gioup (3.15) and lhe No ADHD No IIIicil gioup (3.19).

Iig. 6. Mean Ciade Ioinl Aveiage (CIA) of each of lhe lhiee gioups. * The CIA of lhe
ADHD gioup (3.O5, oul of a possilIe 4.O) vas significanlIy Iovei lhan lhal of lhe No ADHD
IIIicil Use gioup (3.15) and lhe No ADHD No IIIicil gioup (3.19).


139
Il shouId le noled lhal ve cannol leII fion lhese dala hov nany sludenls in lhe ADHD
gioup acluaIIy used slinuIanl nedicalions. Noi can ve leII if lhe CIA of lolh gioups lhal
used slinuIanl diugs vouId le even Iovei if lhose sludenls didnl use lhe diugs. Thal is,
ve canl leII if lhe diugs veie effeclive, eilhei lecause lhey voiked oi lecause lhe sludenls
leIieved lhe diugs voiked.
Lasl, Iiguie 7, leIov, sunnaiizes iepoiled ieciealionaI diug use of Tolacco, AIcohoI, and
Maiijuana of lhese sane gioups. In each case lheie vas a significanl diffeience anong lhe
gioups in fiequency of diug use. Ioi each diug, posl-hoc conpaiisons indicaled lhal a
giealei peicenl of lhe No ADHD IIIicil Use and ADHD gioups used lhese diugs conpaied
vilh lhe No ADHD No IIIicil Use gioup. OnIy in lhe case of aIcohoI did lhe ADHD gioup
use Iess lhan lhe iIIicil slinuIanl useis, aIlhough lhey sliII diank significanlIy noie
fiequenlIy lhan lhose vho didnl use slinuIanls iIIicilIy.
OveiaII, ieciealionaI diug use in oui sludenl sanpIe vas veiy nodesl. NeveilheIess, lhe
significanl diffeience lelveen ADHD-diagnosed and Non-diagnosed-non-slinuIanl useis
vas unexpecled, and ve can onIy specuIale aloul lhe ieasons foi lhis iesuIl. Iiisl, peihaps,
leIieving lhal lheii synplons aie effecliveIy conlioIIed ly slinuIanl nedicalions, lhese
sludenls feeI lhey aie alIe lo use olhei diugs iesponsilIy. Second, lecause of lhe
inpuIsiveness lhal oflen chaiacleiizes ADHD, lhese young aduIls nighl nol le alIe lo
inhilil olhei diug use, especiaIIy if lhe diugs aie offeied in lhe sociaI conlexl of a paily, oi
olhei nonacadenic enviionnenl, vhen sludenls nighl nol le using lheii slinuIanls
nedicaIIy. Thiid, consideiing lhal aIcohoI and naiijuana aie sedaling, ADHD sludenls
nighl use lhen lo counleiacl lhe slinuIaloiy effecl of lhe nedicalions, lhal is, lo heIp lhen
ieIax oi go lo sIeep. Il is aIso possilIe lhal lhose vilh ADHD (and nonADHD, iIIicil useis)
have conoilid condilions (such as conducl disoidei) oi olhei iisk faclois lhal inciease use.
These dala shov lhal, aIlhough lhe CIA of lhe ADHD sludenls vas significanlIy Iovei lhan
lhal of lhe nonADHD-IIIicil useis, lolh gioups endoised significanlIy giealei ieciealionaI
diug use lhan sludenls vho did nol use slinuIanl diugs iIIicilIy. UnfoilunaleIy, ve canl leII
fion lhese dala if peihaps ADHD sludenls veie noie vuIneialIe lhan nonADHD sludenls
lo a deliinenlaI effecl of ieciealionaI diugs on acadenic peifoinance, oi if lolh gioups
nighl have had a lellei CIA vilhoul such use.
Oui iesuIls shoved lhal a najoiily of ADHD diagnosed sludenls (and nany vilhoul lhe
diagnosis) leIieved lhal slinuIanls inpioved acadenic peifoinance. And aIlhough lhe
CIAs of ADHD sludenls veie slalislicaIIy Iovei lhan lhose of nonADHD sludenls lhal did
nol nean lhe slinuIanls didnl heIp. The ain of oui nexl sludy vas lo find oul noie aloul
lhe infIuence of slinuIanl nedicalions on acadenic oulcone. We suiveyed lhe seIf-iepoiled
sludy halils and slialegies of ADHD-diagnosed and non-diagnosed undeigiaduales, lo
deleinine if lhey diffeied in iesponse lo lhe acadenic denands of lhe coIIege cuiiicuIun
(Advokal el aI., 2O11).
A lolaI of 143 sludenls vilhoul ADHD (ConlioI gioup) and 92 sludenls vilh an ADHD
diagnosis (ADHD gioup) conpIeled lhe suivey. The aveiage age of lhe lvo gioups,
appioxinaleIy 21 yeais, did nol diffei, and nosl pailicipanls in each gioup veie Caucasian
(81.8 and 89.1 foi ConlioI and ADHD, iespecliveIy), aIlhough lheie veie significanlIy
noie naIes in lhe ADHD gioup (38 conpaied lo 17.5).


140

Iig. 7. Ieicenl of iespondenls in each gioup as a funclion of lhe fiequency vilh vhich lhey
used lolacco, aIcohoI and naiijuana. *In each case, lhe ADHD and lhe No ADHD IIIicil Use
gioups endoised significanlIy noie use lhan lhe No ADHD, No IIIicil Use gioup. The
ADHD gioup aIso used aIcohoI significanlIy Iess lhan lhe No ADHD IIIicil Use gioup.


141
The aveiage age al vhich lhe ADHD pailicipanls ieceived lhe diagnosis vas lelveen 15
and 16 yeais, aloul 5 yeais lefoie enleiing coIIege. WhiIe neaiIy 98 of lhis gioup had
laken ADHD nedicalion, onIy 78.3 (72 iespondenls) veie cuiienlIy using lhe diugs, vhiIe
19.6 (18 iespondenls) slaled lhal lhey veie nol cuiienlIy laking lhe nedicalions. When
asked vhy lhey nighl nol le laking slinuIanl nedicalions, lhe najoiily ciled lhe piolIen
of side effecls. AIlhough specific side effecls veie nol aIvays nenlioned (I did nol Iike lhe
vay il nade ne feeI, .nake ne feeI ciappy, lhe negalive side effecls oulveigh lhe
posilives), sone individuaIs ciled headaches, iiiilaliIily, lenpoiaiy heail iale eIevalion,
nausea, sIeep inleifeience and 'anlisociaI feeIings as exanpIes of undesiialIe ieaclions. Iive
in lhis sulgioup aIso slaled lhal lhey eilhei didnl need lhe diugs anynoie, oi, lhey vanled
lo see if lhey didnl need lhen anynoie.
SiniIai lo lhe pievious sludy, noie lhan 9O of lhe sludenls vilh ADHD endoised lhe
slalenenl lhal nedicalions heIped lhen acadenicaIIy. Mosl of lhen slaled lhal lhe diugs
heIped lhen lo focus oi lo concenliale lellei i.e. pay allenlion, slay avake, and oiganize
lheii sludying. Hovevei, ieIaliveIy fev sludenls (n = 6) vilh ADHD specificaIIy slaled lhal
lhey look nedicalion lo avoid disliaclions.
Wilh iegaid lo acadenic peifoinance, ConlioI and ADHD sludenls look lhe sane anounl
of Advanced IIacenenl Ciedils (an aveiage of 8.1 foi lhe ConlioIs and 6.7 foi ADHD
sludenls). Ioi lhose fev in each gioup vho look lhe SAT (SchoIaslic Aplilude Tesl, a nalionaI
exan sonelines iequiied foi coIIege adnission), lheie vas no diffeience in lheii seIf-iepoiled
SAT scoies. They did nol diffei in lhe nunlei of schoIaiships avaided, veie enioIIed foi lhe
sane nunlei of senesleis (lelveen 6 and 7), look lhe sane nunlei of ciedils pei seneslei
(aloul 14.5), and sludied lhe sane nunlei of houis pei veek (aloul 9.5 lo 1O.5).
These lvo gioups aIso did nol diffei slalislicaIIy on nany of lheii ansveis lo queslions
aloul sludy halils. The sane piopoilion of lolh gioups leIieved lhal lhey sludied aloul
lhe sane as olhei sludenls and lhal lhe quaIily of lheii cIass noles vas eilhei lellei oi
lhe sane as lhose of olhei sludenls. The sane piopoilion in each gioup did nol ieviev
lheii noles eilhei lefoie oi aflei cIass, and onIy sonelines iead assigned ieading lefoie
cIass. Aloul lhiee-quaileis of each gioup slaled lhal lhey veie sonevhal accuiale al
piedicling hov veII lhey did aflei exans. The facl lhal lheie vas no slalislicaI diffeience
lelveen nonADHD-diagnosed sludenls, and lhose vilh ADHD in iesponse lo lhese queslions
suggesls lhal lhe diagnosis did nol seen lo pionole lellei sludy halils in lhe ADHD gioup.
Hovevei, lhe ConlioI and ADHD gioups did diffei on seveiaI acadenic vaiialIes, as shovn
in TalIe 1. (AIlhough lhe vaIues of ADHD sludenls vho slaled lhal lhey did nol lake
slinuIanl nedicalions aie shovn foi sone of lhe vaiialIes, lhe slalislicaI iesuIls aie lased
on a conpaiison lelveen ConlioI and aII ADHD sludenls).
As in oui pievious iepoil, lhe coIIege CIAs of ADHD sludenls veie slalislicaIIy Iovei lhan
lhal of lhe ConlioIs. In lhis sludy ve aIso found lhal ADHD sludenls had a significanlIy
Iovei high schooI CIA and ACT scoie lhan ConlioIs. AIlhough snaII, lhis diffeience vas
delecled in spile of lhe facl lhal a nininun high schooI CIA and ACT scoie veie iequiied
foi adnission lo lhe univeisily. The lalIe aIso shovs lhal ADHD sludenls veie significanlIy
noie IikeIy lo vilhdiav fion a cIass, lo say lhal lhey veie voise lhan olhei sludenls al
pIanning foi and conpIeling cIass assignnenls, fiequenlIy laking cIass noles, sludying
ahead of line foi exans and avoiding disliaclions.


142
ConlioI (n)
(N = 143)
ADHD (n) ADHD No Meds
(N = 92) (n = 18)
I **
High SchooI CIA
CoIIege CIA
ACT Scoie
Tines Wilhdiavn fion a CIass

IIanning foi cIass assignnenl
ellei
Woise
Aloul lhe sane

ConpIeling cIass assignnenl
ellei
Woise
Aloul lhe sane

Iiequency of nole-laking
NeaiIy eveiy Iecluie
Sonelines
Read soneone eIses noles
Neilhei lake noles noi iead olheis noles

When you sludy foi an exan do you
Sludy veII lefoie lhe exan
Sludy in lhe day oi lvo lefoie lhe exan
olh silualions couId happen

Avoiding disliaclions vhiIe sludying
ellei
Woise
Aloul lhe sane
3.55 O.47 (141)
3.12 O.49 (142)
25.45 5.2 (124)
1.6 1.7 (139)

32.9 (47)
13.3 (19)
53.8 (77)

33.6 (48)
2.1 (3)
62.9 (9O)

82.5 (118)
16.1 (23)
1.4 (2)
O

39.2 (56)
6O.1 (86)
O.7 (1)

16.8 (24)
33.6 (48)
49.O (7O)
3.38 O.43 (89)
2.94 O.44 (91) 2.9O O.46
24.1 3.O (8O) 24.6 2.61 (16)
2.3 2.4 (89) 3.28 3.89 (18)

26.1 (24) 27.8 (5)
35.9 (33) 38.9 (7)
38.O (35) 33.3 (6)

3O.4 (28) 33.3 (6)
19.6 (18) 22.2 (4)
47.8 (44) 44.4 (8)

63.O (58)
27.2 (25)
5.4 (5)
4.3 (4)

25 (23) 16.7 (3)
69.6 (64) 83.3 (15)
5.4 (5"

16.3 (15) 11.1 (2)
64.1 (59) 66.7 (12)
18.5 (17) 22.2 (4)
O.OO6
O.OO6
O.O32
O.OO8

<O.OO1

<O.OO1

O.OO2

O.O11

<O.OO1

* UnIess olheivise indicaled, scoies aie peicenl, ** p vaIues aie foi ConlioI vs aII ADHD iespondenls
CIA and ACT scoies aie aII seIf-iepoiled
TalIe 1. +,-./01, 2-31-45/6 78-9 :1;;/3/. </9=//> ?@>93@56 ->. +:A:B:1-C>@6/.
?@55/C/ D9E./>96 *
These iesuIls shov lhal ConlioI and ADHD-diagnosed sludenls diffei in sone of lheii seIf-
iepoiled sludy halils. ul lhese dala aIone donl leII us if lhese endoisenenls aie ieIevanl lo
lhe acadenic achievenenl of eilhei gioup. In olhei voids, ve didnl knov if lhe slalislicaIIy
significanl diffeiences in piofessed sludy halils veie ieIaled lo lhe iespeclive CIAs. We


143
lheiefoie anaIyzed lhe ansveis lo sone of lhe queslions on vhich lhe lvo gioups diffeied
as a funclion of CIA. The iesuIls aie sunnaiized in TalIe 2.
Theie veie significanl diffeiences vilhin lhe gioups on seveiaI neasuies. ConlioI sludenls
vho slaled lhey veie 'lellei al pIanning and conpIeling assignnenls, look 'fiequenl noles
in cIass and 'avoided disliaclions, had highei CIAs lhan lhose vho said lhey veienl,
suggesling lhal lheii judgnenls veie accuiale. Hovevei, lhe CIA of ConlioI sludenls did
nol diffei as a funclion of vhelhei oi nol lhey said lhal lhey sludied 'ahead of line oi jusl
days lefoie an exan. In olhei voids, ConlioI sludenls did nol 'pay a piice in CIA foi
vailing unliI a fev days lefoie exans lo sludy. In conliasl, lhe CIA of ADHD sludenls
vho slaled lhal lhey sludied 'veII lefoie an exan, vas significanlIy highei lhan lhe CIA of
lhose (lhe najoiily of lhis gioup) vho said lhey sludied in lhe 'day oi lvo lefoie an exan.
UnIike ConlioI sludenls, ADHD sludenls did 'pay a piice foi vailing unliI lhe exan vas
inninenl lefoie lhey legan lo sludy. This diffeience seened lo epilonize a fundanenlaI
lehavioiaI inpaiinenl in ADHD, so ve exanined il fuilhei.

VaiialIes ConlioI ADHD
IIanning foi cIass assignnenl
ellei
Woise
Aloul lhe sane
ConpIeling cIass assignnenl
ellei
Woise
Aloul lhe sane
Iiequency of nole-laking
NeaiIy eveiy Iecluie
Sonelines
Read soneone eIses noles
When you sludy foi an exan do you
Sludy veII lefoie lhe exan
Sludy in lhe day oi lvo lefoie lhe exan
Avoiding disliaclions vhiIe sludying
ellei
Woise
Aloul lhe sane
*
3.26 O.43 (46)
2.92 O.52 (19)
3.O6 O.5O (77)
*
3.3O O.44 (48)
2.49 O.82 (3)
3.O2 O.47 (9O)
*
3.13 O.46 (117)
3.O6 O.57 (23)
2.25 O.35 (2)
NS
3.12 O.48 (56)
3.1O O.5O (86)
*
3.3O O.51 (24)
2.91 O.5O (48)
3.18 69 (69)
*
3.O9 O.39 (23)
2.79 O.41 (33)
2.93 O.48 (35)
*
3.O4 O.42 (28)
2.67 O.39 (18)
2.97 O.46 (43)
NS
3.O O.46 (57)
2.86 O.42 (24)
2.76 O.39 (5)
*
3.16 O.35 (22)
2.86 O.47 (64)
NS
3.O O.44 (15)
2.88 O.46 (58)
3.O7 O.4O (17)
* p < O.O5, foi CIAs vilhin each of lhe 2 gioups, as a funclion of lheii ansveis lo each queslion
TalIe 2. F-,9@36 +;;/,91>C ?@55/C/ GH+ I D: !>& @; ?@>93@5 ->. +:A:B:1-C>@6/. D9E./>96
ecause ve had asked lhe sludenls if lhey veie laking ADHD nedicalions, ve couId
dislinguish lelveen lhose ADHD sludenls vho said lhey did (n = 72) fion lhe snaIIei
gioup, vho said lhey didnl (n = 18). The exislence of lhese sulgioups aIIoved us lo
conpaie lhe CIA of ADHD sludenls vho did oi did nol lake lhe diugs, as a funclion of


144
vhelhei oi nol lhey sludied ahead of line foi exans. This iesuIled in 4 gioups, vilh lhe
foIIoving CIAs ( Slandaid Liiois): Those vho look lhe nedicalions, and did nol sludy
ahead of line (n = 47), 2.88 O.48, lhose vho used lhe diugs and did sludy eaiIy (n = 19)
3.15 O.35, lhose vho did nol lake lhe nedicalions, and did nol sludy ahead of line (n =
15), 2.84 O.47, and lhose fev vho did nol lake lhe diugs lul did sludy eaiIy (n=3) 3.19
O.36. A lvo-vay anaIysis of lhese CIAs found no effecl of nedicalion, lul a slalislicaIIy
significanl effecl of sludy inleivaI, (I = 4.O6, p = .O47).
This pieIininaiy anaIysis shoved lhal, if ADHD sludenls uliIized lhe veII-knovn slialegy
of sludying ahead of line foi exans, lhey couId oveicone lheii achievenenl deficil, ctcn if
|ncq didn| |a|c s|inu|an| ncdica|icns. In spile of lhe facl lhal onIy 3 sludenls 'sludied ahead of
line vilhoul using lhe diugs, lheii CIA vas conpaialIe lo lhal of lhe 19 undeigiaduales
vho did lake lhe diugs in addilion lo using good sludy halils. OlviousIy lhis oulcone
needs lo le vaIidaled in a Iaigei gioup of individuaIs. ul, lhe dala suggesl lhe oplinislic
inpIicalion lhal lhe CIA dispaiily lelveen ADHD and nonADHD sludenls couId le
eIininaled if ADHD sludenls veie alIe lo deveIop veII-eslalIished sludy halils.
UnfoilunaleIy, il is nol cIeai fion lhese dala aIone if laking slinuIanl nedicalions acluaIIy
heIps ADHD sludenls lo deveIop leneficiaI sludy halils. Thal is, do lhe slinuIanl diugs
heIp sludenls lo pIan ahead, e.g., lo legin sludying ahead of line so lhal lhey can
conpensale foi lheii cognilive deficil` If so, vhy didnl lhis lehavioi occui in noie of lhe
ADHD sludenls`
These dala piovide pieIininaiy enpiiicaI evidence lhal, as vilh eIenenlaiy and high schooI
sludenls, aduIl coIIege sludenls vilh ADHD aie Iess IikeIy lo ieach lhe sane acadenic IeveI
as lheii non-ADHD counleipails, even vhen lhey use slinuIanl nedicalions. SlinuIanls do
nol necessaiiIy noinaIize acadenic achievenenl, even vhen lhey can le adninisleied al
lhe nosl appiopiiale doses and duialions foi naxinun efficacy, and, even in a popuIalion
lhal is consideied lo le Iess inleIIecluaIIy inpaiied lhan lhe lypicaI aduIl vilh ADHD.
Il shouId le noled lhal even lhose ADHD sludenls vho did nol engage in good sludy halils
veie nol faiIing. Theii aveiage CIA vas jusl alove a 'C, vhich neans lhey veie alIe lo
piogiess lovaids giadualion al a noinaI pace. On lhe olhei hand, lhe alsoIule diffeience
lelveen lhe CIAs of ADHD sludenls and ConlioI sludenls vas nol veiy Iaige, onIy aloul a
lhiid of a giade. Yel lhis diffeience vas consislenl, and il is suipiising lhal lhe slinuIanls
veie nol noie effeclive in naiioving lhe gap. Why aienl lhe slinuIanl nedicalions noie
cogniliveIy effeclive`
4. Discussion
In lheii consideialion of lhis queslion, aikIey and Cunninghan (1978) iaised lhe possiliIily
lhal lhe piolIen vilh slinuIanl nedicalion nighl le lhal il nade hypeiaclive chiIdien Iess
avaie of lheii enviionnenl, peihaps noie inleIIecluaIIy 'consliicled and iigid and Iess
inquisilive oi inleiesled in Ieaining. SiniIaiIy, Cadov noled lhal slinuIanl diugs nighl
pioduce 'cognilive peiseveialion, akin lo anphelanine-induced sleieolypies (lhal is, lhe
iepelilive peifoinance of an invaiianl lehavioiaI sequence)( SulsequenlIy, CaiIson and
unnei (1993) pioposed lhe lein 'cognilive loxicily lo desciile lhis sane hypolhesized
phenonenon.


145
Rollins and Sahakian (Rollins & Sahakian 1979, Sahakian & Rollins, 1977& piovided an
insighlfuI discussion of lhis poinl, pioposing lhal slinuIanl-induced sleieolypy nighl pIay
a ioIe in lhe lehavioiaI effecl of lhe slinuIanls. They noled lhal, .aIlhough sleieolypy
nay inpiove peifoinance in ceilain silualions, peihaps ly focusing oi channeIing
allenlion, il nay aIso Iead lo inpaiinenls vhen lehavioiaI fIexiliIily is iequiied (p. 944).
Theii ieviev sunnaiized iesuIls of nuneious sludies in ADHD-diagnosed chiIdien,
incIuding aclivily neasuies and conpIex noloi lasks, cognilive lasks, inleIIigence lesls,
veilaI fIuency and Ianguage lesls, and allenlion and vigiIance lesls. Acioss aII lhese
calegoiies, lhe giealesl inpiovenenl fion slinuIanls vas seen in aclivily lesls (neasuied
vilh pholo ceIIs, acloneleis and slaliIineliic appaialus) and lhe Ieasl anounl of
inpiovenenl occuiied in lhe piolIen-soIving lesl calegoiy.
SulsequenlIy, lhese ieseaicheis ollained evidence foi slinuIanl-induced 'cognilive
peiseveialion. They conducled a sludy in chiIdien vho had leen on nelhyIphenidale foi 4
lo 29 nonlhs (Dyne el aI., 1982). Lach chiId vas lesled 3 lines, fiisl, undei a 'no diug
piaclice condilion, lhen on lvo liiaIs of eilhei pIacelo oi diug (1 ng/kg). The lasks
incIuded a lesl of 'fIexiliIily of lhinking, lhe Wisconsin Cail Soil Tesl (WCST), invoIving a
sel of iesponse caids vhich couId le soiled accoiding lo coIoi foin oi nunlei. Suljecls
veie nol loId vhich vaiialIe vas coiiecl foi soiling, onIy vhen lhe choice vas iighl oi
viong, lhey had lo figuie il oul foi lhenseIves. Aflei 1O caids veie soiled coiieclIy lhe
exaninei changed lhe soiling vaiialIe vilhoul leIIing lhe suljecl vho lhen had lo
deleinine lhe nev 'coiiecl soil. Suljecls veie scoied on lhe nunlei of eiiois as veII as
coiiecl caids soiled. 'Ieiseveialive Liiois veie nislakes in vhich lhe suljecls soiled
accoiding lo a piioi calegoiy aflei lhey had aIieady leen loId lhal soil vas viong.
The iesuIls shoved lhal aIlhough aII chiIdien inpioved lheii speed oi peifoinance on
neasuies of allenlion, none inpioved on lhis fIexiliIily neasuie and nosl gol voise. This
iesuIl has since leen iepIicaled (Tannock & Schachai, 1992), aIlhough nol in aII cases
!Svailvood el aI., 2OO3). Moieovei, Tannock and Schachai (1992) found lhal lhis
inpaiinenl iecoveied iapidIy (lhal is, loIeiance deveIoped).
NeveilheIess, consislenl vilh lhe WCST dala, Schioedei el aI., (1987) found lhal
nelhyIphenidale inpaiied peifoinance of 15 noinaI naIe voIunleeis, 18 - 4O yeais oId, on
a unique pioceduie. The lask vas an aicade-Iike gane caIIed TeIekinesis Slai Wais, vhich
vas highIy engaging.., as opposed lo lhe noie nonolonous lasks connonIy used in lhese
neuiopsychoIogicaI sludies. SeveiaI neasuies veie ollained fion lhe suljecls
peifoinance in lhis gane, vhich iefIecled lhe slialegies used ly each pIayei, and indicaled
if lhey veie inpioving oi nol. In each case, lhe dala shoved lhal suljecls given
nelhyIphenidale, al doses of O.15 oi O.3O ng/kg, veie pccrcr lhan conlioIs al inpioving
lheii peifoinance lhioughoul lhe lesl session. Diug-liealed suljecls did nol deveIop
adaplive piolIen-soIving slialegies seIecled ly conlioIs.
SiniIaiIy, uins el aI., (1967) aIso desciiled a Ieaining lask lhal vas voisened ly
anphelanine. Suljecls veie sealed in fionl of 8 Iighls, each pIaced alove a key lhal
conlioIIed one of lhe Iighls. The suljecls had lo Ieain vhich singIe key vas lhe coiiecl
iesponse lo each |of 8j Iighl|sj vhen lhe keys veie iandonIy assigned, excepl lhal lhe
coiiecl lullon vas nevei in fionl of lhe Iighl associaled vilh il. The session consisled of 84O
liiaIs laIanced foi fiequency of Iighl/key paiiings. In lhis silualion, lhe d-anphelanine
gioup shoved a significanlIy s|cucr iale of Ieaining lhan lhe pIacelo gioup. Such iesuIls


146
suggesl lhal, due lo lheii piofound effecls on allenlion, slinuIanls nay inpaii adaplive
piolIen-soIving aliIily, peihaps ly inducing peiseveialive lehavioi.
SiniIaiIy, lecause allenlionaI 'oveifocusing and ciealivily nay le inveiseIy ieIaled, lheie
has leen concein lhal slinuIanls nighl deciease ciealivily in peopIe using lhe diugs foi
cognilive enhancenenl. SeveiaI sludies have expIoied lhis possiliIily, noslIy in chiIdien,
vilh nixed iesuIls. Svailvood el aI., (2OO3) found lhal MIH acluaIIy voisened lhe scoies
of ADHD-diagnosed chiIdien on a lalleiy of lesls assessing 'diveigenl lhinking, ieIalive lo
lheii nondiug lesls. Iunk el aI., (1993) sav no effecl of nelhyIphenidale on a lesl lalleiy of
'ciealive lhinking, in young loys, ieIalive lo a nonADHD conpaiison gioup. SoIanlo and
Wendei (1989) aIso iepoiled lhal nelhyIphenidale nainlained 'diveigenl lhinking in
ADHD-diagnosed chiIdien vhen lhe chiIdien veie lesled ovei seveiaI days, ieIalive lo lhe
decIine lhal occuiied on nondiug days. And DougIas el aI., (1995) found lhal . MIH
doses up lo O.9 ng/kg had an incieasingIy posilive effecl on neasuies of nenlaI fIexiliIily
and olhei cognilive piocesses in 17 ADHD chiIdien.
To oui knovIedge, lheie aie no sludies of slinuIanl effecls on ciealivily in ADHD aduIls.
Hovevei, Iaiah el aI., (2OO8) exanined lhe effecl of anphelanine in 16 nonADHD aduIls on
foui lesls of ciealivily, lvo lasks iequiiing diveigenl lhoughl and lvo iequiiing
conveigenl lhoughl (p. 542). OnIy peifoinance on lhe conveigenl lasks vas affecled, and
lhe effecl depended on laseIine peifoinance. The iesuIls suggesled lhal peopIe vho aie
aIieady veiy ciealive nighl le unaffecled oi even inpaiied, vheieas lhose vho veie nol
veiy ciealive lo legin vilh nighl inpiove vilh slinuIanls. Il ienains lo le seen hovevei
vhelhei ADHD-diagnosed aduIls (oi even chiIdien foi lhal nallei) aie acluaIIy Iess
'ciealive lhan lheii nonADHD cohoils.
SlinuIanl-induced peiseveialion and inpaiinenl of cognilive fIexiliIily (ciealivily) have
leen lhe nosl connonIy pioposed ieasons foi vhy lhese diugs pioduce so IillIe Iong-lein
cognilive lenefil. ul, slinuIanls aie aIso synpalhoninelics, lhal is, lhey pioduce lhe sane
effecls as lhe synpalhelic liansnilleis lhal nediale aiousaI and aIeilness. This physioIogicaI
aclion is iaieIy discussed in iegaid lo ADHD, peihaps lecause slinuIanls aie used
lheiapeulicaIIy lo deciease ialhei lhan inciease lehavioiaI aclivily. ul aiousaI is knovn lo
have significanl effecls on nenoiy, nodeiale IeveIs of aiousaI enhance nenoiy vhiIe loo
nuch aiousaI inpaiis nenoiy.
Recenl sludies of iigneII and coIIeagues (iigneII el aI., 2OO6, 2OO7) iIIusliale lhe possilIe
ieIevance of lhis appioach. In one sludy, sepaiale gioups of suljecls veie given eilhei
pIacelo oi nelhyIphenidale vhiIe undeigoing cIassicaI condilioning of a skin conduclance
iesponse. MelhyIphenidale did nol inpaii condilioning, lhe suljecls vho ieceived lhe diug
did acquiie lhe condilioned iesponse. Hovevei, lhe diug incieased lhe nunlei of iesponses
lo lolh, lhe non-condilioned slinuIus and condilioned slinuIus, conpaied lo lhe pIacelo
gioup. This vas desciiled as a geneiaI pallein of nelhyIphenidale-induced aiousaI
incieasing piopensily lo iespond. Il vas concIuded nelhyIphenidale decieased
iesponses lo highIy aiousing slinuIi and incieased iesponses lo lhe Iess aiousing slinuIi
(512).
A second sludy suggesls lhal lhis phenonenon nighl le ieIevanl lo lhe issue of slinuIanls
and cognilion. In lhis case, suljecls veie piesenled vilh a seiies of sIides lhal veie designed
lo leII a sloiy lhal incIuded a veiy 'enolionaI conponenl. One veek Ialei lhe pailicipanls


147
ieluined lo ansvei nuIlipIe choice queslions aloul lhe sloiy. IIacelo-liealed suljecls
shoved lhe expecled enhancenenl of nenoiy foi lhe enolionaI sIides, ieIalive lo lhe
neuliaI sIides. ul nelhyIphenidale-liealed suljecls did nc| shov lhis inciease in nenoiy of
enolionaI naleiiaI, even lhough lhe diug had incieased lheii puIse and lIood piessuie.
UnIike pIacelo-liealed suljecls, lhose given lhe diug shoved conpaialIe ielenlion acioss
aII phases of lhe sloiy. In olhei voids, nelhyIphenidale eIininaled lhe piefeienliaI
ielenlion of lhe infoinalion on lhe enolionaI sIides. These dala suggesl lhal lhe
physioIogicaI aiousaI pioduced ly slinuIanl diugs nay le ieIevanl lo lhe facl lhal lhey do
nol seen lo piovide Iasling cognilive lenefil.
5. ConcIusion
Theie is a paiadox in iegaid lo lhe use of slinuIanl nedicalions indicaled foi lhe liealnenl
of ADHD. On lhe one hand, lheie is nuch iecenl nedicaI, IegaI and elhicaI concein aloul
escaIaling use of lhese diugs, lolh Iicil and iIIicil, piinaiiIy lo enhance cognilion. On lhe
olhei hand, lheie is suipiisingIy IillIe evidence lhal lhe slinuIanl diugs liuIy aie 'cognilive
enhanceis. ResuIls fion neuiopsychoIogicaI sludies confiin lhal vhiIe slinuIanls
appaienlIy inciease allenlion in aduIls diagnosed vilh ADHD, lhe diugs pioduce veiy
nodesl and inconsislenl inpiovenenl on a vaiiely of olhei neuiopsychoIogicaI lasks.
AIlhough iesponses nay le faslei, inaccuiacy and eiiois peisisl, especiaIIy on lesls of
'disliacliliIily. InluiliveIy, il vouId seen IogicaI lhal diugs lhal inpiove allenlion and
concenlialion shouId pionole Ieaining and acadenic achievenenl. Yel, foi noie lhan 3O
yeais dala have shovn lhal lhis is nol lhe case in iegaid lo chiIdien and adoIescenls.
Lvidence piesenled heie suppoils lhe sane concIusion foi aduIl coIIege sludenls. Whelhei
lhis Iack of effecliveness is due lo diug-induced peiseveialion, infIexiliIily, aiousaI oi sone
olhei facloi(s) ienains lo le deleinined.
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IusiIIo, S. (2OO8). Misuse and Diveision of SlinuIanls Iiesciiled foi ADHD: A
Syslenalic Reviev of lhe Lileialuie. ]curna| cf |nc Ancrican Acadcnq cf Cni|d c
Adc|csccn| Psqcnia|rq, VoI.47, No. 1, (}anuaiy 2OO8), pp. 21-31, ISSNO89O-8567
WoIf, L.L. (2OO1). CoIIege Sludenls Wilh ADHD and Olhei Hidden DisaliIilies. Anna|s cf |nc
Ncu Ycr| Acadcnq cf Scicnccs, VoI.931, No. 1, (}une 2OO1), pp. 385-395, ISSNOO77-
8923
Woods, S.I., Lovejoy, D.W. & aII, }.D. (2OO2). NeuiopsychoIogicaI Chaiacleiislics of AduIls
Wilh ADHD: A Conpiehensive Reviev of IniliaI Sludies. Tnc C|inica|
Ncurcpsqcnc|cgis|, VoI.16, No. 1, (Ieliuaiy 2OO2), pp. 12-34, ISSN1385-4O46
Zeeuvs, I. & Soelens, L. (2OO7). VeilaI Menoiy Ieifoinance Inpioved via an Acule
Adninislialion of D-Anphelanine. Hunan Psqcncpnarnacc|cgq, VoI.22, No. 5, (}uIy
2OO7), pp. 279-287, ISSNO885-6222
8
Motor SkiIIs in ChiIdren with ADHD:
Comparative Study from the
FarmacoIogicaI Treatment
}ose Ainando Vidaile CIaios
1
and ConsueIo VeIez AIvaiez
2

1
Unitcrsidad Au|cncna dc Maniza|cs, Dcpar|ncn| cf Hunan Mctcncn|,
8cdq-Mctcncn| Rcscarcn Grcup,
2
Unitcrsidad dc Ca|das, Dcpar|ncn| cf Puo|ic Hca||n,
Prcnc|icn and prctcn|icn Rcscarcn Grcup,
Cc|cnoia
1. Introduction
(CaiIIaid el aI., 2OO4) affiin lhal lhe lein Hypeiaclivily is aloul a lype of disluiling
lehavioi lhal vas aIvays slignalized ly lhe leins agilalion, psychonoloi inslaliIily and
hipeikinesia. And lhe leins psychonoloi and hipeikinesia iefei lo a noloi lehavioi
iesuIling fion allenlion and excilalion piolIens leconing an oulei piesence, on lhe olhei
hand, (Vidaile el aI., 2OO9) on lhe Isychonoloi piofiIe of lhe chiIdien cIinicaIIy diagnosed
vilh TDAH in lhe cily of ManizaIes, concIuded hov lhe noliIily faclois of lhe diagnosed
chiIdien piesenled noinaI iank vaIues vhich veie significanlIy voise vhen conpaiing
lhen vilh lhe heaIlhy chiIdien in aII lhe ages, lhis chaplei liies lo denonsliale lhe iesuIls
ollained in a ieseaich piocess, lhal shovs lhe diffeiences happened in lhe psychonoloi
piofiIe in chiIdien diagnosed vilh lhe TDAH lhal ieceives phainacoIogicaI liealnenl vilh
lvo vaiialIes of anaIysis (sex and lhe lype of TDAH) as a lasis.
The neuiochenicaI hypolhesis vhich poses a dysfunclion of fionlo sliialaI conneclions
eilhei of analonicaI oi funclionaI oiigin, has leen lhe juslificalion foi lhe use of
phainacolheiapy (incIuding nelhyIphenidale oi RilaIin, a slinuIanl lhal aclivales lhe
inhililoiy nelvoik lehavioi). This hypolhesis ienains alliaclive fion a heuiislic poinl of
viev, il lends lo considei aII lhe coilex as a iefIecling oigan of fionlaI Iole, ialhei lhan
seeing il as lhe conlioI cenlei of sociaI lehavioi, vhich aIso addiesses enviionnenlaI
iesponses (IIiszka el aI., 1996 y Tannock, 1998) and vheie il is consideied lhe expiession of
lhe noloi skiIIs as a sociaIizing eIenenl.
In lhis papei lhe aulhois liy lo piovide eIenenls lhal shov lhe noloi skiIIs lehaviois in
chiIdien diagnosed vilh ADHD and laking nedicalions and aIso lhis papei aIIovs nev
hypolheses lo lhe scienlific evidence foi lhis ieIalionship. Ioi lhis ieason, lhe oljeclive of
lhis papei is lo eslalIish lhe diffeiences in lhe lehavioi of lhe psychonoloi piofiIe of
chiIdien cIinicaIIy diagnosed vilh ADHD and laking phianochoIogicaI liealnenl in lhe cily
of ManizaIes, CoIonlia.


158
The deveIopnenl of lhis papei has piinaiiIy a lheoielicaI and concepluaI appioach of lhe
disoidei fion lhe scienlific evidence eslalIished ly diffeienl aulhois vheie issues as lhe
definilion, pievaIence, elioIogy, conoilidilies and lheiapeulic inpIicalions aiise, naking
enphasis on noloi skiII and conoilidily, secondIy lhe iesuIls ollained in lhe sludy shov
lhe ieIalionship lelveen lhe psychonoloi piofiIe of chiIdien diagnosed fion
phainachoIogicaI liealnenl.
2. Attention Deficit Disorder and hyperactivity
The allenlion deficil disoidei vilh hypeiaclivily is an inpoilanl heaIlh piolIen, foi ils ovn
chaiacleiislics, and foi ils aIleialions lhal aie associaled oi liiggeied as a iesuIl of
inallenlion oi hypeiaclivily. IeopIe vilh lhis syndione, nol onIy suffei lhe diiecl effecls of
lhe disoidei, lul aIso lhe acadenic, sociaI oi Ialoi inpacl invoIved, and il oflen peisisls
even aflei you have sulnilled lhe disoidei. The allenlion deficil disoidei vilh
hypeiaclivily (ADHD) is, aIong vilh dysIexia, lhe nosl inpoilanl cause of schooI faiIuie.
Disoidei Allenlion Deficil is knovn ly lhe acionyns: ADD (Allenlion Deficil Disoidei),
ADS (Allenlion Deficil Syndione), AD (Allenlion Deficil), ADHD (Alenlion Deficil
Hipeiaclivily Disoidei), and noie connonIy ADHD (Allenlion Deficil Hypeiaclivily
Disoidei). The (Aneiican Isychialiic Associalion, 2OO2) chaiacleiizes il as "a peisislenl
pallein of inallenlion and / oi hypeiaclivily-inpuIsivily lhal is sliongei and seveie lhan
lypicaIIy olseived in individuaIs of a siniIai IeveI of deveIopnenl". These lhiee dinensions:
inallenlion, hypeiaclivily and inpuIsivily aie lhe axes of lhe disoidei and lhey aie
chaiacleiized as foIIovs:
Allenlion disoideis aie lhe inaliIily lo nainlain lhe slandaid caie foi Iong peiiods of line,
chaiacleiized ly fIeeling allenlion and inhililed inpuIses, in lhe vaking slale is one of lhe
nanifeslalions of lhis disoidei. IeopIe vho aie inallenlive have difficuIly concenlialing on
one lhing and lecone loied vilh a lask aflei onIy a fev ninules. Lack of allenlion can le
infeiied fion lhe olseivalion of lehavioi, as, foi exanpIe, if a chiId is nol peifoining a lask
foi lhe iequiied line, a lask lhal is avaiIalIe lo olhei chiIdien vilh lhe sane age, inleIIigence
and schooIing, fion vhich is diffeienl (aikIey, 1991l).
The diagnoslic ciileiia foi allenlion deficil disoidei in DSM-IV veision (1995) and DSM-IV-
TR (2OO2) have oflen nol enough allenlion lo delaiIs oi caieIess nislakes done in
schooIvoik, in lhe voik oi olhei aclivilies. Il oflen has difficuIly suslaining allenlion in
lasks oi pIaying aclivilies. Il oflen does nol seen lo Iislen vhen spoken lo diieclIy. Il oflen
does nol foIIov insliuclions and faiIs lo finish schooIvoik, choies oi dulies in lhe voikpIace
(nol due lo opposilionaI lehavioi oi faiIuie lo undeisland insliuclions). Il oflen has
difficuIly oiganizing lasks and aclivilies. Il oflen avoids, disIikes oi is ieIuclanl lo engage in
lasks lhal iequiie suslained nenlaI effoil (such as schooIvoik oi househoId). Il oflen Ioses
lhings necessaiy foi lasks oi aclivilies (e.g. loys, schooI assignnenls, penciIs, looks oi looIs).
Il is oflen disliacled ly iiieIevanl slinuIi. Il is oflen foigelfuI in daiIy aclivilies.
Hypeiaclivily is lhe second conponenl of ADHD and lypicaIIy nanifesled ly excessive and
conlinuous novenenl vhen il is inappiopiiale lo do so, ieslIessness, neivousness and
inaliIily lo sil vilhoul gelling up, lo "le iunning" conlinuousIy, as having an inleinaI
engine, and laIking loo nuch. The piolIens of chiIdien vilh ADHD incIude lolh an excess
of aclivily and inappiopiiale aclivily depending on lheii age and ciicunslances (aikIey, el

Motor Skills in Children with ADHD: Comparative Study from the Farmacological Treatment

159
aI., 199Ol). Il is aIso said lo le desolidienl, vho do nol slop lapping lheii fingeis, noving in
lheii seals oi lo annoy lheii cIassnales, (WhaIen, 1986, WhaIen y Henkei, 1991a, AinoId, el
aI., 1997l).
Hypeiaclive chiIdien seen lo have piolIens ieguIaling lheii aclions accoiding lo lhe
vishes of olheis oi lhe denands of conlexl, (Teichnei, el aI., 1996, SoIanlo, el aI., 2OO1,
SIusaiek, el aI., 2OO1). Hypeiaclive lehavioi is usuaIIy exlended lo a gioup of lehaviois
such as aggiession, conslanl aclivily, disliacliliIily, inpuIsiveness, inaliIily lo concenliale
and difficuIly in pailicipaling in siIenl aclivilies such as ieading and aclivilies lhal iequiie
a siniIai lehaviois, aIlhough lhey nay ieIale lo each olhei, lhey do nol aIvays coiiespond
vilh hypeiaclivily ilseIf.
The diagnoslic ciileiia foi hypeiaclivily in lhe veision of lhe DSM-IV (1995) and DSM-IV-TR
(2OO2) aie: He oflen fidgels vilh hands oi feel oi squiins in seal. He oflen Ieaves seal in
cIassioon oi in olhei silualions in vhich ienaining sealed is expecled. He oflen iuns aloul
oi cIinls excessiveIy in silualions in vhich il is inappiopiiale (in adoIescenls oi aduIls il
nay le Iiniled lo suljeclive feeIings of ieslIessness). He oflen has difficuIly pIaying oi
engaging in Ieisuie aclivilies quielIy. He oflen "is ongoing." He oflen laIks excessiveIy.
InpuIsivily is lhe lhiid conponenl of ADHD, lhis lehavioi luins inlo inpalience, inaliIily
lo poslpone a iepIy, lo ansvei lefoie lhe queslion has leen nade in fuII, and lo slop
fiequenlIy, causing piolIens in sociaI silualions. AIso, individuaIs can nake inappiopiiale
connenls, dispIay a Iack of allenlion lo undeislanding lhe iuIes, luffooneiy, elc.. Thal is,
chiIdien aie unalIe lo conlioI lhenseIves, lo adapl lheii lehavioi lo enviionnenlaI
denands and deIay gialificalion. (aikIey, 1997) desciiled lhe nuIlidinensionaI naluie of
lhese synplons, accoiding lo il, incIuding cognilive and lehavioiaI aspecls. ehaviois
associaled vilh hypeiaclivily and inpuIsivily aie: sociaI disinhililion, Iack of caulion in
dangeious silualions and inpuIsiveIy lieaking sociaI noins, so lhal lhese chiIdien suffei
conlinuous accidenls and aie easiIy iejecled ly equaI gioups.
The diagnoslic ciileiia foi inpuIsivily in lhe DSM-IV veision (1995) and DSM-IV-TR (2OO2)
aie: Il oflen lIuils oul ansveis lefoie queslions have leen conpIeled. Il oflen has difficuIly
availing a luin. Il oflen inleiiupls oi inliudes on lhe aclivilies of olheis (eg, lulls inlo
conveisalions oi ganes.
Iion lhese conponenls ADHD has leen cIassified: piedoninanlIy hypeiaclive,
piedoninanlIy conlined and piedoninanlIy inallenlion. Ioi nany aulhois, ADHD is lhe
nosl connon disoidei in chiIdhood (Shayvilz y Shayvilz, 1991, aikIey, el aI., 1971,
iedeinan el aI., 1996a, WoIiaich el aI., 1996) and il appeais lo le peisislanl inlo
adoIescence and aduIlhood (aikIey, el aI., 199Ol, Ieiguson, el aI., 1993). The pievaIence of
ADHD ianges lelveen 3 and 7 in geneiaI popuIalion and lelveen 1O and 15 in
cIinicaI popuIalion (Iischei, el aI., 199O).
The pievaIence of ADHD synplons vaiies depending on vho iepoils (paienls oi leacheis),
age and sex of chiIdien and lhe evaIualion ciileiia used (Anadoi y Ioins, 2OO1).
LpidenioIogicaI sludies indicale lhal lhe pievaIence of ADHD vaiies ly age, sullype of lhe
disoidei (ADHD inallenlive lype oi hypeiaclive-inpuIsive lype) and gendei. In lhis sense,
ADHD hypeiaclive-inpuIsive lype is foui lines noie connon in loys lhan giiIs (4:1), and
ADHD inallenlive lype is in 2:1 ialio. olh sullypes aie noie connon lelveen eighl and
len yeais, (WoIiaich el aI., 1996, alhia el aI., 1991).


160
In CoIonlia, lheie has leen seveiaI pievaIence sludies, such as one invoIving chiIdien of 5
lo 7 yeais in lhe cily of ManizaIes, in vhich individuaI inleivievs veie used lased on DSM-
IV. The pievaIence of lhe disoidei vas 8.2. These dala confiined lhose piovided ly
diffeienl Iileialuie souices, finding lhal lhe disoidei vas noie connon in chiIdien vho
veie 6 yeais oId, lhe naIe / fenaIe ialio vas 5 lo 1, lhe nosl connon age of onsel of
synplons, accoiding lo paienls vas al 5 yeais and accoiding lo leacheis al 6 yeais (Vidaile
y VeIez, 1999).
SulsequenlIy, lhese aulhois deveIoped a second phase vilh chiIdien 8 lo 12 yeais, il vas
found lhal lhe pievaIence vas 7.1. ConpaialiveIy, lhe pievaIence vas Iovei lhan lhe one
found in lhe fiisl sludy, vilh lhe diffeienliaI vaiialIe lelveen lhe age of lhe suljecls. olh
sludies aIso suggesl lhe inpoilance of lhe piolIen of ADHD in lhis cily of CoIonlia and
lhe need lo conlinue lo advance knoving aloul lhe piolIen (Vidaile y VeIez, 2OO1).
Anolhei sludy found a pievaIence of 16.1. The diagnoslic ciileiia used a Iisl of synplons
lhal coiiesponded exaclIy lo lhe 18 ilens of DSM-IV ciileiion foi diagnosis of ADHD. Dala
veie ollained fion paienls of chiIdien and adoIescenls fion 4 lo 17 yeais in lhe cily of
ManizaIes (Iineda el aI., 2OO1).
In lhe cily of CaIi, a sludy on lhe neuiopsychoIogicaI and lehavioiaI piofiIes of chiIdien
vilh ADHD (ai el aI., 2OO3) vas done. In addilion lo desciiling lhe neuiopsychoIogicaI
piofiIes of chiIdien, a pievaIence of ADHD of 16 vas shoved. In 2OO5, il vas eslalIished
fion lhe sludy on lhe pievaIence of ADHD in CoIonlian adoIescenls fion Salanela lovn
(Anlioquia) a pievaIence accoiding lo DSM-IV 15.86 (Coinejo el aI., 2OO5).
Iievious sludies shov lhal in CoIonlia lheie is a high pievaIence of ADHD, nuch highei
lhan in sludies eIsevheie. This disciepancy couId le expIained as a iesuIl of seveiaI faclois
vhich incIude lhe use of noie oi Iess iesliiclive ciileiia in eslalIishing lhe diagnosis, oi lhe
exislence of psychosociaI iisk faclois of lhe enviionnenl fion vhich popuIalion sanpIes aie
exliacled. Added lo lhis, lheie aie olhei inpoilanl eIenenls as foIIovs: fion lhe lolaI
popuIalion diagnosed, onIy 7.4 ieceived a diagnosis confiined ly a sliucluied psychialiic
inleiviev, and onIy 6.6 of palienls have liealnenl vhich couId indicale lhal lheie couId le
a suliegislei in lhe diagnosis in deveIoped counliies.
AIlhough lhe DSM ilseIf in ils diffeienl veisions indicales lhe alsence of evidence lo suggesl
oiganic disoideis in lhe elioIogy of ADHD, iecenl sludies have leen pioviding ieIevanl
infoinalion in lhis aiea. Ioi exanpIe, lheie is sliong evidence lhal genelic faclois aie
inpoilanl in causing lhe disoidei, lul aIso olhei faclois aie consideied: liochenicaI,
neuioIogicaI, enviionnenlaI, viiuses, piolIens duiing piegnancy, voiking and olheis lhal
aIlei liain deveIopnenl.
Since genelic faclois, ieseaich in lhis fieId in lhe elioIogy of ADHD aie lased on sludies of
lvins and faniIies. The sludies iesuIls vilh faniIies have shovn a highei incidence of
ADHD oi synplons lheieof, in lioIogicaI paienls of lhese chiIdien (Shayvilz y Shayvilz,
1991, iedeinan, el aI., 1992, Iaiaone, 1996). AIso, a highei piopoilion of psychialiic
disoideis in lioIogicaI paienls of chiIdien vilh ADHD vas found, a highei incidence of
anxiely disoideis and depiession in nolheis and anlisociaI peisonaIily disoideis and
aIcohoIisn in paienls vas found (iedeinan, el aI., 199O, iedeinan, el aI., 1991, Iaiaone, el
aI., 1998a, SchaiII, el aI., 1999).


161
A sludy shovs lhal lhe lioIogicaI paienls of chiIdien vilh ADHD have highei iisk of
allenlion deficil (Iiick, 1994). Hovevei, sone sludies have shovn lhe exislence of
enviionnenlaI faclois invoIved in lhe piesenlalion and seveiily of ADHD synplons and
lheii associalion vilh olhei palhoIogies such as aggiessive lehavioi (Shayvilz y Shayvilz
1991, iedeinan, el aI.,1991, Augusl, el aI., 1996a, iedeinan, el aI., 1997). In a sludy
conducled lo evaIuale lhe associalion lelveen ADHD and disoideis of fiisl-degiee
lioIogicaI paienls and adoplive paienls of chiIdien vilh ADHD, il is suppoiled in lhe
hypolhesis lhal ADHD has a significanl lioIogicaI conponenl (Spiich, el aI., 2OOO). The dala
found in lvins sludies suppoil lhe hypolhesis of a genelic conponenl in lhe nanifeslalion
of ADHD. A giealei concoidance lelveen nonozygolic lvins lhan in dizygolic lvins vas
found. These iesuIls suppoil lhe idea of a genelic infIuence in lhe elioIogy of lhe disoidei
(CiIIis, el aI., 1991, Sheinan, el aI., 1997l).
Il has leen found lhen lhe nanifeslalion of ADHD is expIained in 5O ly genelic faclois. Il
vas aIso found a concoidance foi ADHD of 81 in nonozygolic lvins and dizygolic lvins
29 (Coodnan y Slevenson, 1989, Sheinan, el aI., 1997a, SiIleig, el aI., 1998). SiniIaiIy il
vas found a genelic infIuence in lhe a elioIogy of ADHD in chiIdhood, vhiIe lhe eneigence
in adoIescence vilh aggiessive lehavioi expIained vouId piefeialIy le in an enviionnenlaI
infIuence (SiIleig, el aI. 1996 p.8O3). Accoiding lo lhe dala alove, il couId aigue lhal lhe
iesuIls ollained fion sludies of lvins and faniIies suppoil lhe hypolhesis of poIygenic
inheiilance in lhe liansnission of ADHD.
Iion lhe neuiochenicaI faclois, iecenl findings suggesl a neuiochenicaI disoidei in lhe
elioIogy of ADHD, finding changes in ceieliaI lIood fIov and nelaloIisn (Teelei y
Seniud-CIikenan, 1995). These changes pioduce Iess aclivalion in lhe fionlaI, lenpoiaI,
and Iinlic aieas. Aflei conducling vaiious ieseaiches, il has leen conjecluied an undeiIying
genelic piedisposilion lo lhe elioIogy of ADHD, vhich caiiies a hypofunclionaI of
dopanineigic palhvays in lhe piefionlaI and Iinlic syslen, invoIved in lhe nechanisn
iesponsilIe foi lhe nanifeslalion of synplons ADHD (aikIey, el aI., 1992).
Iion a lehavioiaI poinl of viev, lhe deficiency of dopanine in lhe piefionlaI iegion iesuIls
in an inaliIily lo conlioI inpuIses and a difficuIly in pIanning and caiiying oul a sequence
of aclions ained al achieving a goaI, lhe difficuIly in deIaying gialificalion and excessive
noloi skiII aclivily, key fealuies of allenlion deficil disoidei vilh hypeiaclivily. olh
noiepinephiine and epinephiine, and dopanine have leen ieIaled lo lhe palhophysioIogy
of ADHD (IIiszka, el aI., 1996). These chenicaI nedialois aie iesponsilIe foi liansnilling
slinuIi fion neuion lo neuion and lhey aie invoIved in expIaining nany psychopalhoIogic
changes. The aulhois suggesled lhal lhese lhiee neuioliansnilleis had sone kind of
piolIen, naneIy one in neuioliansnilleis dopanine hypofunclionaI.
Olhei sludies (CasleIIanos, el aI., 1996l, Ainslein, el aI., 1996) have iefoinuIaled lhe
calechoIanine hypolhesis ly enphasizing lhe ioIe pIayed ly dopanine and noiepinephiine
in lhe palhophysioIogicaI expIanalion foi ADHD. These aulhois piopose lhe exislence of a
sulaclivacin and oveiaclivalion in lvo dopanineigic iegions as nechanisns in lhe genesis
of ADHD. The sulaclivacin vouId le Iocaled in lhe coilicaI iegion (e.g. anleiioi cinguIale)
and il vouId le iesponsilIe foi cognilive deficils of lhese chiIdien, and oveiaclivalion in lhe
iegion vouId le sulcoilicaI (e.g. caudale nucIeus) and il vouId expIain lhe excessive neuiaI
aclivily (Svanson, el aI., 1991l), noling lhal il seens unIikeIy lhal ADHD is associaled vilh
jusl one hypofunclionaI of lhe dopanineigic syslen.


162
In facl, lhe seIeclive dopanine agonisl adninislialion has nol shovn inpiovenenl in
synplons of ADHD (Navaiio y Manzanaque, 1998). Add lo lhal lhe conpIex vel of
conneclions avaiIalIe lo lhe dopanine neuioliansnillei. Today, il has leen discoveied up
lo five diffeienl sullypes of lhese neuioliansnilleis, each one vilh diffeienl ioules and
diffeienl ioIes oi lehavioiaI ciicuils (Navaiio, 2OOO). Il nighl le concIuded lhal in lhe
iesuIls of ieseaich on lhe neuiochenicaI conponenls in expIaining lhe palhophysioIogy of
ADHD lheie aie nany queslions lo le ansveied, as a faiIuie lo denonsliale a diiecl
ieIalionship lelveen one lype of neuioliansnillei and ils effecls on lhe chiId's lehavioi.
Iion lhe neuioanalonicaI faclois, sludies using neuioinaging lechniques have found
diffeiences, aIlhough discoidanl in liain noiphoIogy of chiIdien vilh ADHD (CasleIIanos
el aI., 1996l, CasleIIanos el aI., 1996a). LaiIy sludies vilh lhese lechniques had nuneious
nelhodoIogicaI liases, (Casey el aI., 1997, Svanson el aI., 1998). A hypolhesis cuiienlIy
suppoiled in a neuioanalonicaI sludy of ADHD is invoIving lhe piefionlaI Iole in
expIaining lhe synplons of lhis disoidei, (CaleIIanos el aI., 1996a, CoIly, 1991, CaleIIanos el
aI., 1994). This aiea, in pailicuIai, lhe fionlaI Iole, is iesponsilIe foi pIanning, diiecling,
naking decisions and evaIualing lhe iesuIls of oui aclions, vhal has leen iefeiied lo as lhe
geneiaI syslen of seIf-ieguIalion of lehavioi (aikIey el aI., 1992).
The ieIalionship lelveen dysfunclion in lhe piefionlaI coilex aieas and deficils in iesponse
inhililion in visuaI-noloi lasks in a sanpIe of 13 chiIdien vilh ADHD and 1O noinaI (Ross
el aI., 1994) has leen exanined. ChiIdien vilh ADHD shoved significanl diffeiences
conpaied vilh lhe conlioI gioup, in lhe execulion of iesponse inhililion lasks, lul nol in
visuospaliaI nenoiy lasks oi iesponse Ialency. The aulhois associaled lhese deficils lo a
dysfunclion in lhe doisoIaleiaI coilex, olhei aulhois, lased on sludies of neuionaI ciicuils
inleiconnecled idenlifies five analonicaI sliucluies lhal nay iepiesenl an inpoilanl
palhophysioIogicaI nodeI in expIaining lhe genesis of ADHD (Ross el aI., 1994). These
sliucluies have conneclions vilh noloi and sensoiy coilex.
Sludies using MRI indicale lhal sone iegions of lhe fionlaI Iole (anleiioi, supeiioi and
infeiioi) and lasaI gangIia (caudale nucIeus and gIolus paIIidus) aie Iovei in chiIdien vilh
ADHD lhan in noinaI chiIdien. Thus, il has found a lolaI liain voIune 5 snaIIei in
chiIdien vilh ADHD lhan in noinaI ones, pailicuIaiIy in lhe aiea of lhe caudale nucIeus, a
deficil in piefionlaI neuiaI piocessing in chiIdien vilh ADHD conpaied lo lhe conlioI
gioup and a snaIIei voIune of vhile nallei in lhe iighl fionlaI Iole (SiIleislein el aI., 1998,
Seniud-cIikenan e l aI., 2OOO). These aulhois suggesl lhal noiphoIogicaI changes in lhe
fionlaI Iole and lhe caudale nucIeus aie inveiseIy coiieIaled vilh neasuies of inhililion
and exleinaIizing lehavioi of chiIdien vilh ADHD. The iesuIls of lhese sludies aie
consislenl vilh lheoielicaI nodeIs of lhe aIleied funclion of fionlo-sliiale and paiielaI Ioles.
Wilh iegaid lo iisk faclois, seveiaI sludies have indicaled lhe exislence of iisk faclois in lhe
expIanalion of ADHD (}ohnslon y IeIhan, 1986,uinIey, 1993, MiIleigei el aI, 1997, Max el
aI., 1998). Anong lhe pioposed iisk faclois incIude: snoking in piegnanl vonen,
conpIicalions duiing piegnancy and chiIdliilh, exposuie lo chenicaIs and liain injuiy
(Wozniak el aI., 1999). UIlinaleIy, and lased on lhe checked iesuIls on elioIogy, il is IikeIy lo
le a neuioanalonicaI and neuiochenicaI lasis in lhe expIanalion of ADHD. The findings in
faniIy sludies of lvins and genelics suppoil lhe hypolhesis of a poIygenic inheiilance in lhe
liansnission of ADHD. The iesuIls in neuiochenisliy and neuioanalony of lhe elioIogy of


163
lhis disoidei pose nany queslions lo le ansveied, as lhe faiIuie lo denonsliale a diiecl
ieIalionship lelveen one lype of neuioliansnillei and ils effecls on lehavioi. AIlhough lhe
nechanisns iesponsilIe aie unknovn in lhe genesis of ADHD, sludies on palhophysioIogy
poinl lo lhe exislence of neuioanalonicaI, genelic and enviionnenlaI faclois as veII as in
lhe expiession and seveiily of ADHD (Kasdejo el aI., 2OO1).
2.1 Therapeutic impIications
Al piesenl, lhe liealnenl of suljecls vilh ADHD noves in lhiee diieclions: fiisl, a ie-
educalion oiienlalion vhich has seveiaI vaiianls depending on lhe enphasis given lo
acadenics oi cognilive-lehavioiaI disluilances, lhe second one is an inleidiscipIinaiy
appioach in vhich diffeienl piofessionaIs (physician, psychoIogisl, educaloi, physicaI
educaloi, elc.). have lheii iespeclive aieas in lhe vaiious nanifeslalions of lhis disoidei, and
lhe lhiid one lhal is phainacoIogicaI in naluie, nol vilhoul conlioveisy, lul il offeis
ieseaich on iesuIls, nol onIy noie nuneious lul aIso noie accuiale lhan lhe olheis.
In geneiaI, neuiophainacoIogicaI liealnenl of ADHD, ains lo inpiove lhe neive inpuIses
lhal acl on ceilain fionlosliialaI ciicuils. Dopanineigic and noiadieneigic nedialion
lelveen neive inpuIses and lhe oplinaI funclioning of lhese ciicuils vouId iesuIl in a
sulslanliaI ieduclion in synplons of ADHD, especiaIIy in iegaid lo execulive funclions.
Medicalion liealnenl vas slailed in 1937 vhen iadIey desciiled lhe effecls of lenzediine
in lhe lehavioi of chiIdien. Since lhen il has cIeaiIy docunenled lhe ioIe and efficacy of
slinuIanls and il has leen denonslialed lheii effecliveness in lhe liealnenl of noloi skiII
aclivily and Iack of allenlion. MelhyIphenidale (MIH) and dexlioanphelanine (DA) aie
lhe nedicalions nosl connonIy used slinuIanls. AIleinaliveIy, lhe liicycIic anlidepiessanls
have lenefiled sone palienls.
AIlhough liealnenl of lhe hypeiaclive chiId is lased on foui lheiapeulic piIIais, lhe nedicaI
phainachoIogic appioach has a speciaI ieIevance. Ioi yeais, aIleinalive liealnenls foi
ADHD have leen confined lo lhe use of psychoslinuIanls, and lheii favoialIe effecls in
ieducing lhe synplons and nanifeslalions of ADHD aie lhe nedicalions of fiisl-Iine
liealnenl. These nedicalions inpiove lhe lehavioi lelveen 7O and 9O of chiIdien oIdei
lhan 5 yeais (aikIey, 1988). The efficacy of lhese slinuIanls has leen shovn fion pIacelo-
conlioIIed doulIe-lIind sludy in chiIdien and aduIls, a 65-85 of ADHD palienls had a
cIinicaI iesponse lo nelhyIphenidale, conpaied lo 4-3O vilh pIacelo (WiIens y Spencei,
2OOO). Scienlific evidence suggesls lhal nelhyIphenidale and anphelanine saIls aie equaIIy
effeclive in lhe liealnenl of ADHD in chiIdien (VilieIIo el aI., 2OO1, Monlaes-Rada el aI.,
2OO9).
The nev foinuIalions of lhese conpounds have denonslialed Iong-acling, al Ieasl, siniIai
efficacy lo lhe innediale ieIease (Iaiaone e l aI., 2OO6), vhich is siniIai lhioughoul lhe
diffeienl slages of Iife, incIuding pieschooI, chiIdien, adoIescenls and aduIls (}ensen el aI.,
2OO1, Ranos-Quiioga el aI., 2OO6, Conneis el aI., 2OO1). Despile lhe high efficiency,
appioxinaleIy 2O-35 of palienls do nol iespond lo lhese liealnenls (Conneis el aI.,
aikIey, 1977).
The lenefil vilh lhe use of slinuIanls is 75 lo 9O. suljecls ieceiving lhis liealnenl nol
onIy aie Iess inpuIsive, ieslIess and disliacled and lhey inleinaIize lhe infoinalion lellei,
have lellei ieIalionships, eslalIish connilnenls in a lellei vay and lhus lhey auloconlioI


164
noie efficienlIy, and lhey Iel lhen le noie accepled and Iiked ly lheii peeis and ieceive
Iess punishnenl, inpioving seIf-esleen. Hovevei, lhis lype of phainacoIogicaI
inleivenlion has sone iesliiclions, such as nisuse of nedicalion, lhe phainacodependency
lhal occuis in sone peopIe and lhe nisconceplion lhal lhe phainacoIogicaI liealnenl is
suslained as lhe onIy aIleinalive lo lhe piolIen of allenlion, ignoiing olhei aIleinalives such
as inlegiaI liealnenl (Ieinndez }aen, 1999).
RecenlIy lheie have leen iesuIls iefeiied lo a MuIlinodaI Sludy of ChiIdien vilh Allenlion
Deficil / hipeiaclivily Disoidei (MTA Coopeialive Cioup, 2OO3). This sludy has shovn lhal
slinuIanl nedicalion had cIeaiIy supeiioi iesuIls lo lhose ollained vilh lehavioiaI
liealnenl and enviionnenlaI caie. In addilion, conlined lheiapy (lehavioiaI and
phainacoIogicaI) vas nol significanlIy supeiioi lo nedicaI lheiapy aIone. The use of
slinuIanls oflen pioduces an innediale inpiovenenl in lehavioi, il aIso inpioves seIf-
conlioI, allenlion, aggiession, and inleipeisonaI ieIalionships, especiaIIy al faniIy and
schooI IeveI. Il slales lhal il is inpoilanl foi leacheis lo knov lhal nedicalion do nol conlioI
lhe chiId, lhey sinpIy heIp fiIlei disliaclions aIIoving lhen lo concenliale on lhe lasks lhey
peifoin, heIping lo ieduce inpuIsiveness and faciIilale lellei decision-naking (Aiias, 2OO3).
Conceining lhe effecls of sone nedicalion used in ADHD on lhe noloi skiII, sludies aie
scaice. A sludy on lhe effecl of nelhyIphenidale in chiIdien vilh ADHD and DCD on fine
noloi skiIIs of lhese lvo gioups and a conlioI gioup. The iesuIls shoved lhal chiIdien vilh
ADHD-DCD, peifoined lhe noloi lasks vilh giealei noloi skiII deficiency lhan chiIdien in
lhe conlioI gioup. In pailicuIai, lhe aclivilies of nanuaI dexleiily sullesls had pooiei
quaIily of handviiling, and diev noie quickIy lul Iess accuialeIy lhan heaIlhy
giaphonoloi lasks. AppIying nelhyIphenidale, nanuaI dexleiily and inpioved quaIily of
lhe handviiling and lhe leals in lhe giaphonoloi lask veie Iess iapid and noie accuiale
(Houve y Schoenakei, 2OO6). In shoil, lhe nosl videIy used nedicalion lo lieal ADHD is
nelhyIphenidale. Ils effecliveness is suppoiled ly nuneious sludies ovei five decades
(Conneis el aI., 2OO1, Ailigas-IaIIaies, 2OO4, Rappoil el aI., 1994, WhaIen el aI., 1979). The
aclion of nelhyIphenidale is a seIeclive inhililion of dopanine ieuplake and acls lo
inpiove lolh acadenic peifoinance, such as sociaI inleiaclion, and a geneiaI lehavioi,
since il ieduces hypeiaclivily and keeps allenlion. Undei ieseaich lheie aie nedicines
deiived fion nicoline, vhich use inpioves dopanineigic neuioliansnission, nenoiy and
execulive funclions (Iaiaone el aI., 1997).
Iion lhe knovn conponenls oi inlegialed nuIlinodaI liealnenls, lvo issues shouId le
highIighled: fiisl, vaiialions in lhe nunlei of piofessionaIs inlegialed inlo lhe piogian, and
lhe second, in leins of oljeclives and nelhods lhal aie oiienled piinaiiIy lo ieduce oi
pievenl dysfunclions associaled vilh ADHD synplons (aggiession, negalivisn, anlisociaI
lehavioi, elc.). In lhis iegaid, il is noled lhe effecliveness of liealnenls nade fion conducl
nodificalion, vhen iecognizing lhe chiId voiking vilh paienls and educalois in paiaIIeI.
IhysicaI aclivily, and TDH-oiienled lheiapeulic nodaIily couId le a ioule of consideialIe
inleiesl, vhen in advance, accuialeIy desciiled noloi alnoinaIilies in lhese palienls have
leen found.
In aduIlhood, aloul 15 lo 2O of chiIdien vilh allenlion deficil disoidei and hypeiaclivily
conlinue lo expeiience synplons of lhis disoidei, anolhei lhiid have synplons of
anlisociaI peisonaIily disoidei. A significanl peicenlage shovs nedicalion aluse (16),
especiaIIy vhen lvo aie piovided lefoie adoIescence lehavioiaI piolIens and acadenic


165
pailneis aie coiiecled. If lhis is done, a gioup foined ly lhe nosl seveie cases viII sliuggIe
in aduIlhood vilh peisislenl synplons of lhe disoidei. (Conneis el aI., 2OO1). Lileialuie
iefeis lo onIy 2O. The chiIdien vho do nol ieceive a liealnenl oi il is inconpIele, an 8O
has a lad Iong-lein piognosis vilh eneigence of expIosive conducl disoideis in
adoIescence, disociaI conducl disoidei, ciininaI-lype peisonaIily disoidei, aIcohoIisn, diug
aluse, jol inslaliIily and difficuIlies in peisonaI ieIalionships.
Il is geneiaIIy consideied lhal 8O of chiIdien vilh ADHD have a favoialIe Iong-lein
piognosis, vhen piioi lo adoIescence lehavioiaI piolIens aie coiiecled and acadenic
pailneis. If lhis is done, lhe Iileialuie speaks of onIy 2O, a gioup foined ly lhe nosl
seveie cases viII sliuggIe in aduIlhood vilh peisislenl synplons of lhe disoidei (Conneis
el aI., 2OO1). Of lhe chiIdien vho did nol ieceive any liealnenl oi il is inconpIele, 8O have
a pooi Iong-lein, expIosive eneigence of lehavioiaI disoideis in adoIescence, conducl
disoidei, peisonaIily lype of ciine, aIcohoIisn, diug aluse, jol inslaliIily and difficuIlies in
peisonaI ieIalionships.
In aduIlhood, aloul 15 lo 2O of chiIdien vilh allenlion deficil disoidei and hypeiaclivily
conlinue lo expeiience synplons of lhis disoidei and anolhei lhiid have synplons of
anlisociaI peisonaIily disoidei. il shovs a significanl peicenlage of nedicalion aluse (16),
especiaIIy vhen lheie aie lvo. Lvidence has leen conpiIed in oidei lo indicale lhal a high
peicenlage of cases, ADHD is acconpanied ly olhei psychopalhoIogic diioideis (Zaiin el
aI., 1998, ennell, 2OOO). This nakes lhe cIinicaI sludy of hypeiaclivily difficuIl and iaises
lhe inevilalIe queslion of diffeienliaI diagnosis lelveen ADHD and vaiious disoideis lhal
nay coexisl, such as palleins of najoi depiession, anxiely disoideis, opposilionaI defianl
disoidei, lhe dissociaI and Ieaining disoideis (Augusl el aI., 1996a, Lpslein el aI., 1992,
Alikoff y KIein, 1992).
Conoilidily iefeis lo a high piolaliIily of associalion of lhese diseases in one peison, and il
does nol necessaiiIy inpIy a causaI ieIalionship oi inleidependence lelveen diffeienl
coexisling disoideis. (Ailigas-IaIIaies 2OO3) slales lhal al Ieasl lvo condilions lo give a
usefuI neaning lo lhe lein conoilidily aie iequiied.
These condilions aie lhal lhe piesence of conoilidily condilions a piesenlalion, a piognosis
and a lheiapeulic appioach foi each conoilidily piocess. The condilion of lhe fiequency
vilh vhich one appeais vhen lhe olhei is piesenl is highei lhan lhe isoIaled pievaIence in
lhe geneiaI popuIalion isoIaled.
AppioxinaleIy 45 and 65 of chiIdien vilh ADHD have olhei lehavioiaI and enolionaI
piolIens, such as conducl disoidei, opposilionaI-defianl disoidei, anxiely-dipiession
disoideis, elc. (Alikoff y KIein, 1992). This has Ied lo considei ADHD as a heleiogeneous
disoidei, usuaIIy seen as a disoidei, vhich usuaIIy occuis vilh olhei psychopalhoIogicaI
piolIens, vhich inleiacl and nodify lhe diagnosis significanlIy in lhe cIinicaI
phenonenoIogy, nol onIy in lhe psychoIogicaI chaiacleiislics lul aIso in lhe psychosociaI
consequences, in lhe cIinicaI couise, in lhe piognosis and in iesponse lo lhe liealnenl of lhis
conpIex associalion (Mcuinell el aI., 1999).
Iion lhe cIinicaI peispeclive, chiIdien vilh ADHD associaled vilh olhei disoideis aie of
giealei seveiily, lhey aie affecled in seveiaI donains of chiId deveIopnenl (sociaI,
acadenic, enolionaI and physicaI inleiaclion) and lhey conlinue lo deveIop noie favoialIy


166
lhan chiIdien vilh ADHD vilhoul conoilidily (Alikoll y KIein, 1992, }ensen el aI., 1996,
Rappoil el aI 1999). The sludies eslalIish lhe foIIoving associaled disoideis: Conoilidily
vilh conducl piolIens, conoilidily vilh Ieaining disoideis, conoilidily vilh anxiely
disoideis, conoilidily vilh nood disoideis vilh changes of lhe noloi skiIIs.
Il is cIeai lhal one of lhe conoilidily disoideis of ADHD is shoved in lhe noloi skiII. These
noloi skiII dysfunclions seen lo affecl nany individuaIs vilh ADHD, lo lhe poinl lhal lhe
quaIily of noloi skiII peifoinance duiing lhe fiisl 5-6 yeais couId le a piedicloi of
sulsequenl onsel of synplons of ADHD, and even lhe associalion lelveen cIunsy noloi
skiII and ADHD is a voise piognosis of lhe pallein (Kioes el aI., 2OO2, IascuaI-Caslio Viejo,
2OO4, Kasdejo y CiIIleig, 1999).
Sone sludies lhal have conpaied lhe fine noloi skiIIs of individuaIs vilh ADHD lo a
conlioI gioup have found lhal lhe fiisl ones shoved Iess noloi skiII aliIily lhan lhe Iallei
and lhe lype of difficuIlies olseived diffeied ly lhe sullypes of lhe disoidei (Iiek el aI.,
1999, Slegei el aI., 2OO1). In lhis sense, lhe aulhois found lhal nen affecled ly allenlion
deficil and coiiesponding lo lhe conlined lype (ADHD and Hypeiaclivily ) dispIayed Iess
skiII lhan lhose allached lo lhe hypeiaclive-inpuIsive lype and lhe conlioI gioup. AIso, in
geneiaI, aII chiIdien vilh ADHD had pooiei fine noloi skiII peifoinance lhan conlioIs.
These deficiencies aie iefIecled in lolh lhe cIunsiness lo le vilh lheii lody lo occupy a
space and nove in il vilh a viIIfuI and synloIized noliIily fIuid enough (Mazel y HouzaI,
1981).
Hovevei, sone sludies disagiee vilh lhese iesuIls, noling lhe alsence of diffeiences anong
peopIe noloi skiIIs vilh ADHD and conlioIs (Leung y ConnoIIy, 1998). ased on noloi
skiIIs chaiacleiislics pievaIenl in chiIdien vilh ADHD, il shovs lhe exislence of a high
piopoilion of chiIdien vilh such deficils vho have difficuIlies in gioss noloi skiIIs
deveIopnenl (aueineislei, 2OO2). As a iesuIl of lhese deficiencies, suljecls nay appeai
avkvaid in lheii novenenls, expiessing difficuIly vhen iunning and junping. Wilh
iegaid lo fine noloi skiII deveIopnenl, lhe difficuIlies aie nanifesl in lasks lhal invoIve
giasping oljecls (such as a foik and a knife), lulloning cIolhes, pIaying vilh a laII, coIoiing
vilhin lhe Iinils of lhe figuie, viile Iines oi viile in a unifoin size, oi iun lhe sciipl vilh an
acceplalIe caIIigiaphy and conpIele lhe viillen voik in lhe cIassioon.
On lhe olhei hand, hypeiaclivily in chiIdien has leen associaled vilh noloi cooidinalion
piolIens, and ol is slaled lhal, cuiienlIy, lheie aie enough dala lo aigue lhal hypeiaclive
chiIdien have visuaI noloi skiII deficils, highei noloi skiII ieaclion lines (lhey need noie
line lo iespond a noloi skiII al lhe onsel of a slinuIus) and nake noie eiiois (OijaIes, 2OO2).
The sludy ained lo conpaie lhe peifoinance of fine noloi skiII deveIopnenl, gioss noloi
skiII, visuaI noloi skiII in chiIdien of 6 yeais, lhe sludy voiked vilh 49 chiIdien vilh
ADHD and 48 noinaI chiIdien conpaiing lheii peifoinances. The iesuIls shoved
significanl diffeiences lelveen gioups, indicaling lhal lhe noloi skiII deveIopnenl of
chiIdien vilh ADHD vas significanlIy Iov conpaied lo olhei chiIdien, aII peicepluaI-noloi
skiII neasuies. They aIso shoved lhe exislence of significanl coiieIalions anong aII
vaiialIes consideied noloi skiIIs in ieIalion lo hypeiaclive and inallenlive chiIdien. AIso,
iegiession anaIysis indicaled lhal lhe lolaI visuaI noloi skiII and noloi skiII oulcones veie
significanl piediclois of gioup cIassificalion vilh and vilhoul ADHD. These iesuIls confiin
lhe inpoilance of eaiIy assessnenl and liealnenl of lhe disoidei (Yochnan el aI., 2OO6).


167
The aulhois ciled alove indicale lhal, vhiIe peifoining a neuioIogicaI exaninalion, il is
usuaIIy nol conpIele and aIso il does nol oulIine lhe noloi skiIIs alnoinaIilies lhal couId le
seen. The Iov inpoilance allached lo psychonoloi deveIopnenl, and noie specificaIIy lo
lhe noloi skiIIs vilhin lhe ADHD synplons, vilh lhe pievaIence of lhese disoideis in
palienls affecled ly lhis syndione, conslilules a gap in lhe knovIedge of ADHD.
Oveiconing lhis ignoiance couId le a concein fion lhe lheoielicaI and appIied poinl of
viev. Anolhei sludy on lhe infIuence of disoidei of lhe deveIopnenl cooidinalion and
allenlion deficil disoidei in chiIdien associaled novenenls, ained lo deleinine lhe
ieIalionship lelveen associaled novenenls (AMs) and lhe IeveI of noloi peifoinance of
chiIdien. Il vas ieseaiched vhelhei chiIdien vilh DeveIopnenl Cooidinalion Disoidei
(DCD), lhose vilh ADHD and heaIlhy suljecls diffeied in lhe seveiily of associaled
novenenls. The lolaI sanpIe vas 1O chiIdien vilh DCD, 1O vilh ADHD and 1O leIonged lo
a conlioI gioup, il vas found lhal lvo gioups vilh Iiniled noloi skiII had AMs
significanlIy noie seveie lhan lhe heaIlhy gioup. These iesuIls suggesl lhal lhe IeveI of
noloi peifoinance shouId le consideied in fuluie ieseaich, liying lo undeisland individuaI
diffeiences in lhe seveiily of AMs, as veII as a funclion of noloi Ieaining, as veII as a deficil
Iinked lo ADHD (Licaii el aI., 2OO6).
In geneiaI, il is eslinaled lhal ovei 5O of chiIdien vilh ADHD nay have noloi skiII
piolIens (Ainslein el aI., 1996, Yochnan el aI., 2OO6). Hovevei il aIso noled lhal lhe
diagnosis and cIinicaI noniloiing of palienls (incIuding neuioIogic exaninalion) is noslIy
veiy supeificiaI (Yochnan el aI, 2OO6, Licaii el aI., 2OO6). These aulhois expIain lhal lhis
silualion couId iesuIl fion lhe facl lhal lhose vho nade lhe diagnosis and liealnenl lend lo
le doclois and psychoIogisls lhal focus piinaiiIy on lhe synplons of lheii fieId and, lhey
aie usuaIIy unavaie of lhe nuances of lhe noloi skiII.
The sludy on lhe ieIalionship lelveen ADHD and lhe aliIily foi lhe spoil (Yochnan el aI.,
2OO6), lhe sludy sanpIe vas 1OO nen vilh ADHD, aged 6 lo 16 yeais vilh noinaI IQ, lhal is
on lhe 85 peicenliIe, noloi skiII vas evaIualed ly lhe vievs of paienls iegaiding lheii
chiIdien's skiII foi diaving, viiling, and piolIens foi vaIking, junping and pIaying, chiIdien
ansveied a queslionnaiie of 8 queslions ieIaled lo lheii Iove of spoil, lype of spoil, lhe
posilion lhey pIayed foollaII if lhey piacliced il, lhe assessnenl of spoils peifoinance (lolh
slaff and paienls and peeis), lhe fiequency and discipIine in spoil piaclice and aIso if spoil
vas piaclicedi oi inslead of foollaII vhal olhei physicaI aclivily vas piacliced. The iesuIls
shoved lhal lhe nosl connon neuioIogicaI invoIvenenl vas hypolonia, il vas expiessed in
aII joinls in lhe foin of hypeiexlension and hypei-fIexiliIily in lhe feel, vheie hypolonia vas
noie evidenl and il vas piesenl in pIano-vaIgus feel, foicing an avkvaid vaIk, in geneiaI, lhe
excessive shouIdei and liunk eIaslicily coexisled vilh a significanl gIolaI nuscIe povei.
A 67 said lhey pIay spoils and a 2O chose foollaII, foIIoved ly cycIing vilh a 12.
Svinning, laekvondo, laskellaII, elc., veie lhe Iess chosen ly chiIdien. A 42 of lhose
vho conislenlIy piacliced spoil expiessed lheii nolivalion foi lhis aclivily, vhiIe 58
acknovIedged lhal lhey conlinued piaclicing spoils al lhe lehesl of lheii paienls. AInosl aII
consideied lo have a salisfacloiy peifoinance in spoils, lul lhe paienls of haIf of lhen
iecognized lhal lhe inpIenenlalion vas pooi conpaied vilh olhei chiIdien. In geneiaI, lhis
sludy is inleiesled in ieseiaching lhe possilIe ieIalionship lelveen lhe noloi skiII efficiency
of chiIdien vilh ADHD and spoils piaclice. Hovevei, lhe evaIualion of lhe noloi skiIIs
lased soIeIy on paienlaI opinions and spoils peifoinance, neasuied onIy ly lhe opinions


168
of chiIdien lhenseIves and lheii paienls is fai fion neeling lhe nelhodoIogicaI
iequiienenls of a iigoious noloi skiII assessnenl.
The lheiapeulic polenliaI vaIue of noloi skiIIs in lhe liealnenl of ADHD has leen lhe
suljecl of vaiious sludies in iecenl yeais. In nosl of lhen, il is consideied vilhin a
nuIlinodaI liealnenl, vhich hanpeis lhe assessnenl of lhe effecls of exeicise in isoIalion.
In olhei cases, lhe effecl of lhe aclivily is evaIualed (exeicise and olheis) on vaiious
nanifeslalions of lhe syndione. Ioi exanpIe, il has leen shovn lhal noloi skiII piaclice on
cognilive funclioning, and especiaIIy lo vigoious physicaI aclivily can lenefil chiIdien
suffeiing fion allenlion deficil disoidei and hypeiaclivily (Lenuia el aI., 2OOO).
In anolhei sludy, aeiolic exeicise vas used (vaIking on lieadniII) in chiIdien vilh ADHD
and il vas found lhal exeicise couId have a posilive effecl on lhe lypicaI lehaviois of lhe
disoidei, il nay piovide lhe chiId vilh ADHD lhe foIIoving lenefils: On a physicaI IeveI:
coiiecl IaleiaIily piolIens oi cooidinalion and lo voik gioss and fine noloi skiII. Al IeveI
of educalion: lo pionole noloi skiII Ieaining, faciIilale lhe undeislanding of lody sliucluie
and pionole undeislanding of lhe novenenl. Al lhe sociaI IeveI: shaiing a gioup aclivily,
Ieain lo iespecl iuIes, lo accepl olheis and le iespecled ly lhe gioup (TanliIIo el aI., 2OO2).
Hovevei, lhis voik does nol specify lhe iesuIls ollained aflei an aeiolic exeicise piogian,
neieIy pioposing lhe supposed lenefils lhal couId iesuIl of lhe piogian. Sone of lhese
lenefils, such as lhe ones lhe aulhois piopose al a sociaI IeveI, vouId le difficuIl lo gel
lhiough lhe lieadniII vaIk, as lhis aclivily does nol inpIy, in piincipIe, sociaI ieIalions noi
lhe deveIopnenl of iespecl foi seIf and olheis. Noi il is easy lo undeisland hov IaleiaI oi
cooidinalion piolIens couId le coiiecled, noi inpioving lhe fine noloi skiIIs ly voiking
in lhe lieadniII, and so on. In addilion, sludies of lhis naluie, fai fion cIaiifying lhe
ieIalionship lelveen physicaI exeicise and ADHD, nay even Iead lo confusion.
In ieIalion lo lhe exeicise as pail of liealnenl, (aikIey, 2OO3) piesenls sone case sludies of
ADHD palienls vhose liealnenl incIuded physicaI exeicise and/oi spoils, nainIy inlense
aeiolics, affiining lo have seen a cIeai lenefil. In any of lhese sludies, lhe lype of exeicise
piesciiled lo lhe suljecls is nol nade opeialive, noi lhe inpiovenenls ollained aie
quanlified. Whal lhe aulhoi offeis is a liief desciiplion of lhe liealnenl, indicaling lhe
exeicise piesciiplion and adding an anecdolaI connenl on lhe effecls ollained.
Sludies of chiIdien vilh ADHD laking slinuIanls and noled lhal lhe peifoinance of lhese
chiIdien in leins of filness and gioss noloi skiIIs vas leIov aveiage, vhen il is conpaied
vilh lhe slandaids eslalIished foi chiIdien of lhis age and gendei. They aIso shoved lhal
alhIelic inconpelency and acadenic faiIuie couId conliilule lo lhese chiIdien nainlain a
Iov seIf-concepl, vhich caused lhen a feeIing of voilhIessness and fiuslialion vilh sociaI
aclivilies (Winnick, 2OO4).
Moloi skiIIs can piovide a Iaige fieId of Ieaining lo inpiove sociaI skiIIs in individuaIs vilh
ADHD. If lheie aie diffeienl causes and foins of ADHD, lheie nusl le seveiaI vays lo
leach chiIdien vilh lhis disoidei. Il is suggesled specific insliuclionaI slialegies foi leacheis
lo heIp chiIdien vilh ADHD lo nainlain focus and concenlialion in diffeienl schooI sellings
(Winnick, 2OO4). These slialegies invoIve a highIy sliucluied appioach and consislenl
ioulines, eslalIishing iuIes, lhe use of lehavioi nanagenenl piogians, cIeaiIy expiess lhe
expeclalions expecled, choose aclivilies lhal invoIve sIov, conlioIIed novenenls lo ieduce


169
hypeiaclivily and inpuIsivily, lo highIighl ieIevanl connands, lo encouiage lhe chiId
peinanenlIy, lo change lhe noloi skiII lasks peinanenlIy, lo nininize conpelilive ganes
and aclivilies lo encouiage coopeialion.
In lhe sane vay, physicaI aclivily is ieconnended lo chiIdien vilh ADHD, as fai as
possilIe. Il is consideied lhal al Ieasl an houi a day of aeiolics, kaiale do, svinning,
dancing, gynnaslics and olhei spoils shouId le piovided. These aulhois considei lhal
eneigy expendiluie nade ly lhe chiId lo exeicise viII aIIov highei IeveIs of sliIIness. They
aIso aigue lhal highei-IeveI of exeicise of lhe chiId iequiies noie concenlialion, vhich
geneiaIize lo inleIIecluaI lasks. AIlhough lolh aigunenls nay le ieasonalIe, lo ieduce
hypeiaclivily ly incieasing eneigy expendiluie, vhich vouId achieve in aII cases, a
lenpoiaiy ieduclion and nol a nodificalion of lhe neuiopsychoIogicaI nechanisns lhal
undeiIie lhe elioIogy of lhe disoidei. AIso, lo expecl a liansfei fion lhe aIIeged
concenlialion geneialed ly exeicise lo inleIIecluaI lasks suggesls a veiy supeificiaI
knovIedge of lhe funclioning of allenlion piocesses.
2.2 DeveIopment disturbances in ADHD
AIlhough iniliaIIy noloi skiII difficuIly vas used as a calch-aII ioon vheie aII lhe painlings
veie noie heleiogeneous, nov il lends lo iigoiousIy define ils scope. Ioi exanpIe, Iesions
and neuioIogicaI synplons aie excIuded and lhe concepl of noloi skiII difficuIly foi noloi
inpaiinenls of lhe chiId vhose elioIogy is of anolhei naluie is ieseived. These
shoilconings aie iefIecled in lolh lhe avkvaidness lo le vilh lheii lody lo occupy a space
and lo nove in il vilh a synloIized and inlenlionaI noliIily (aikIey, 2OO3).
The inleiesl in sludying noloi skiII funclioning in ADHD and in disciininaling chiIdien
vilh ADHD fion lhose vilh neuioIogicaI disoideis is nol nev (Koniad el aI., 2OOO). This
inleiesl has leen ievilaIized in pail ly ieseaich on DAMI (CiIIleig, 2OO3, Kasdejo y CiIleil,
1998) conducled in Sveden and aIso ly olhei conliilulions on neuioinaging sludies ieIaled
disoideis, indicaling lhal lolh cIinicaI expeiience and expeiinenlaI evidence suggesl lhe
ioIe of noloi skiII faclois in ADHD.
A vaiiely of neuioIogicaI lesls have shovn lhal chiIdien vilh ADHD aie diffeienl fion lhe
conlioI gioup in noloi size skiIIs. This incIudes iepelilive novenenls (Caile y Hinshav,
1996, DenckIa y RudeI, 1978), difficuIlies in fine noloi skiIIs associaled vilh hypeiaclive-
inpuIsive oi disanlencin synlonps (Iilchei el aI., 2OO3), cooidinalion faiIuies (}ucaile el
aI., 2OO3), piolIens in conlioIIing lhe novenenls and especiaIIy vhen lheie is no visuaI
feedlack (LIiasson el aI., 2OO4), laIance deficiencies (Raleigei y Winnei, 2OO3),
naIadjuslnenl in ihylhnic lealing sequenliaI lasks (Lenuia el aI., 2OOO), excessive
unnecessaiy novenenl (Moslofsky el aI., 2OO3), difficuIly vilh noloi skiIIs Acquisilions
(Kaialekin el aI., 2OO3), and sIov cenliaI noloi skiII piocessing (UcIes el aI., 2OOO), Iovei
noloi skiIIs and inleivaIs and nunlei of eiiois inciease (TanliIIo el aI., 2OO2).
In geneiaI, il is eslinaled lhal ovei 5O of chiIdien vilh ADHD nay have noloi skiII
piolIens (aikIey el aI., 199Ol, Yochnan el aI., 2OO6). The Iov inpoilance allached lo
psychonoloi deveIopnenl, and noie specificaIIy lo lhe noloi skiIIs vilhin lhe ADHD
synplons, vilh lhe pievaIence of lhese disoideis in palienls affecled ly lhis syndione
conslilule a gap in knovIedge of ADHD. Oveiconing lhis ignoiance couId le of inleiesl
fion lhe lheoielicaI and appIied poinl of viev.


170
The diffeienlialion lelveen sullypes of ADHD have shovn lhal lhe nixed sullype has
giealei difficuIlies in gioss noloi skiIIs, vhiIe lhe "inallenlive" sullype is Iess in fine
noloi skiIIs and nanuaI skiII lesls (Iiek y Skinnei, 1999). MeanvhiIe, cIinicaI sludies have
highIighled lhe piesence of noloi skiII dysfunclion in ADHD, lul il does nol indicale
vhal specific piocess is ADHD invoIved: noloi skiII piogianning, piepaialion,
adjuslnenl, elc.
3. Motor skiIIs in chiIdren with ADHD: Comparative study from a
pharmacoIogicaI treatment
This ieseaich voik ains lo shov lhe piaclicaI eIenenls, as evidenced ly lhe iesuIls
piesenlalion lhal seek a slalislicaI appioach lo lhe exisling lheoielicaI cIain lhal affiins lhal
chiIdien vilh ADHD vho aie undeigoing nedicalion lheiapeulicaIIy piesenl a diffeienl
psychonoloi piofiIe conpaied lo chiIdien vilh ADHD vho aie nol ieceiving nedicalion.
This eslalIished a nelhodoIogy piocess lhal slails vilh a desciiplive coiieIalionaI sludy.
SanpIing fiane vas used as 422 chiIdien lelveen 5 and 12 yeais oId fion ManizaIes
CoIonlia vilh a nedicaI diagnosis of ADHD, vhich exceeded lhe iepiesenlalive sanpIe
size of 397 suljecls, caIcuIaled ly using lhe LpiInfo piogian , v. 6.O4, designed ly lhe
Cenlei foi Disease ConlioI in AlIanla, in ils Spanish veision, and consideiing a lolaI
popuIalion of 46,387 chiIdien, vilh 95 confidence and a naigin of eiioi of 5. Theii
disliilulion ly age and gendei vas 3O6 naIe (72,5) and 116 fenaIe (27,5).
AIso 3O8 chiIdien fion lhe lolaI sanpIe did nol use nelhyIphenidale and 114 did nol use
nelhyIphenidale if consuned. Regaiding lhe sullype of ADHD il vas found lhal 84 (2O.6)
veie diagnosed vilh piedoninanlIy inallenlive, 184 (43, 6) piedoninanlIy hypeiaclive
and 151 (35.8) vilh conlined doninance. An age iange lelveen 5 and 12 vas chosen,
lecause 5 yeais is usuaIIy sel vhen fiisl diagnosed ADHD and lecause in pievious sludies
(Vidaile and VeIez, 1999, 2OO1) il had voiked vilh lhese ages and lhey had shovn eIevaled
IeveIs of disoidei pievaIence. IncIusion ciileiia foi heaIlhy chiIdien veie: leing aged
lelveen 5 and 12 yeais, leIonging lo any genie, leing physicaIIy fil lo deveIop lhe
iespeclive evaIualions and having lhe coiiesponding infoined consenl. Ioi chiIdien
diagnosed vilh lhe disoidei, in addilion lo lhe alove iequiienenls, an ADHD diagnosis is
iequiied ly a ceilified physician.
ChiIdien vho had any olhei palhoIogy such as ceieliaI paIsy, nenlaI disoideis, Ianguage
disoideis and anxiely disoideis, anong olheis, oi vho have had liaunalic piocesses lhal
aIlei lhe noliIily duiing lhe Iasl nonlh veie excIuded fion lhe sanpIe. Once aII
adninislialive aulhoiizalions veie ollained in oidei lo knov in vhich schooIs veie
chiIdien vilh ADHD. The inlegiaI seivice unil vas (inleidiscipIinaiy unil undei lhe
Minisliy of Lducalion of lhe cily, vhich is nade up of physicians, psychoIogisls, speech
lheiapisls and occupalionaI lheiapisls, and vho aie iesponsilIe foi lheiapeulic inleivenlion
in chiIdien vilh diffeienl piolIens and lo piovide pedagogicaI suppoil lo leacheis and
paienls).
The sociodenogiaphic vaiialIe dala veie ollained lhiough a queslionnaiie of open and
cIosed queslions and lhe coiiesponding psychonoloi vaiialIes ly using lhe psychonoloi
olseivalion lalleiy (IO) pioposed ly Da Ionseca. Il is a syslen foi olseiving lhe vaiious
conponenls of lhe noloi syslen, and lhe dala ollained aIIov lo iefIecl lhe degiee of


171
neuioIogicaI oiganizalion of lhe chiId, aIIoving lhe idenlificalion of aIleialions. The
lheoielicaI lasis on vhich lhe IM lased ils pioposaI consisls of conliilulions fion Luiia,
iefoinuIaled and iepuiposed ly Da Ionseca piovide juslificalion foi lhe neuiopsychoIogicaI
dala.
The assessnenl vas conducled individuaIIy vilh each of lhe chiIdien in lheii ovn schooI
and in lheii sludy scheduIe. In lhe case of lhe onIy hospilaI caie cenlei, lhe pioceduie vas
siniIai and lhe chiIdien veie assessed duiing lhe line lhey venl lo ieceive lheii liealnenls.
Lxcepl in lhis case, and in oidei lo avoid infoinalion lias due lo convenience, a lIind
piocess of neasuienenl vas condecled: lhe evaIualois did nol knov vhich veie chiIdien
diagnosed vilh ADHD. IinaIIy, lhe physician of inlegiaI seivice unil iepoiled vhich of lhe
chiIdien assessed veie diagnosed vilh lhe disoidei, aIIoving lhe ieviev of nedicaI iecoids
lo piove lhe diagnosis of ADHD and lo confiin lhe incIusion and excIusion of chiIdien.
The sludy iesuIls aie desciiled fiisl lhiough a univaiiale anaIysis lhen a livaiiale anaIysis lhal
shovs lhe ieIalionship lelveen psychonoloi piofiIes and vaiialIe sullypes and gendei.

!"#$%&'(')'* ,*'-$./ 0*/12/3%# !/*%/3)45/
Apiaxic (veak) 1 O,2
Dispiaxico(Salisfacloiy) 73 17,3
Lupiaxic (Cood) 336 79,6
Hipeipiaxic (LxceIIenl) 12 2,8
TolaI 422 1OO,O
TalIe 1. Isychonoloi piofiIe of chiIdien cIinicaIIy diagnosed vilh ADHD.
The psychonoloi piofiIe of 422 chiIdien vas 79.6 eupiaxic, il naens noinaI, vhiIe 17.3
vas dispiaxic oi peifoined vilh difficuIly.

Iig. 1. ResuIls ollained in lhe pailicipanl sanpIe ly laking nedicalions (nelhyIphenidale)


172
Il is ienaikalIe hov 1OO of lhe sanpIe pailicipaling in lhe sludy onIy 27 use
nelhyIphenidale.

!"#$%&'(')'* ,*'-$./ 6"/
(/7$%4)$'3
8' 2"/
(/7$%4)$'3
0%$4 9 0%$4 9
Apiaxic (veak) 1 ,9 O O
Dispiaxic(Salisfacloiy) 18 15,8 55 17,9
Lupiaxic (Cood) 89 78,1 247 8O,2
Hipeipiaxic (LxceIIenl) 6 5,3 6 1,9
TolaI 114 1OO,O 3O8 1OO,O
TalIe 2. ResuIls of psychonoloi piofiIe in chiIdien vho use nedicalion conpaied vilh
lhose vho do nol use il.
In lhis sludy vas found lhal fion 114 chiIdien laking nedicalion, 83.3 (95) aie naIe and
16.7 (19) fenaIe. Depending on lhe IeveI of schooIing, lhe Iaigesl piopoilion vas Iocaled
in lhe lhiid giade of schooI (28 loys), 26 in lhe fiisl giade and 22 in fouilh giade and
accoiding lo lhe age of chiIdien nedicaled, lhe giealei piopoilion vas 7 and 1O yeais (21
chiIdien) and 8-9 and 11 yeais (14 chiIdien).

Iig. 2. Isychonoloi piofiIe iesuIls in chiIdien vho use nedicalion conpaied vilh lhose
vho do nol use il.
Nolice aIlhough lhe nean diffeience foi each of lhe noloi skiIIs faclois assessed in cIinicaIIy
diagnosed chiIdien is highei in chiIdien vho use nedicalion conpaied lo lhose vho do nol
use il vhen conpaiing lhese diffeiences, il vas found lhal lheii diffeiences aie nol
slalislicaIIy significanl.


173
:4*$4;./ < %&$.7*/3 =&'
2"/ (/7$%4)$'3
< %&$.7*/3 =&' 7'
3') 2"/ (/7$%4)$'3
6 >$5? @$.4)?
Tone 3,O6 3,OO 16834,OOO ,49O
aIance 2,96 2,83 16OOO,5OO ,124
LaleiaIily 1,22 1,21 17411,OOO , 854
ody nolion 2,7O 2,56 15791,OOO ,O79
Lsliucluialion espaciaI 1,96 1,86 16339,5OO ,235
CIolaI Iiaxia 1,89 1,78 16221,5OO ,189
Iine Iiaxia 2,5O 2,42 163O8,5OO ,218
TalIe 3. Conpaiison lelveen gioups of chiIdien vilh ADHD fion ollained iesuIls in
faclois of psychonoloi piofiIe

:4*$4;./ < %&$.7*/3 =&' 2"/
(/7$%4)$'3
< %&$.7*/3 =&' 7'
3') 2"/ (/7$%4)$'3
6 >$5? @$.4)?
Tone 3,O2 3,OO 486,OOO ,9O3
aIance 2.91 2,78 452,OOO ,547
LaleiaIily 1,24 1,17 46O,5OO ,538
ody nolion 2,6O 2,56 473,OOO ,756
Lsliucluialion espaciaI 1,89 1,78 464,OOO ,756
CIolaI Iiaxia 1,91 1,61 4O3,OOO ,2O3
Iine Iiaxia 2,45 2,5O 476,OOO ,792
TalIe 4. Conpaiison lelveen gioups of chiIdien vilh ADHD piedoninanlIy hypeiaclive
fion iesuIls ollained in lhe faclois of psychonoloi piofiIe
Conpaiing lhe noloi skiII faclois anong chiIdien diagnosed vilh ADHD piedoninanlIy
hypeiaclive diffeiences in lhe neans aie nol slalislicaIIy significanl. Il vas found fion lhe
psychonoloi piofiIe 55 chiIdien use nelhyIphenidale of vhich 69.1 have a noinaI piofiIe
(Lupiaxic), 5.5 hypeipiaxic and 23.6 dispiaxic.

:4*$4;./ < %&$.7*/3 =&' 2"/
(/7$%4)$'3
< %&$.7*/3 =&' 7'
3') 2"/ (/7$%4)$'3
6 >$5? @$.4)?
Tone 3,2O 3,O9 2358,5OO ,346
aIance 3,O6 2,84 2189,OOO ,1O2
LaleiaIily 1,2O 1,19 2593,5OO ,943
ody nolion 2,74 2,62 2462,OOO ,566
Lsliucluialion espaciaI 2,OO 1,85 2351,5OO ,32O
CIolaI Iiaxia 1,94 1,83 2365,5OO ,341
Iine Iiaxia 2,49 2,43 2472,5OO ,599
TalIe 5. Conpaiison lelveen gioups of chiIdien vilh ADHD piedoninanlIy inallenlion of
lhe ollained iesuIls of lhe psychonoloi piofiIe faclois
Conpaiing lhe noloi skiII faclois anong chiIdien diagnosed vilh ADHD and piedoninanlIy
inallenlion, lhe diffeiences in lhe neans aie nol slalislicaIIy significanl. Il is nolevoilhy lhal in
ieIalion lo lhe psychonoloi piofiIe, il did nol occui in lhese apiaxic piofiIe chiIdien and a
highei piopoilion of chiIdien vilh piedoninanlIy inallenlive piofiIe veie noinaI.


174
:4*$4;./ < %&$.7*/3 =&'
2"/ (/7$%4)$'3
< %&$.7*/3 =&' 7'
3') 2"/ (/7$%4)$'3
6 >$5? @$.4)?
Tone 3,OO 2,91 1338,OOO ,651
aIance 2,91 2,78 1287,OOO ,443
LaleiaIily 1,23 1,24 14OO,5OO ,895
ody Nolion 2,91 2,46 918,OOO ,OO4
Lsliucluialion. LspaciaI 2,O9 1,84 1142,OOO ,117
CIolaI Iiaxia 1,77 1,77 1396,OOO ,895
Iine Iiaxia 2,56 2,36 1148,5OO ,117
TalIe 6. Conpaiison lelveen gioups of chiIdien vilh ADHD piedoninanlIy conlined of
lhe ollained iesuIls of lhe faclois of psychonoloi piofiIe.
Conpaiing lhe noloi skiII faclois anong chiIdien diagnosed vilh ADHD piedoninanlIy
conlined, lhe nean diffeiences veie nol slalislicaIIy significanl in lhe lody nolion vaiialIe.
Il is inpoilanl lo highIighl in lhese chiIdien lhe apiaxic piofiIe and in a highei piopoilion
lhe chiIdien vilh conlined pievaIence ollained an exceIIenl oi hipeipiaxic piofiIe.

!&4*(4%&'.'5$%4. A*/4)(/3)
A#,/ '- ABCD A')4.
E34))/3)$'3 D#,/*4%)$F$)# G'(;$3/7
YLS 57 35 22 114
NO 3O 149 129 3O8

VaIue gI Sig. asinlolic (liIaleiaI)
Chi-squaie of Ieaison 83.237
a
2 .OOO
Reason of veiosiniIilude 75.874 2 .OOO
LineaI pei IineaI associalion 6O.599 1 .OOO
N of vaIid cases 422
TalIe 7. ReIalion lelveen consunplion of nedicalion and sullype of ADHD
The lalIe alove shovs lhal lheie seens lo le a ieIalionship lelveen lhe consunplion of
nedicalion and sullype of ADHD (p <O.OO).
The dala alove shov diffeiences in nean scoies achieved in lhe deveIopnenl of noloi skiIIs
deveIoped ly chiIdien cIinicaIIy diagnosed vilh ADHD vho use nedicalion in ieIalion lo
lhe ones vho do nol, lul lhese diffeiences veie slalislicaIIy significanl onIy foi chiIdien
vilh Conlined ADHD piedoninanl facloi in lhe nolion of lody (p <O.OO4), lhe olhei
faclois and each of lhe sullypes veie nol found diffeiences slalislicaIIy significanl.
(IeIhan el aI., 199O) exanined lhe effecliveness of nelhyIphenidale lo inpiove lhe
peifoinance of hypeiaclive chiIdien in lhe gane of laselaII. AIlhough nedicalion did nol
enhance skiIIs foi lhe gane, il pioduced significanl effecls on allenlion, so lhal invoIvenenl
in lhe aclivily vas highei. In shoil, vhiIe psychoslinuIanl nedicalion did nol nake
chiIdien noie skiIIed pIayeis, lheii leannales lhoughl lhal lhey shoved a lellei
disposilion lovaids lhe gane.
These iesuIls have a posilive naluie lecause, as suggesled ly IeIhan el aI (IeIhan el aI.,
199O), peeis aie noie lenevoIenl in judging a chiId vho sliives and nakes nislakes foi his


175
cIunsiness, lhan vhen a feIIov is judged ly eiiois nade due lo his uninleiesl foi lhe gane.
Iapeis pulIished in iecenl yeais ly lhe MuIlinodaI Tiealnenl Sludy of ChiIdien vilh
Allenlion Deficil / Hypeiaclivily Disoidei (MTA Coopeialive Cioup, 1999 confiin lhe
efficacy of psychoslinuIanls in lhe liealnenl of ADHD.
In facl, a nunlei of iepoils have shovn lhal nelhyIphenidale decieases in chiIdien vilh
ADHD lheii disoledience, lheii veilaI aggiession and lheii anlisociaI lehaviois (Hinshav
el aI., 1993, KIein el aI., 1997), il faciIilales lhe slandaidizalion of lheii lehavioi in cIass
(Rappoil el aI., 1994) and il favois sociaI inleiaclions vilh cIassnales (WhaIen y Henkei,
1991). SiniIaiIy, olhei ieseaich has found inpiovenenls in lhe peifoinance of chiIdien
vilh ADHD / C on honevoik such as nalh piolIens, void ieading (Snilh el aI., 1998)
and quaIily of viiling (Tucha y KIaus, 2OO1) lhe adninislialion of nelhyIphenidale.
4. ConcIusion
In allenpling lo soIve lhe oljeclive of lhe sludy, il can le concIuded lhal lhe psychonoloi
piofiIe of chiIdien diagnosed vilh ADHD is eupiaxic and il is cIassified in lhe sane
calegoiy as chiIdien vho consune and donl consune nedicalion, and lhey aie Iocaled in
lhe sane piofiIe foi eupiaxic heaIlhy chiIdien, aIlhough lheii scoie is Iovei and lhe
peifoinance IeveIs of each facloi aie voise. LxceplionaIIy, lheie veie no diffeiences in lhe
psychonoloi piofiIe of diffeienl faclois, lul in lhis case, il is aIso deficienl in heaIlhy
chiIdien. (Vidaile el aI., 2OO9).
In geneiaI, sludies of noloi skiIIs in chiIdien vilh ADHD aie oveiIy sinpIislic and naiied
ly nelhodoIogicaI shoilconings. This nakes il difficuIl lo knov pieciseIy: noloi lehavioi
of chiIdien vilh ADHD, lhe nosl appiopiiale lype of exeicise in inpioving such synplons,
neuioIogicaI and liochenicaI palhvays lhiough vhich expIain lhe inpiovenenls nade and
ils effecliveness conpaied lo olhei liadilionaI liealnenls liadilionaI, oi as pail of a
nuIlinodaI liealnenl.
Il is lheiefoie ieconnended lo iniliale a syslenalic piocess lhal aIIovs lhe coIIeclion of
infoinalion on an ongoing lasis and lheiely nake peinanenl noniloiing lo piocesses
conducled vilh nuIlinodaI inleivenlion in chiIdien diagnosed vilh ADHD. The incIusion
of lhis condilion in lhe poIicy of eaiIy chiIdhood al nalionaI IeveI, given ils high pievaIence
and lhe possiliIily of effeclive nanagenenl in lhe leginning of schooI age.
5. Study Iimitations
The sludy Iinilalions veie: lhe alsence of slialified sanpIing ly sex and lhe Iov
pailicipalion of chiIdien sludying in piivale inslilulions, lhis vaiialIe vouId have enalIe lo
idenlify possilIe diffeiences ly socioecononic slalus.
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Max, }.L., Aindl, S., CasliIIo, C.S., okuia, H., Rolin, D.A., Lindgien, S.D., Snilh, W.L., Salo,
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184
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127O.
9
MethyIphenidate and DysIipidemia
Cideon Chaiach, Nechenia Kaysai,
AIexandei Ralinovich, Oii Aigov and Moshe Weinliaul
"#$%&'(#)' *+ ,)'#&)%- .#/010)# 2345 6#- 7808 9*:&%;<= .#/01%- 3#)'#&5
9%1<-#& >%1:-'= *+ .#/010)#5 6#- 7808 ?)08#&;0'=5 6#- 78085
,;&%#-
1. Introduction
MelhyIphenidale is one of lhe diugs lhal has leen shovn lo eIicil lehavioiaI sensilizalion
(1). MelhyIphenidale vas synlhesized ly Cila chenisl Leandio Ianizzon. His vife,
Maigueiile, had Iov lIood piessuie and vouId lake lhe diug as a slinuIanl lefoie pIaying
lennis. He naned lhe sulslance RilaIine, aflei his vife's nicknane, Rila (2).
Ils use has incieased iapidIy ovei lhe yeais and cuiienlIy lhe diug is oflen piesciiled foi a
Iaige span of ages fion chiIdhood lhiough adoIescence and up lo aduIlhood, lhus
faciIilaling lhe sludy of ils effecl on hunan physioIogy. Theiefoie, il lheie is an alundance
of oppoilunilies lo sludy ils vaiious effecls on lhe hunan oiganisn.
MelhyIphenidale is a pipeiidine deiivalive, sliucluiaIIy ieIaled lo anphelanines and acls as
a CNS slinuIanl. MelhyIphenidale has leen videIy used since 1937 foi nuneious
indicalions incIuding allenlion deficil hypeiaclivily disoidei (ADHD), naicoIepsy, calapIexy
(3) and conducl disoidei (4) in chiIdien and adoIescenls as veII as aduIls (4). AIlhough il
has leen indicaled foi ADHD since 1957 il has gained videspiead use duiing lhe Iasl lvo
decades (5). MelhyIphenidale vas found lo affecl liain sleioI nelaloIisn in nice ly
inhililion of lhe incoipoialion of ils piecuisois, acelale and gIucose, inlo lhe liain and ly
ieduclion of lhe liains sleioI IeveIs (6). This ieduclion vas found lo occui vilhin 24 houis
in lhe neuionaI ceIIuIai nenliane, lhe sile of nelhyIphenidales aclion (6).
2. Risk factors of atheroscIerosis and cardiovascuIar disease
AlheioscIeiosis is a sIovIy piogiessive piocess slailing al a young age (7). Theiefoie, nany
effeclive neasuies aie laken eaiIy in Iife lo pievenl fuluie caidiovascuIai disease
voiIdvide, lhe nosl inpoilanl leing lhe avaieness of a piopei IifeslyIe, incIuding physicaI
aclivily, a piopei diel, and alslaining fion diugs and halils lhal nay inciease lhe
IikeIihood of alheioscIeiosis lhiough lhe deveIopnenl of diffeienl iisk faclois (e.g.,
hypeiIipidenia).
SeveiaI iepoils (8-9) found no associalion lelveen pioIonged adninislialion (1 lo 4 yeais)
of nelhyIphenidale lo hypeiaclive loys iegaiding henalopoielic, endociine (incIuding
lIood gIucose IeveIs), hepalic oi caidiovascuIai funclion. This is unIike lhe
hypeichoIesleioIenic effecl of vaiious psycholiopic nedicalion (see leIov) lhal can cause


186
hypeichoIesleioIenia secondaiy lo choIeslasis(1O). Il is knovn lhal choIeslasis can cause
hypeichoIesleioIenia (1O). Seiun choIesleioI appeaied lo le doninanlIy affecled ly
Iipopiolein X. Inlia-hepalic choIeslasis Ieading lo iefIux of liIe Iipids inlo lhe lIood sliean
and sulsequenl foinalion of Iipopiolein X appeais lo le lhe nechanisn (11) undeiIying
lhis phenonenon "
2.1 MethyIphenidate's toxicity
The lheiapeulic use of nelhyIphenidale foi lhe nanagenenl of ADHD in chiIdien is
conslanlIy incieasing. As lheiapeulic use lhis incieases lhe iisk of uninlenlionaI oveidoses,
nedicalion eiiois, and inlenlionaI oveidoses caused ly aluse, nisuse, oi suicide allenpls.
Side effecls, vhich incIude neivousness, headache, insonnia, anoiexia, and lachycaidia
inciease IineaiIy vilh dose (3). CIinicaI nanifeslalions of oveidose incIude agilalion,
haIIucinalions, psychosis, Ielhaigy, seizuies, lachycaidia, dysihylhnias, hypeilension, and
hypeilheinia. Hepaloloxicily vas iepoiled in iodenls (11). A possilIe nechanisn is
inhililion of cylochione p-45O (12). Theie aie fev iepoils aloul diffeienl oigan faiIuie.
These veie nanifesled ly alnoinaI Iivei funclion enzynes, pooi uiine oulpul,
hypolension, lachypnea, lachycaidia, alnoinaI lIood gases, iising seiun UN and
ciealinine, and hypeiaclive deep-lendon iefIexes (13). Despile ils aluse polenliaI, lheie is
disagieenenl iegaiding lhe exlenl lo vhich nelhyIphenidale is leing diveiled fion
Iegilinale use lo aluse in chiIdien and adoIescenls.
Conlkovsky el aI (14) iepoiled a deciease of 26 in seiun gIucose vaIues aflei
nelhyIphenidale inilialion in a palienl posl- ceieleIIai lunoui ieseclion.
eing a neuioslinuIanl, lhe possilIe Iinkage of nelhyIphenidale lo lhe caidiovascuIai
syslen vas invesligaled. The dala aie conlioveisiaI. SanueIs el aI. (8) invesligaled lhe effecl
of nelhyIphenidale on lIood piessuie. Theii sludy piovided evidence foi a possilIe
negalive caidiovascuIai effecl of lhe slinuIanl nedicalion on chiIdien vilh ADHD. VilieIIo
(15) did nol find cIinicaIIy significanl changes in caidiovascuIai funclion in lhe najoiily of
cases invesligaled. Hovevei, Langendijk el aI (16) in lheii ieviev shov an inciease in lIood
piessuie and heail iale anong aduIls liealed vilh nelhyIphenidale as leing a iisk facloi foi
caidiovascuIai evenl, and Rappoil el aI (17) desciiled a liansienl inciease in lIood piessuie
and heail iale anong chiIdien liealed ly nelhyIphenidale foi ADHD. This vas dose
dependenl and easiIy ieclified vilh dosage adjuslnenl. Spivak el aI (18) iepoiled a
lhionlocylhopenia and decieased IeveIs of noiepinephiine, dopa and seiolonine in
chiIdien liealed foi lhiee nonlhs vilh nelhyIphenidale vhich neans inhililoiy inpacl on
pIaleIels aclivalion.
Heail faiIuie due lo idiopalhic diIaled caidionyopalhy (DCM) is unconnon in young
peopIe. Cocaine and anphelanines aie knovn lo have caused diIaled caidionyopalhy (19).
Theie aie veiy fev iepoils Iinking nelhyIphenidale lheiapy lo DCM. Tvo iepoils fion
Noivay desciiled seiious caidionyopalhy in young palienls liealed vilh nelhyIphenidale
(2O-21). One of lhen vas seveiIy olese (MI-4O). An olesily-Iinked suscepliliIily lo lhe
loxic effecl of nelhyIphenidale couId, lheiefoie, pIay a ioIe in lhe deveIopnenl of DCM in
lhis palienl. This is ienaikalIe especiaIIy vilh iegaids lo lhe shoil (one yeai) duialion of
lhe liealnenl. Wilh a MI of 4O lhe alove nenlioned palienl had suffeied fion exliene
olesily. The hypeidynanic ciicuIalion, vilh incieased caidiac oulpul, lhoughl lo le a

Methylphenidate mproves Lipid Profile

187
conpensaloiy adaplalion lo incieased adipose lissue nay, al lhe expense of Iefl venliicuIai
hypeiliophy and ienodeIing, Iead lo non ischenic diIaled caidionyopalhy in seveie olese
suljecls (22, 23). This is, hovevei, unIikeIy lo le lhe onIy cause. Hunan olesily is aIso
chaiacleiized ly synpalhelic neivous aclivalion (23). The concein is lhal nelhyIphenidale
is lhe iesponsilIe agenl. AIlhough lhe nunlei of palienls liealed vilh lhis diug is high, and
lhe iepoiled caidiovascuIai side effecls aie fev, scienlisls veie conceined aloul lhe seiious
Iong lein iesuIls lhis side effecl couId have on chiIdien and young aduIls. No guideIines aie
avaiIalIe lo heIp idenlify individuaIs pione lo caidionyopalhy due lo cenliaI slinuIaling
diugs.
Caidiac adveise effecls fion nelhyIphenidale have leen shovn lo affecl nyocaidiaI uIlia-
sliucluie in ials. This effecl vas iiieveisilIe aflei 12 veeks (24, 25). MelhyIphenidale is a
diug vhich slinuIales lhe cenliaI neivous aclion and pioduce siniIai effecls as
anphelanines. olh diugs inciease synaplic and inliaceIIuIai noiepinephiine and
dopanine in iodenls and laloons (25, 26). Ioi anphelanine lhe nechanisn has leen
shovn lo liiggei lolh an incieased ieIease of calechoIanines and lIocking lheii synaplic
ieuplake and degiadalion (26-27). Il is lhe inciease in adieneigic aclion lhal is leIieved lo le
caidioloxic ovei line and pionole caidionyopalhy (24, 28). This can le undeislood ly lhe
olseivalion lhal, in liansgenic nice, nyocaidiaI ovei expiession of lela-adieneigic
ieceplois vas associaled vilh nyocyle apoplosis and lhe deveIopnenl of diIaled
caidionyopalhy (27, 29).
3. MethyIphenidate and dysIipidemia
In nany cases nelhyIphenidale is piesciiled foi exlended peiiods of line, usuaIIy slailing
fion chiIdhood oi adoIescence. Theiefoie, in lhe Iong iun any nelaloIic consequence of lhe
liealnenl nighl le deIeleiious, especiaIIy vhen alheioscIeiosis is consideied. Iion lhis
peispeclive, il seened essenliaI lo sulslanliale lhe polenliaI of nelhyIphenidale lo affecl
Iipid piofiIe. In oidei lo evaIuale lhis, ve fiisl Iooked inlo lhe possiliIily lhal olhei
psycholiopic diugs have an inpacl on choIesleioI and liygIiceiides.
HypeiIipidenia is one of lhe najoi iisk faclois foi alheioscIeiosis and caidiovascuIai diseases
(3O, 31). The causes of Iipid nelaloIisn alnoinaIilies aie nainIy genelic. LslalIished causes
foi secondaiy dysIipidenia incIude inappiopiiale IifeslyIe, Iivei disease, ienaI disease and
lhyioid disease (7, 9). The vaiious diugs lhal aie knovn lo affecl Iipid nelaloIisn incIude
hoinones (gIucocoilicoids, esliogens and andiogens), lela-lIockeis, and diuielics (3, 7, 32-4O).
SeveiaI psycholiopic diugs veie iepoiled lo cause secondaiy hypeiIipidenia, especiaIIy
cailanazepine, phenolaililaI, liicycIic anlidepiesanls (in pailicuIai aniliiplyIine), second-
geneialion anlipsycholic nedicalion, nainIy oIanzapine lul aIso iispeiidone and zipiasidone.
In lheii exlensive ieviev Ruelsch and co-viileis eIaloiale on veighl gain induced ly
psycholiopic nedicalions (38). Accoiding lo lhis and nany olhei iepoils veighl gain is lhe
nainslay of lhe psycholiopic phainacoIogicaI induced hypeiIipidenia. Weighl gain vas
found lo induce dysIipidenia in coiieIalion vilh dosage and duialion of liealnenl (38). In
addilion lo incieased lolaI choIesleioI and Iov-densily Iipopiolein choIesleioI (LDL-c) lheie
vas aIso a lendency lo eIevale lIood piessuie IeveIs and lhus enhance lhe inpacl on lhe
deveIopnenl of alheioscIeiosis (31-34)., These can aggiavale heaIlh iisks, incIuding highei iale
of coionaiy heail desease, ischenic slioke due lo inpaiied gIucose loIeiance, dialeles
neIIilus, dysIipidenia, iespiialoiy piolIens.


188
Weighl gain appeais lo le nosl pioninenl vilh sone nood slaliIizeis (e.g. Iilhiun,
vaIpioale, 34-38). Accoiding lo cuiienl concepls, appelile and feeding aie ieguIaled ly a
conpIex of neuioliansnilleis, neuionoduIalois, cylokines and hoinones inleiacling vilh
lhe hypolhaIanus, incIuding Ieplin and lunoi neciosis facloi syslen (37-39). The
phainacoIogic nechanisns undeiIying veighl gain aie piesenlIy pooiIy undeislood:
possilIy lhe vaiious aclivilies al sone ieceploi syslens nay induce il, lul aIso genelic
piedisposilion pIays an inpoilanl ioIe. In addilion lhe insuIin-Iike effecl of Iilhiun is veII
knovn.
Weighl gain has leen desciiled since lhe discoveiy and lhe use of lhe fiisl psycholiopic
diugs, lul seens lo inlensify especiaIIy vilh sone of lhe second geneialion anlipsycholic
nedicalions. Undeislanding of lhe side effecls of psycholiopic diugs, incIuding lheii
nelaloIic consequences (veighl gain, dialeles, dysIipidenia) is essenliaI in oidei lo avoid,
fiislIy, a iisk of Iack of conpIiance vilh lhe ensuing iisk of ieIapse and ie-hospilaIizalion,
and secondIy, lhe acule, Iife lhiealening evenls (dialelic keloacidocelosis and non kelolic
hypeiosnoIai cona) and Iong lein iisk conpIicalions of dialeles and oveiveighl (31,37,39).
Many psycholiopic diugs (especiaIIy nelhyIphenidale) veie designed lo le slailed eaiIy in
chiIdhood in oidei lo inpiove vaiious laigel oigan, cognilive and neuiopsychialiic
funclions. These nedicalions appeaied lo le veiy polenl and significanlIy changed Iife
quaIily, vhich Ied lo lheii videspiead use aII ovei lhe voiId (5). This nedicalions aie oflen
conlinued foi a Iong peiiods (yeais) and nay cause unfavoialIe nelaloIic effecls. Radei
and Holls (4O) iepoiled lhal sone of lhese diugs affecl Iipid and Iipopiolein nelaloIisn
and inciease oi deciease alheiogenicily.
MelhyIphenidale is lhe nosl alundanlIy used nedicalion foi lhe liealnenl of ADHD in aII
ages voiIdvide (5). Il is veII knovn lhal nelhyIphenidale has an effecl on inliaceIIuIai
choIesleioI in lhe liain, lul lo dale ils effecl on pIasna Iipid nelaloIisn has leen sludied lo
a Iiniled exlenl in cIinicaI selling (6, 41). We iecenlIy pulIished lhe iesuIls of a iandonized
sludy lhal exanined lhe effecl of nelhyIphenidale on lIood Iipid IeveIs (42). A lolaI of 42
oulpalienls vilh an eslalIished diagnosis of ADHD veie sludied. The laseIine
chaiacleiislics of lhe sludy gioup aie piesenled in TalIe 1. Theie veie 22 naIes and 2O
fenaIes vhose nedian age vas 16 yeais (iange 11-31). TalIe 2 dispIays lhe diffeiences in lhe
exanined paianeleis lefoie and aflei a 3 nonlh liealnenl ly nelhyIphenidale. MI didn'l
change duiing lhe sludy peiiod. Significanl deciease vas found in lolaI choIesleioI, LDL- c
and liygIiceiides IeveIs. Non significanl changes veie seen in HDL-c, apoIipopiolein A and
apoIipopiolein IeveIs. The changes in Lp (a) unexpecledIy luined oul lo le slalislicaIIy
significanl. Theie veie no gendei- lased diffeiences in any of lhese paianeleis aflei
adjuslnenl accoiding lo age, noi any coiieIalions lelveen lhe Iipid paianeleis.
This is lhe fiisl invesligalion inlo lhe inpacl of nelhyIphenidale on pIasna Iipid piofiIe and
alheioscIeiosis. The iesuIls of lhe cuiienl sludy shoved lhal nelhyIphenidale has a
significanl and posilive inpacl on lhe Iipid and Iipopiolein piofiIe vilh iegaid lo
alheioscIeiosis. Il significanlIy decieases lolaI choIesleioI, liigIyceiides and lhe nain
alheioscIeiolic Iipopioleins, LDL-c and Lp(a). Theie is no good expIanalion of Iipid
Ioveiing nechanisn. Hovevei, in conliasl lo olhei psycholiopic nedicalion il didn'l cause
veighl gain. The possilIe expIanalion: anphelanine ieIaled agenls-(incIuding
nelhyIphenidale) inciease synaplic dopanine ly slinuIaling piesynaplic ieIease of lhe Iasl


189
VaiialIe
Median
Lovei
quailIiIe
Uppei
quailIiIe
Age (yeais) 16 14 22
MaIes 52
MI ## 2O 24
T-ChoI(ng/dI) 157 142 179
HDL-C(ng/dI) 51 45 64
LDL-C(ng/dI) 93 74 114
TiigI(ng/dI) 76 58 1OO
Apo A(ng/dI) 122 1O9 137
Apo (ng/dI) 71 56 83
Lp(a)(ng/dI) 23 9 4O
MI,lody nass index , HDL-C, high densily Iipopiolein,
LDL-C, Iov densily Iipopiolein, Apo A, apoIipopiolein A
Apo , apoIipopiolein , Lp (a), Iipopiolein (a).
TalIe 1. Ialienl chaiacleiislics (n = 42"

VaiialIe Median Lovei quailIe Uppei quailIe $@A
AMI O O O.3 $"#%
A T-ChoI (ng/dI) &' -15 -3 O.OOO2
A HDL-C(ng/dI) 2 O 4 O.1
A LDL-C(ng/dI) -5 -8 1 O.O16
A TiigI(ng/dI) &( -15 -3 O.O16
A Apo A(ng/dI) -4. -12 7 O.16
A Apo (ng/dI) -2 -5. 5 O.6
A Lp(a)(ng/dI) -2 -5 O O.OOO7
AnonHDLC(ng/dI) &)) -18 -2 O.OOO1
A-diffeience
* ased on WiIcoxson lesl.
TalIe 2. Diffeiences in Iipid piofiIe and MI paianeleis lefoie and aflei lhe liealnenl ly
nelhyIphenidale.
and cause an anoiexigenic effecl ly changes in hypolhaIanic nonoanineigic aclivily and in
lhe anoiexigenic cocaine-anphelanine -ieguIaled liansciipl neuiopeplide ( CART)
expiessed in lhe paiavenliicuIai nucIeus and hypolhaIanic peiifoinicaI nucIeus (43, 44).
ConcIusion: lhe piesenled dala suppoil sone posilive effecls on Iipid piofiIe ly decieasing
lolaI choIesleioI, liigIyceiides, LDL-c and Lp (a). No concIusions couId le ieached conceining
alheioscIeiosis.
4. Limitations
These concIusions aie lenlalive lecause of lhe Iaige iale of eaiIy diop ouls fion lhe sludies,
vhich nay Iinil lhe vaIidily of lhe iesuIls. The sludy vas peifoined on a ieIaliveIy snaII
nunlei of palienls (42 palienls) noslIy leenageis. Theie is nol enough dala aloul inpacl of
nelhyIphenidale on aduIl popuIalion. The iepoiled shoil lein sludy, conducled foi lhiee


190
nonlhs, shoved posilive effecls on Iipid piofiIe. Hovevei il doesn'l aIIov us lo piedicl
vhelhei lhis effecl viII peisisl and vhelhei alheioscIeiosis viII deveIop.
Iuilhei, Iaige, veII-designed liiaIs aie necessaiy lo eslalIish lhe diffeienl nelaloIic effecls
of nelhyIphenidale
5. References
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2 sludy. MelaloIisn 2OO7,56: 614-622.
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|13j Slechyc O, LoIudice T,Denelei S, }acols }. MuIlipIe oigan faiIuie iesuIling fion
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|14j Conlokovsky SR, NeveI R, McDonaId N, WinkeInan MH. Decieased seiun gIucose
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191
|15j VilieIIo . Undeislanding lhe iisk using nedicalions foi allenlion deficil hypeiaclivily
disoidei vilh iespecl lo physicaI giovlh and caidiovascuIai funclion ChiId AdoIes
Isychiali CIin N an 2OO8, 17(2): 459-74 ,xi.
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|18j Spivak , Veief Y, Yoian-Hegesh R, Ciaff L, Aveiluch L Vinokuiov S, Weilznan A,
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|21j Nynaik T, HovIand A, jeinsladl H, NieIsen L. A young nan vilh diIaled
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|22j McCavock }M, Vicloi RC, Ungei RH, el aI. Adiposily of lhe Heail, Revisiled. Ann
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|44j Adanson T, CoiII C, Syec I, Ioilei }. RoIe of lhe peiifoinicaI hypolhaIanic nonoanine
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Part 3
Non-Medication Interventions

10
ADHD and Stress:
The RoIe of Meditation to Reduce Stress,
and Improve Brain Function
and Behavior ReguIation
Saiina }. CiossvaId
1
and Iied Tiavis
2

!
"# %&'(()*+, - .(('/0*12(
3
42512& 6'& 7&*058 4'5(/0'9(52(( *5, 4':5010'5
;5012, "1*12(
1. Introduction
The nunlei of chiIdien voiIdvide diagnosed vilh ADHD incieases eveiy yeai. As
infoinalion aloul lhe nedicaI iisks associaled vilh ADHD nedicalion is leconing noie
videIy undeislood, il is nol suipiising lhal Iaige nunleis of paienls aie seeking aIleinalive
lheiapies as a iesponse lo conceins aloul lhe physioIogicaI and psychoIogicaI effecls of lhe
diugs.
A gioving nunlei of cIinicians aIso suppoil aIleinalive lheiapies, aiguing lhal an enphasis
on nedicaI lheiapy aIone focuses onIy on conlioI of synplons, ialhei lhan allending lo lhe
need foi chiIdien lo deveIop inpoilanl lehavioiaI and sociaI skiIIs (Zanelkin, & Linsl, 1999).
WhiIe lhe use of aIleinalive appioaches such as yoga, nedilalion, exeicise, speciaI diels, and
nuliilionaI suppIenenls foi liealing chiIdien vilh ADHD is leconing videspiead, IillIe is
knovn aloul lhe effecliveness of nany of lhese appioaches. Theie is a gioving lody of
ieseaich on lhe leneficiaI effecls of nedilalion on heaIlh iisks, psychosociaI faclois, and on
liain deveIopnenl. Hovevei lheie is IillIe pulIished ieseaich aloul lhe use of nedilalion
foi ADHD.
2. Stress, anxiety and ADHD
ADHD is associaled vilh inpaiied execulive funclion, specificaIIy liain ciicuiliy goveining
lehavioi (ush, el aI., 2OO5, Duislon, el aI., 2OO4, Zanelkin, el aI., 1993). Dysfunclion of lhese
ciicuils Ieads lo inpuIsivily and Iack of noinaI sociaI inhililion. Il aIso Ieads lo inpaiied
voiking nenoiy, inaliIily lo focus allenlion, and inpaiied lenpoiaI oiganizalion.
Sliess inleifeies vilh execulive funclion and lehavioi ieguIalion (McLven, 1998). Sliess-
inpaiied execulive funclion is associaled vilh inpaiied voiking nenoiy, inpaiied
inpuIse conlioI, and Iack of nenlaI fIexiliIily and coping slialegies. Sliess aIso dianalicaIIy
conpionises seIeclive allenlion and lhe aliIily lo suslain allenlion (Lupien, el aI., 2OO5).

Current Directions in ADHD and ts Treatment 196
In conpaiing synplons of sliess and synplons of ADHD, lheie is a sliiking siniIaiily.
Recenl ieseaich sheds Iighl on lhe ieIalionship lelveen sliess and ADHD. Vance, el aI.,
denonslialed dysfunclion of lhe iighl piefionlaI iegions of lhe liain in ADHD chiIdien
(2OO7). This iegion is iesponsilIe foi deveIoping coping slialegies, infIuencing lhe aliIily lo
handIe sliess. Chionic acule sliess danages lhe lody's aliIily lo ieluin lo non-sliess IeveIs,
Ieading lo chionicaIIy eIevaled IeveIs of coilisoI, a liochenicaI naikei of sliess. In chiIdien
vilh ADHD high coilisoI IeveIs inpaii execulive funclion, seIf-ieguIalion, and Iellei
knovIedge (Iaii, Ciange, & Razza, 2OO5).
Chionic sliess can oiiginale nol onIy fion enolionaI causes lul can aIso iesuIl fion
physicaI oiigins. Sludies of pienaluie liilh and liilh veighl shov an associalion lelveen
physicaI sliess and iisk of ADHD. Danish ieseaicheis found lhal lalies loin pienaluieIy
had up lo 7O giealei iisk of ADHD. SiniIaiIy, lalies loin of Iov liilh veighl had 5O-9O
giealei iisk of ADHD, depending on lhe veighl al liilh (Linnel, Wisloig, Ageilo, Sechei,
Thonsen, & Heniiksen, 2OO6).
LaiIy expeiiences of sliess aie leIieved lo affecl lhe IeveI of iesponsiveness of lhe
hypolhaIanic-piluilaiy-adienaI axis and lhe aulononic neivous syslen. Young chiIdien
exposed lo chionic sliess can lecone condilioned lo highei IeveIs of adienaIine. This iaises
lhe sel poinl, naking lhese chiIdien noie vuIneialIe lo sliess, iesuIling in silualions noie
easiIy liiggeiing sliess iesponses.
3. PharmaceuticaI treatment
The Uniled Slales Cenleis foi Disease ConlioI and Iievenlion eslinales lhal ovei 66 of
chiIdien diagnosed vilh ADHD aie laking nedicalion (CDC, 2OO8). The agency slales,
hovevei, lhal concein peisisls iegaiding lhe side effecls and Iong-lein heaIlh oulcones
associaled vilh lhese diugs (CDC, 2OO5).
Iuilhei, lhe Iong lein effecliveness of phainaceulicaI liealnenl is nixed. The Iaigesl sludy
conducled on ADHD liealnenl vas lhe MuIlinodaI Tiealnenl Sludy of ChiIdien vilh
ADHD, iefeiied lo as lhe MTA, pulIished in 1999, vhich iepoiled effecliveness of diug
liealnenl (MTA Coopeialive Cioup, 1999). Hovevei foIIov-up sludies al lhiee yeais and
eighl yeais, iepoiled no significanl diffeiences in synplons anong lhe chiIdien vho
ieceived lhe inlensive diug liealnenls and lhose vho did nol (MoIina, el aI. 2OO9, }ensen, el
aI. 2OO7). AddilionaIIy, lhose on lhe diug ieginens had significanlIy highei iales of
deIinquency and sulslance use (MoIina, IIoiy, Hinshav, Cieinei, AinoId, & Svanson,
2OO7).
Ieisislenl and negalive side effecls of lhe diugs incIude sIeep disluilances, ieduced
appelile, veighl Ioss, suppiessed giovlh, and nood disoideis. The Iong-lein effecls aie nol
fuIIy knovn al lhis line, hovevei evidence suggesls iisks of caidiac disoideis and sudden
dealh, Iivei danage, and psychialiic evenls. The side-effecls and Iong-lein heaIlh oulcones
associaled vilh lhe diug liealnenl have polenliaIIy inpoilanl heaIlh inpIicalions foi lhe
niIIions of chiIdien vho aie cuiienlIy laking nedicalion foi ADHD (CDC, 2OO5).
ConsequenlIy, lheie is a gioving inleiesl in aIleinalive liealnenl oplions, such as
nuliilionaI appioaches, nedilalion, and yoga.
ADHD and Stress:
The Role of Meditation to Reduce Stress, and mprove Brain Function and Behavior Regulation 197
4. Meditation
Theie aie nany syslens of nedilalion, vhich diffei videIy fion one anolhei in lheii
pioceduies, conlenl, leIiefs, and goaIs. Reseaich has shovn lhal lhe diffeienl lechniques
have diffeienl suljeclive and oljeclive effecls. Medilalion lypes have geneiaIIy leen
cIassified inlo lvo calegoiies: lechniques of concenlialion oi lechniques of conlenpIalion
(Shapiio, 1982). Lach of lhese diffeienl lechniques uses diffeienl piocesses and lhus has
diffeienl effecls (Oine-}ohnson, & WaIlon, 1998, Sheai, 2OO6).
Mosl iecenlIy, Tiavis and Sheai (2O1O) idenlified lhiee lypes of nedilalion piaclices,
cIassified accoiding lo lheii LLC signaluies and lhe coiiesponding cognilive piocesses. The
lhiee cIassificalions aie focused allenlion, open noniloiing, and aulonalic seIf-
lianscending.
Techniques of focused allenlion aie concenlialion lechniques, and aie associaled vilh
voIunlaiy suslained conlioI of allenlion lo keep il focused on lhe oljecl of nedilalion, such
as an evenl, inage, oi sound. The liain aclivily duiing concenlialion nedilalions is
chaiacleiized ly LLC in lhe lela-2 (2O-3O Hz) and ganna (3O-5O Hz) fiequency lands.
Open noniloiing oi nindfuIness-lased lechniques, invoIve dispassionale non-evaIualive
noniloiing of ongoing expeiience. These lechniques aie chaiacleiized ly fionlaI lhela (5-8
Hz) LLC, and peihaps occipilaI ganna (3O-5O Hz) LLC. Aulonalic seIf-lianscending
nedilalion is defined as effoilIess lianscending of lhe nedilalion piocess ilseIf (Tiavis &
Duois, 2OO4, Tiavis & Sheai, 2O1O). LLC aclivily of an aulonalic seIf-lianscending
lechnique is associaled vilh aIpha-1, chaiacleiislic of ieduced nenlaI aclivily and
ieIaxalion.
Reseaich has shovn inpiovenenls in allenlion and fIexiliIily anong a sludy gioup lhal
vas using vaiious diffeienl foins of nedilalion (Rulschnan, 2OO4), and in ADHD
synplons using Sahaja yoga nedilalion, a foin of conlenpIalive oi open noniloiing
nedilalion (Haiiison, Manocha, & Rulia, 2OO4).
The TianscendenlaI Medilalion lechnique faIIs inlo lhe calegoiy of aulonalic seIf-
lianscending. Concenlialion and open noniloiing nedilalions lolh iequiie sone nenlaI
effoil (i.e., hoIding allenlion on ils oljecl oi nainlaining a slance of open noniloiing,
iespecliveIy). The TianscendenlaI Medilalion lechnique is said lo aulonalicaIIy Iead lo lhe
expeiience of consciousness ilseIf, avaieness vilhoul any oljecls of avaieness, a Iov-
sliess slale caIIed lianscendenlaI oi puie consciousness (Tiavis & Ieaison, 2OOO).
Il is desciiled as a sinpIe and effoilIess, non-ieIigious nenlaI lechnique lhal is easy lo Ieain,
and does nol iequiie lhe aliIily lo concenliale oi conlioI lhe nind. ReguIai piaclice of lhe
lechnique cieales a slale iefeiied lo as "ieslfuI aIeilness." The lein iefIecls a conlinalion of
naikedIy decieased nelaloIisn, heail iale, iespiialion iale, and lIood fIov lo lhe Iinls,
siniIai lo deep iesl oi sIeep, vhiIe al lhe sane line nenlaI aIeilness is nainlained, as
neasuied ly LLC (DiIIleck, & Oine-}ohnson, 1987, }evning, WaIIace, & eidelach, 1992,
Oine-}ohnson, 1973, Tiavis, & WaIIace, 1999, WaIIace, 197O).
LLC neasuienenls aIso shov incieases in liain coheience lolh duiing lhe piaclice of lhe
TianscendenlaI Medilalion lechnique and afleivaids in aclivily (Tiavis and Sheai 2O1O,
DiIIleck & Aiaas-VeseIy, 1986, So & Oine-}ohnson, 2OO1). The piinaiy aieas of liain

aclivaled duiing lhe piaclice aie lhe fionlaI and piefionlaI execulive aieas iesponsilIe foi
allenlion, execulive funclion, enolionaI slaliIily, and anxiely (Dixon, el. aI., 2OO5, So, 2OO1,
Ieigusson, 1993, CayIoid, Oine-}ohnson, & Tiavis, 1989).
Iosilive effecls of lhe TianscendenlaI Medilalion lechnique exlend lo lhe noiadieneigic
nelvoiks (}evning, WaIIace, & eidelach, 1992, }evning, WiIson,& Davidson, 1978,
MacLean, WaIlon, Wennenleig, el. aI., 1997, WaIlon, CeIdeiIoos, & MacRae, 1995). The
piaclice of lhe lechnique iesuIls in a deciease in lhe sliess hoinone coilisoI, lolh duiing
nedilalion and IongiludinaIIy, oulside nedilalion duiing aclivily. Iiaclice of lhe lechnique
incieases seiolonin avaiIaliIily, inpioving nood and ieducing lhe aclivalion of lhe liain
cenleis foi feai, anxiely, and angei.
The use of lhe TM lechnique foi sliess ieduclion in adoIescenls has iesuIled in inpiovenenl
in schooI lehavioi, decieases in alsenleeisn and iuIe infiaclions, and ieduclion in
suspensions due lo lehavioi-ieIaled piolIens (aines, auza, & Tiielei, 2OO3). Sludenls
piaclicing lhe TM lechnique shov highei peifoinance on scaIes of seIf-acluaIizalion
(AIexandei, Rainfoilh, & CeIdeiIoos, 1991), incieased enolionaI ieguIalion, and inpioved
veII-leing (Rosaen & enn, 2OO6), as veII as inpioved acadenic peifoinance.
This chaplei desciiles lvo ieseaich sludies exanining lhe effecls of lhe TianscendenlaI
Medilalion lechnique in ieducing sliess, inpioving lhe synplons of ADHD, and
inpioving liain coheience and execulive funclion.
5. PiIot study
The TianscendenlaI Medilalion lechnique vas seIecled foi an expIoialoiy sludy lo evaIuale
vhelhei ieguIai piaclice of lhe lechnique ly chiIdien ages 11 lo 14 vilh ADHD vouId iesuIl
in inpiovenenls in sliess , lehavioiaI synplons, and execulive funclion.
5.1 Subjects
The sludy vas conducled al an independenl schooI foi chiIdien vilh Ianguage-lased
Ieaining disaliIilies. Iailicipalion in lhe sludy vas iesliicled lo sludenls vilh pie-exisling
diagnoses of ADHD. The cohoil vas 1O sludenls ages 11-14, nine loys and one giiI. AII had
a diagnosis of ADHD, six vilh inallenlive-lype and foui vilh conlined-lype. Six sludenls
had conoilidilies incIuding geneiaI anxiely disoidei, dyslhynia, olsessive conpuIsive
disoidei, peivasive deveIopnenlaI disoidei, sIeep disoideis, and lics. Lighl sludenls veie
laking slinuIanls (e.g. Conceila, RilaIin), lhiee of lhose veie aIso on olhei nedicalions such
as anlidepiessanls (e.g. ZoIofl, WeIluliin) and alypicaI anlipsycholics (e.g., RispeidaI). y
viilue of allending lhe schooI, aII sludenls had Ianguage-lased Ieaining disaliIilies.
5.2 Measures
Dala coIIeclion vas divided inlo lvo calegoiies lo coiiespond lo lhe piinaiy and secondaiy
hypolheses: 1) neasuies of sliess, anxiely, ADHD synplons as iepoiled ly paienl, leachei,
and sludenl invenloiies, 2) neasuies of execulive funclion as neasuied ly paienl and
leachei invenloiies, and ly peifoinance lesls. AnecdolaI infoinalion vas coIIecled ly
infoinaI video inleivievs al pie- and posl lesl lines.
ADHD and Stress:
5.2.1 Stress, anxiety, and ADHD symptoms
Teacheis and paienls conpIeled lhe Achenlach ChiId ehavioi CheckIisl (CCL) invenloiy,
vhich is vaIidaled as diagnoslic of ADHD lased on ciileiia defined in lhe Diagnoslic and
SlalislicaI ManuaI of MenlaI Disoideis, fouilh edilion (DSM-IV). The CCL is one of lhe
nosl videIy-used neasuies in chiId psychoIogy, assessing lehavioi and sociaI conpelency.
Il is conposed of 112 ilens, each diffeienlialing cIinicaI fion non-cIinicaI chiIdien.
Sunnaiized in lvo calegoiies: Syndione ScaIes and DSM-Oiienled ScaIes, lhe CCL
piovides eighl synplon sulscaIe scoies and a TolaI IiolIen scoie.
Sludenls conpIeled lhe seIf-adninisleied Achenlach Youlh SeIf-Repoil (YSR) and lhe
Revised ChiIdien's Manifesl Anxiely ScaIe (RCMAS) lo assess oveiaII lehavioiaI and
enolionaI funclioning. The YSR is a conpanion lo lhe CCL, pioviding paiaIIeI neasuies
fion lhe leacheis, paienls, and sludenls. Like lhe CCL lhe YSR has 112 ilens neasuiing
eighl sulscaIe synplons calegoiized undei Syndione ScaIes and DSM-Oiienled ScaIes,
and a TolaI IiolIen scoie. The RCMAS is a 37-ilen seIf-iepoil insliunenl assessing lhe
IeveI and naluie of anxiely in chiIdien and adoIescenls.
5.2.2 Executive function
Teacheis and paienls conpIeled lhe ehavioi Raling Invenloiy of Lxeculive Iunclion
(RILI). The RILI consisls of 86 ilens divided inlo eighl sulscaIes. These scaIes foin lvo
lioadei indices: ehavioiaI ReguIalion and Melacognilion. These lvo indices aie conlined
lo cieale an oveiaII CIolaI Lxeculive Conposile scoie. The RILI assesses lehavioi
ieguIalion and execulive funclioning.
Ioui peifoinance lesls veie used lo neasuie diffeienl aspecls of execulive funclion. The
Cognilive Assessnenl Syslen (CAS) Lxpiessive Allenlion, DeIis-KapIan Lxeculive Iunclion
Syslen (D-KLIS) VeilaI IIuency lesl, Tovei of London (TOL), and Connois CIT II.
The CAS Lxpiessive Allenlion sullesl is a coIoi-void inleifeience lesl. Il neasuies highei
IeveI conpIex allenlion, and aliIily lo inhilil. Nanes of coIois aie piesenled in ink coIois of
eilhei lhe nane of lhe coIoi oi a diffeienl coIoi. When lhe coIoi of ink is diffeienl fion lhe
coIoi nane lhe lask iequiies allenlion, inhililing lhe iefIexive iesponse, and cognilive
piocessing (svilching) lo say lhe coiiecl coIoi.
The D-KLIS VeilaI IIuency sullesl neasuies lhe aliIily lo geneiale voids fIuenlIy,
geneiale voids in specific calegoiies, and shifl allenlion ly svilching fion one calegoiy lo
anolhei. The sludenl is asked lo Iisl as nany voids as possilIe slailing vilh a ceilain Iellei,
lo nane as nany ilens in a calegoiy, and lo nane ilens svilching fion one calegoiy lo
anolhei.
The TOL neasuies highei oidei piolIen-soIving, and is used lo evaIuale difficuIlies in
execulive funclion. Suljecls aie shovn a configuialion of coIoied laIIs slacked on pegs. The
suljecl execules a sequence of noves lhal liansfoins his oi hei loaid lo nalch lhe
dispIayed configuialion vilh lhe laIIs aiianged on lhe designaled pegs.
The Connois' Conlinuous Ieifoinance Tesl (CIT) II is a conpuleiized lesl lhal neasuies
suslained allenlion. The suljecl is piesenled slinuIi on a conpulei scieen (e.g., a Iellei oi
asleiisk) and is asked lo iespond ly piessing a lullon onIy vhen delecling a specified Iellei
aflei seeing anolhei specified Iellei.

5.3 Procedure
Six veeks lefoie lhe slail of lhe inleivenlion, lvo cIassioon leacheis and lvo
adninislialois al lhe schooI veie insliucled in lhe TianscendenlaI Medilalion lechnique, in
lhe sane vay lhe sludenls vouId le (see leIov). The insliuclion in TianscendenlaI
Medilalion is slandaidized and aII piaclilioneis aiound lhe voiId aie insliucled in lhe
idenlicaI vay, lhus assuiing consislency in insliuclion and in piaclice of lhe lechnique.
IoIIoving conpIelion of laseIine assessnenls, sludenls veie piovided lhe slandaid 7-Slep
couise of insliuclion in lhe TianscendenlaI Medilalion lechnique (see 5.4 leIov). AII 1O
chiIdien in lhe gioup veie alIe lo Ieain lhe TM lechnique, and piaclice il successiveIy as
evidenced duiing lhe noining and afleinoon TM sessions and ly iesponses lo couise
assessnenl queslionnaiies.
Ovei lhe 3-nonlh sludy peiiod, suljecls pailicipaled in cuslonaiy foIIov-up checks of
coiiecl nedilalion, vhich is slandaid vilh lhe insliuclion of lhe lechnique. Sludenls
nedilaled al schooI in a gioup foi 1O ninules lvice each day, once in lhe noining and once
in lhe afleinoon. The cIassioon leacheis vho had aIso Ieained TM Ied lhe sludenls in lvice
daiIy nedilalion sessions al lhe schooI, leIIing sludenls vhen lo legin and end nedilalion,
and lining lhe nedilalion. The Ceilified TM leacheis noniloied lhe gioup nedilalion lvo
oi lhiee lines a nonlh lo assuie coiiecl gioup nedilalion.
Iaienls veie encouiaged lo have sludenls conlinue ieguIai nedilalion al hone on
veekends and hoIidays. Hone conpIiance vas nol iigoiousIy noniloied.
5.4 Intervention: The TranscendentaI Meditation technique
The TianscendenlaI Medilalion lechnique is a nenlaI lechnique piacliced foi 1O-2O ninules
lvice each day, silling in a chaii vilh eyes cIosed. The lechnique is laughl ly ceilified
TianscendenlaI Medilalion leacheis. The 7-Slep couise of insliuclion invoIves lvo
infoinalionaI Iecluies (Sleps 1 and 2), a liief inleiviev vilh lhe TM insliucloi (Slep 3),
individuaI peisonaI insliuclion (Slep 4), vhich is foIIoved ly lhiee days of veiificalion of
piaclice and addilionaI infoinalion (Sleps 5-7). The inleiviev is aloul 1O ninules, vhiIe lhe
ienaining sleps aie appioxinaleIy one houi each day. Lach slep can le conducled in a
gioup excepl Slep 4, vhich is conducled individuaIIy, one-on-one. Ieiiodic neelings vilh
lhe sludenl assuies coiiecl piaclice and ieinfoices ieguIaiily of lhe piaclice.
Duiing lhe couise of insliuclion, lhe sludenl Ieains hov lo Iel lhe nind nove fion aclive
focused IeveIs of lhinking lo siIenl, expanded IeveIs of vakefuIness al lhe souice of lhoughl,
vilhoul concenlialion oi effoil (Tiavis, 2OO1).
Aflei lhe peisonaI insliuclion, sludenls in lhe sludy nedilaled in a gioup al lhe leginning
of lhe fiisl peiiod in lhe noining and lhe leginning of lhe Iasl peiiod in lhe afleinoon.
Medilalion sessions veie Ied ly a schooI facuIly nenlei aIso insliucled in lhe TM
lechnique. A ceilified TM leachei peiiodicaIIy noniloied gioup nedilalions, and nel vilh
sludenls individuaIIy as needed lo assuie coiiecl piaclice as desciiled alove. Thiee nonlhs
aflei insliuclion, posl lesling vas adninisleied.
5.5 ResuIts
VaiialIes veie giouped inlo lvo concepluaI calegoiies lo coiiespond lo lhe hypolheses.
One giouping, sliess, anxiely, and ADHD synplons, incIuded lhe associaled vaiialIes fion
ADHD and Stress:
lhe YSR, RCMAS, and CCL. The second giouping, execulive funclioning, incIuded lhe
iesponses fion leacheis on lhe RILI, and lhe dala fion lhe peifoinance lesls. AnaIysis
vas conducled on neasuies foi vhich lheie vas conpIele dala (N=1O).
Iaienl invenloiies and CIT scoies veie nol incIuded in lhe anaIysis lecause fifly peicenl of
lhe paienl posl lesl invenloiies veie nol ieluined, and lhiily peicenl of sludenls had
aIieady Iefl schooI foi sunnei lieak al lhe line of CIT posl lesling.
Rav scoies veie used foi aII anaIyses excepl peifoinance lesls, vhich veie conveiled lo
slandaid scoies using lhe lalIes piovided in lhe lesl nanuaIs. Repealed neasuie
MANOVAs veie used lo lesl foi significanl pie-posllesl diffeiences.
5.6 Stress, anxiety, and ADHD symptoms
Iion lhe YSR, lhe vaiialIes seIecled foi anaIysis veie Anxious/Depiessed, Wilhdiavn/
Depiessed, Affeclive IiolIens, Anxiely IiolIens, Allenlion IiolIens, ADHD IiolIens,
and TolaI IiolIens (TalIe 1). Added lo lhese vaiialIes vas lhe singIe iesuIl of lhe RCMAS.
The anaIysis yieIded significanl inpiovenenl of synplons fion pielesl lo posl lesl
I(1,9)=4.7, p=.O285.
The sane neasuies anaIyzed fion lhe YSR veie seIecled foi anaIysis of lhe leachei iepoiled
CCL. Teachei iesuIls coiioloialed sludenl iepoiled significanl ieduclions in synplons,
I(1,9)=6.5, p=.O155.

Sludenl Teachei
Iielesl Iosl Tesl Iielesl Iosl Tesl
Synplon Mean SD Mean SD LS Mean SD Mean SD LS
Anxious/
Depiessed
5.7 3.6 2.7* 3.7 .8 1O.2 6.4 5.6* 3.6 .7
Wilhdiavn/
Depiessed
4.8 2.7 3.9** 3.O .3 4.3 3.8 3.6 4.O .2
Affeclive
IiolIens
5.8 3.4 4.1* 2.5 .5 5.O 3.7 3.6 3.6 .4
Anxiely
IiolIens
3.2 2.O 1.6** 1.9 .8 3.7 3.5 2.1 2.4 .5
Allenlion
IiolIens
7.O 4.O 5.2* 3.5 .5 23.6 1O.5 22 11.O .2
ADHD
IiolIens
5.4 2.9 4.3 2.7 .4 12.4 5.7 11.7 5.7 .3
TolaI
IiolIens
52.5 25.6 4O* 27.4 .5 63.1 24.8 56* 31.2 .3
* p < .O5. **p< .OO5 LS=Lffecl Size
TalIe 1. "#$%&'(#$ )*+,$ -%./ 0%1*2,3 -,2%443 "&56%,73 (&8 "9:9 -7;1,*;4
5.7 Executive function
The RILI incIudes 3 conposile neasuies: ehavioiaI ReguIalion Index, Melacognilion
Index, and CeneiaI Lxeculive Conposile. The CIolaI Lxeculive Conposile is conposed of

lhe ehavioiaI ReguIalion Index and lhe Melacognilion Index. A iepealed neasuies
MANOVA of lhe CeneiaI Lxeculive Conposile indicaled significanl inpiovenenl in
execulive funclion fion pielesl lo posl lesl, I(1,9) = 5.5, p = .O22. Repealed neasuies
MANOVA on lhe scaIes conpiising lhe lvo indices aIso veie slalislicaIIy significanl:
ehavioiaI ReguIalion Index (Inhilil, Shifl, and LnolionaI ConlioI), I(1,9) = 23.7, p < .OOOO1,
and Melcognilion Index (Iniliale, Woiking Menoiy, IIanning, Oiganize MaleiiaI, and
Moniloiing), I(1,9)=13.7,p=.OO25. TalIe 2 piesenls lhe pie- and posl lesl neans and slandaid
devialions foi lhe individuaI scaIes associaled vilh each index.
The Tovei of London vas onilled fion anaIysis lecause lhe assessnenl has leen found lo
le Iess consislenl lhan olhei neasuies in dislinguishing specific effecls associaled vilh
ADHD fion lhose ieIaled lo Ieaining disoideis (Seigeanl, Ceuils, & OosleiIaan, 2OO2).

<2%=>%4, <*4, >%4,
-#(.% ?%(& -9 ?%(& -9
ehavioiaI ReguIalion
Index (RI)
54.1 16.9 46.4* 13.2
Inhilil 19.O 6.9 17.1* 6.5
Shifl 18.5 5.3 15.5 3.9
LnolionaI ConlioI 16.6 6.7 13.8* 4.3
Melacognilion Index (MI) 94.8 32.1 85.3 23.2
Iniliale 15.1 3.7 13.2* 3.2
Woiking Menoiy 22.8 4.2 2O.1* 5.3
IIan/Oiganize 21.8 4.4 2O.6 5.5
Oiganizalion of MaleiiaIs 14.6 4.9 13.2 5.O
Moniloi 2O.4 5.9 18.2* 4.5
CeneiaI Lxeculive
Conposile (CLC)
151.6 37.7 131.7* 33.1
* p < .O5
TalIe 2. Teachei ehavioi Raling Invenloiy of Lxeculive Iunclion (RILI)
The peifoinance neasuies anaIyzed veie lhe CAS and lhe D-KLIS (TalIe 3). The CAS
scoies of Lxpiessive Allenlion and Accuiacy Ralio veie conlined vilh lhe D-KLIS scoies
foi Calegoiy IIuency and Calegoiy Svilching. A iepealed neasuies MANOVA yieIded a
significanl inpiovenenl in scoies on lhese peifoinance neasuies fion pie lo posllesl,
I(1,9)=5.O, p=.O26.

Measuie
Iie-Tesl Iosl Tesl
Mean SD Mean SD
CAS Lxpiessive Allenlion 36.1O 1O.63 44.7O* 13.59
CAS Accuiacy 37.7O 2.21 39.4O* 1.27
D-KLIS Calegoiy IIuency 25.1O 7.83 28.7O 7.61
D-KLIS Calegoiy Svilching 8.3O 3.19 9.6O 2.63
* p < .O5.
TalIe 3. Ieifoinance Measuies
ADHD and Stress:
6. Randomized controIIed triaI of brain function
To fuilhei undeisland lhe effecls of lhe TianscendenlaI Medilalion lechnique on chiIdien
vilh ADHD, a second sludy expIoied inpiovenenls in liain coheience and liain
deveIopnenl. The puipose vas lo piovide insighl inlo lhe undeiIying nechanisns of
olseived changes. A iandonized conlioIIed liiaI exanined lhe LLC coheience, lhela/lela
ialio, and execulive funclion.
LLC sludies iepoil decieased aclivalion in ADHD popuIalions in paiielaI aieas of lhe liain
lhal veave sensoiy inpul inlo conciele peiceplion (SiIk el aI., 2OO5), highei densily and
anpIilude of lhela aclivily (di MicheIe, Iiichep, }ohn, & Chalol, 2OO5, }anzen, Ciaap,
Slephanson, MaishaII, & Iilzsinnons, 1995), and Iovei densily and anpIilude of aIpha and
lela aclivily (aiiy, CIaike, & }ohnslone, 2OO3). Thela/lela povei ialios aie highIy
coiieIaled vilh seveiily of ADHD synplons (Monaslia, Lulai, & Linden, 2OO1, Monaslia el
aI., 1999).
Duiing nenoiy lasks, lhela LLC is geneialed in lhe hippocanpus and is lhoughl lo lIock
oul iiieIevanl slinuIi duiing nenoiy piocessing. In ADHD suljecls, giealei lhela aclivily
nay lIock oul ieIevanl as veII as iiieIevanl infoinalion.
Anolhei liain naikei of ADHD is LLC coheience, a neasuie lhal iefIecls lhe nunlei and
slienglh of conneclions lelveen diffeienl liain aieas (Thalchei, WaIkei, & Ciudice, 1987).
In chiIdien diagnosed vilh ADHD, coheience in aII fiequencies is iepoiled Iovei (aiiy,
CIaike, McCailhy, & SeIikovilz, 2OO7, 2OO9). AIpha coheience is lhoughl lo pIay an
inpoilanl ioIe in allenlion and consciousness.
6.1 Subjects
As in lhe pievious sludy, lhe suljecls veie sludenls al an independenl schooI foi chiIdien
vilh Ianguage-lased Ieaining diffeiences. Lighleen sludenls veie slialified ly age, and
iandonIy assigned lo Ieain TM innedialeIy (TM Cioup: 6 loys, 3 giiIs, aveiage age 12.9
1.3) oi Ieain TM in lhiee nonlhs (DeIayed-Slail Cioup: 7 loys, 2 giiIs, aveiage age 13.O
1.6). Co-noilidilies incIuded CeneiaI Anxiely Disoidei (3 suljecls), Olsessive ConpuIsive
Disoidei (1 suljecl), and Aulisn (3 suljecls). In each gioup, five of lhe nine suljecls veie on
ADHD nedicalion.
6.2 Measures
The DeIis-KapIan Lxeculive Iunclion Syslen (D-KLIS) VeilaI IIuency and lhe Tovei of
London veie used lo iepIicale lhe pievious sludy. Invenloiies incIuded lhe RILI, lhe
Achenlach ChiId ehavioi CheckIisl, and lhe SpieIleigei Slale Tiail Anxiely ScaIe.
LLC vas iecoided duiing a conpulei-adninisleied paiied choice ieaclion-line lask lo
caIcuIale lhela/lela ialios and palleins of LLC coheience. The lask legan vilh a dispIay on
a conpulei scieen of a one- oi lvo-digil nunlei, foIIoved ly a lIank scieen, lhen anolhei
one- oi lvo-digil nunlei. Suljecls veie asked lo piess a Iefl- oi iighl-hand lullon lo
indicale vhich nunlei vas Iaigei in vaIue.

6.3 ResuIts
The piinaiy anaIysis lesled diffeiences fion laseIine lo lhe 3-nonlh posllesl. The
TianscendenlaI Medilalion gioup piacliced lhe TM lechnique foi lhiee nonlhs aIong vilh
lhe cuiiicuIun designed foi chiIdien vilh Ianguage-lased Ieaining disaliIilies, lhe deIayed-
slail conpaiison gioup ieceived onIy lhe cuiiicuIun al lhe schooI. In lhis anaIysis lvo
iepealed neasuies MANOVAs veie conducled~psychoIogicaI and peifoinance vaiialIes
in one, and coheience in lhe olhei~and an ANCOVA of lhela/lela ialio diffeiences,
covaiying foi pielesl scoies.
A secondaiy anaIysis of lhe deIayed-slail gioup conpaied diffeiences fion laseIine lo lhe
3-nonlh posllesl , vhen lhese suljecls veie nol yel nedilaling, lo diffeiences fion lhe 3-
nonlh lo lhe 6-nonlh posllesl, vhen lhese suljecls veie nedilaling.
6.3.1 Theta/beta ratios
The ANCOVA of lhela/lela diffeiences, covaiying foi pielesl scoies yieIded significanl
decieases in lhela/lela ialios in lhe TM gioup (I(1,17) = 4.7, p = .O5). The aveiage
lhela/lela ialio seen in noinaI popuIalions is 3. Al pielesl, lolh gioups veie veII alove
aveiage (TM=9, deIayed-slail=1O.2). Al lhe 3-nonlh posl lesl, lhela/lela ialios incieased in
lhe deIayed-slail (11.9) gioup, vhiIe lhe TM suljecls noved cIosei lo noinaI vaIues (7.6). Al
lhe 6-nonlh posl lesl, aflei lolh gioups veie piaclicing lhe TM lechnique, lhela/lela ialios
decieased in lolh gioups (TM=4.9, deIayed-slail=7.6).
Ioi lhe deIayed slail gioup, lhela/lela ialios aIso significanlIy decieased fion lhe 3-nonlh
lo 6-nonlh posllesl (-4. 3) conpaied lo laseIine lo 3-nonlh posllesl (1.3) (I(1,8) = 5.1, p =
.O53), iepiesenling lhe iesuIls of lhiee nonlhs piaclice of lhe lechnique.
6.3.2 Coherence maps
Coheience naps duiing pielesl, 3-nonlh, and 6-nonlh posllesls veie aveiaged vilhin each
gioup and sulliacled: coheience al 3-nonlh posllesl ninus coheience duiing pielesl foi lhe
deIayed-slail and TM gioup vho had leen nedilaling foi 3-nonlhs, and 6-nonlh posllesl
ninus 3-nonlh posllesl in lhe deIayed-slail gioup aflei lhey had leen nedilaling foi 3-
nonlhs. These coheience diffeience naps piesenl coheience in lhela (5.O-7.5 Hz), aIpha (8.O-
12 Hz), lela1 (13-2O Hz), and ganna lands (2O.5-5O Hz).
Coheience naps (Iiguie 1) shov fev sensois vilh highei coheience in lhe deIayed-slail
gioup al lhe 3-nonlh posllesl conpaied lo lheii pielesl vaIues (lop iov). In conliasl, lheie
veie nany fionlaI and paiielaI aieas vilh highei coheience in lhe TM gioup al 3-nonlh
posllesl conpaied lo pielesl vaIues (niddIe iov), and lheie veie nany fionlaI and paiielaI
aieas vilh highei coheience in lhe deIayed-slail gioup al lhe 6-nonlh posllesl conpaied lo
lhe 3-nonlh posllesl vaIues (lollon iov).
The DeIis-KapIan Lxeculive Iunclion Syslen (D-KLIS) VeilaI IIuency and lhe Tovei of
London veie used lo iepIicale lhe pievious sludy. Invenloiies incIuded lhe RILI, lhe
Achenlach ChiId ehavioi CheckIisl, and lhe SpieIleigei Slale Tiail Anxiely ScaIe. Hovevei
nol enough invenloiies veie ieluined lo piovide sufficienl conpIele dala foi anaIysis.
ADHD and Stress:

Thiee coheience-diffeience naps aie piesenled in lhis figuie. In lhe lop iov is coheience duiing lhe 3-
nonlh posllesl ninus laseIine coheience foi lhe deIayed-slail suljecls. The niddIe iov is coheience
duiing lhe 3-nonlh posllesl ninus laseIine coheience foi lhe TM suljecls. The lollon iov is coheience
duiing lhe 6-nonlh posllesl ninus 3-nonlh posllesl foi lhe deIayed-slail suljecls, vho had leen
nedilaling ovei lhis line.
Iig. 1. Coheience naps
@ABABAC >*D%2 */ E*&8*&
Theie veie no significanl diffeiences lelveen gioups fion pielesl lo posl lesl foi lhe
Tovei of London. Theie appeais lo have leen significanl Ieaining effecls in suljecls in
lolh gioups on lhis lesl. As nenlioned alove, The Tovei of London has leen found lo le
Iess consislenl lhan olhei neasuies in dislinguishing specific effecls associaled vilh
ADHD fion lhose ieIaled lo Ieaining disoideis. ConsequenlIy lhis nay nol le a usefuI
neasuienenl foi a popuIalion lhal aIso has eslalIished Ieaining disoideis, as vas lhe case
in lhese sludies.
@ABAFAF 9=GHI- J%2'(. /.+%&#7
Theie veie significanl incieases fion pielesl lo 3-nonlh posllesl in Lellei IIuency foi lhe
TM gioup (I(1,15) = 7.7, p = .O17), and no significanl gioup diffeiences on olhei conponenls
of lhe VeilaI fIuency lesl.

Theie veie aIso significanl incieases in D-KLIS in lhe deIayed-slail gioup aflei lhey Ieained
TM conpaied lo lhe line fion laseIine lo lhe 3-nonlh posllesl (I(1,8) =7.8, p = O.O24).
7. Discussion
Sliess and anxiely can oveivheIn and Iessen lhe effecliveness of lhe individuaI.
Anxiousness conliilules lo pooi inpuIse conlioI, inaliIily lo suslain allenlion, inpaiied
voiking nenoiy, and Iack of cognilive fIexiliIily. This iaises lhe queslion as lo vhelhei, in
sone cases, il is lhe synplons of sliess and anxiely lhal aie leing diagnosed as ADHD.
Whelhei lhese piolIens aie a iesuIl of ADHD oi aie lhe cause of ADHD-Iike synplons,
lhese sludies suggesl lhal ieducing sliess and anxiely ly lhe TianscendenlaI Medilalion
lechnique can polenliaIIy ieduce ADHD synplons and inpiove execulive funclion.
Conpaied lo olhei nedilalion lechniques, lhe TianscendenlaI Medilalion lechnique nay le
pailicuIaiIy suiled lo chiIdien vilh ADHD. Il is easy lo Ieain and is Ieained in Iess lhan an
houi. The lechnique does nol invoIve conlioIIing lhe nind, and once Ieained iequiies no
olhei line inveslnenl lhan lhe 1O-15 ninule sessions lvice a day. Yel changes in lhe liain
aie seen vilhin a shoil line.
The TianscendenlaI Medilalion lechnique can le done anyvheie one can sil and cIose lhe
eyes. Theiefoie il is poilalIe, and a peisonaI neans of seIf-ieguIalion foi ADHD chiIdien.
To naxinize lhe lenefils, lhe ieconnended iouline is one nedilalion session in lhe
noining and one in lhe Iale afleinoon, eveiy day. Incoipoialing lhe TM piogian in a schooI
selling, as vas used foi lhese sludies, piovides an exceIIenl neans of nainlaining ieguIaiily,
lenefiling nol onIy lhe sludenls lul aIso lhe schooI. Teacheis anecdolaI connenls ieveaIed
lhal leacheis veie alIe lo leachei noie, and lhe sludenls veie alIe lo Ieain noie lecause
lhey veie Iess sliessed and anxious.
Wilh iecenl ieseaich shoving ieduced aliIily lo cope vilh sliess and sIovei liain
deveIopnenl in ADHD chiIdien, a lechnique lhal can posiliveIy affecl lolh of lhese faclois
can le a vaIualIe iesouice foi liealnenl of ADHD. The lechnique does nol confIicl vilh
olhei cognilive oi lehavioiaI appioaches, oi vilh nedicalion. Wilh Iess sliess and anxiely,
lhe chiId nay le noie iesponsive lo olhei inleivenlions, polenliaIIy incieasing lheii
effecliveness.
olh sludies veie snaII, lheiefoie ve cannol infei sliong cause and effecl ieIalions lelveen
TM piaclice and ieduclion in ADHD synplons. Hovevei, lhe fiisl sludy incIuded a
nunlei of oljeclive peifoinance lesls of allenlion and execulive funclion lo suppoil seIf-
iepoil invenloiies lhal aie connonIy used lo diagnosis ADHD. This aIIoved foi vilhin-
sludy coiioloialion of iesuIls. The second sludy piovided a sliong sludy design of a
iandonized conlioIIed liiaI.
olh lhe psychosociaI inpiovenenls and inpioved liain funclion seen in lhese sludies aie
consislenl vilh pievious ieseaich on lhe TianscendenlaI Medilalion lechnique. IsychosociaI
ieseaich shovs ieduced anxiely, incieased enolionaI ieguIalion, and inpioved sociaI
lehavioi in non-ADHD sludenls. Sludies of lhe effecl of lhe TM lechnique on execulive
funclion shov incieased fionlaI liain coheience, associaled vilh noie effeclive execulive
funclioning, inpioved allenlion, giealei enolionaI slaliIily, and decieased anxiely.
ADHD and Stress:
These iesuIls suggesl lhal fuilhei ieseaich is vaiianled lo assess lhe inpacl of
TianscendenlaI Medilalion piaclice as a polenliaI liealnenl oplion foi ADHD, eilhei aIone
oi as adjuncl liealnenl. Il vouId le vaIualIe lo iepIicale lhe iesuIls vilh Iaigei gioups, and
fuilhei sludy inpiovenenls in liain coheience and liain deveIopnenl lo gain insighl inlo
lhe undeiIying nechanisns of olseived changes.
8. ConcIusions
The iniliaI piIol sludy iepiesenls lhe fiisl syslenalic sludy of lhe effecls of lhe
TianscendenlaI Medilalion lechnique on lhe synplonaloIogy of ADHD. The iesuIls
indicale lhal TianscendenlaI Medilalion piaclice 1) can le Ieained and successfuIIy
piacliced ly chiIdien vilh ADHD, 2) has lhe polenliaI lo ieduce sliess, anxiely, and sliess
ieIaled ADHD synplons vilhin lhiee nonlhs, and 3) can iesuIl in inpiovenenls in
execulive funclion.
In lhe iandon assignnenl sludy, lhiee nonlhs piaclice of lhe TM lechnique iesuIled in 1)
significanl decieases in lhela/lela ialios, 2) significanl incieases in lhela coheience, and
liends foi incieases in aIpha and lela coheience duiing lasks, and 3) significanl incieases in
Lellei IIuency. The singIe-gioup vilhin anaIysis yieIded siniIai decieases in lhela/lela
ialios and incieases in Lellei IIuency aflei lhe deIayed-slail gioup Ieained TM.
9. AcknowIedgements
The aulhois vouId Iike lo lhank lheii co-invesligaloi WiIIian Slixiud, Ih.D., Depailnenl of
Isychialiy, Ceoige Washinglon Univeisily SchooI of Medicine and HeaIlh Sciences.
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70'622,S*/U "2+6 V2:9+8 3I(1), 65-82.
}ensen, I. S., AinoId, L., Svanson, }. M., VilieIIo, ., Alikoff, H. ., CieenhiII, L. L., el aI.
(2OO7). 3-Yeai IoIIov-up of lhe NIMH MTA Sludy. #'9&5*+ '6 1<2 .H2&0/*5 ./*,2H?
'6 4<0+, *5, .,'+2(/251 >(?/<0*1&? 8 L@ (8), 989-1OO2.
}evning, R., WaIIace, R., & eidelach, M. (1992). The physioIogy of nedilalion: a ieviev. A
vakefuI hyponelaloIic inlegialed iesponse. J29&'(/025/2 *5, 70'S2<*=0'&*+ V2=02)(8
!@, 415-424.
}evning, R., WiIson, A. I., & Davidson, }. M. (1978). AdienocoilicaI aclivily duiing
nedilalion. D'&H'52( *5, 72<*=0'&, LI, 6O3-6O6.
Linnel, K. M., Wisloig, K., Ageilo, L., Sechei, N. }., Thonsen, I. H., & Heniiksen, T. .
(2OO6). CeslalionaI age, liilh veighl, and lhe iisk of hypeikinelic disoidei. .&/<0=2(
'6 N0(2*(2 05 4<0+,<'', , 91, 655-66O.
Lupien, S. }., Iiocco, A., Wan, N., Maheu, I., Loid, C., Schianek, T., el aI. (2OO5). Sliess
hoinones and hunan nenoiy funclion acioss lhe Iifespan. >(?/<'529&'25,'/&05'+':?,
3O (3), 225-242.
MacLean, C. R. K., WaIlon, K. C., Wennenleig, S. R., Levilsky, D. K., Mandaiino, }. I.,
Waziiia, R., el aI. (1997). Lffecls of lhe TianscendenlaI Medilalion piogian on
ADHD and Stress:
adaplive nechanisns: changes in hoinone IeveIs and iesponses lo sliess aflei 4
nonlhs of piaclice. IsychoneuioendociinoIogy, 33ALC8 277-295
McLven, . S. (1998). Iioleclive and danaging effecls of sliess nedialoisZ J2) [5:+*5,
#'9&5*+ '6 R2,0/052, PPMAPC8 171-179.
MoIina, . S., Hinshav, S. I., Svanson, }. M., AinoId, L. L., Lpslein, }. N., Hoza, ., el aI.
(2OO9). The MTA al 8 yeais: piospeclive foIIov-up of chiIdien liealed foi
conlined-lype ADHD in a nuIilsile sludy. #'9&5*+ '6 1<2 .H2&0/*5 ./*,2H? '6 4<0+,
*5, .,'+2(/251 >(?/0*1&? 8 LM (5), 484-5OO.
MoIina, ., IIoiy, K., Hinshav, S., Cieinei, A., AinoId, L., & Svanson, }. (2OO7). DeIinquenl
lehavioi and eneiging sulslance use in lhe MTA al 36 nonlhs: IievaIence, couise,
and liealnenl effecls. #'9&5*+ '6 1<2 .H2&0/*5 ./*,2H? '6 4<0+, *5, .,'+2(/251
>(?/<0*1&? 8 L@ (8), 1O28-1O4O.
Monaslia, V. }., Lulai, }. I., & Linden, M. (2OO1). The deveIopnenl of a quanlilalive
eIeclioencephaIogiaphic scanning piocess foi allenlion deficil-hypeiaclivily
disoidei: ieIialiIily and vaIidily sludies. J29&'K(?/<'+':?8 !B(1), 136-144.
Monaslia, V. }., Lulai, }. I., Linden, M., VanDeusen, I., Cieen, C., Wing, W., el aI. (1999).
Assessing allenlion deficil hypeiaclivily disoidei via quanlilalive
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MTA Coopeialive Cioup. (1999). A 14-nonlh iandonized cIinicaI liiaI of liealnenl
slialegies foi allenlion-deficil/hypeiaclivily disoidei. The MTA Cooipeialive
Cioup. ModaIily Tiealnenl Sludy of ChiIdien vilh ADHD. .&/<0=2( '6 %252&*+
>(?/<0*1&? 8 B@ (12), 1O73-86.
Oine-}ohnson, D.W. (1973). Aulononic slaliIily and TianscendenlaI Medilalion.
>(?/<'('H*10/ R2,0/0528 PB8 341-349.
Oine-}ohnson D., & WaIlon, K. C. (1998). AII appioaches lo pievenling oi ieveising effecls
of sliess aie nol lhe sane. .H2&0/*5 #'9&5*+ '6 D2*+1< >&'H'10'58 !3ABC8 297-299.
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sludenls: a quaIilalive iepoil. [\K+'&28 3ABC, 422-425.
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283.
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419-44O.
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Heiscovilch, I., el. aI.(1993). iain nelaloIisn in leenageis vilh allenlion-deficil
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11
The VaIue of
Coached Behaviour Modification
in the Effective Management of
Attention Deficit Hyperactivity Disorder (ADHD)
TiIIa OIiviei* and Ana Cones
Nc|scn Mandc|a Mc|rcpc|i|an Unitcrsi|q,
Scu|n Africa
1. Introduction
A||cn|icn Dcfici| Hqpcrac|iti|q Discrdcr (aIso iefeiied lo as ADHD) depicls a veiy connon,
chionic, neuiolioIogicaI, nedicaI, liain-lased, lehaviouiaI disoidei (OIiviei, Cones &
CieyIing, 2OO9:237), vilh psychialiic co-noilidilies, such as depiession, anxiely, sulslance
aluse and lehaviouiaI disoideis (Cooding, 2OO7a:4O), oflen conlinuing lhiough chiIdhood
and adoIescence, inlo aduIlhood (Sheinan, Rasnussen & aydaIa, 2OO8:347, Weyandl &
DuIauI, 2OO8:311, Young & Anaiasinghe, 2OO9:116).
Il is lhoughl lo le caused ly an inlaIance of lvo neuioliansnilleis lo lhe liain: dopanine
and seiolonin (Cooding, 2OO7a:4O). Accoiding lo Iaikei & ouleIIe (2OO9:2O4), ADHD is
nov undeislood as peivasive inpaiinenl in lhe seIf-ieguIalion of lehavioui. The nane
ADHD is fiequenlIy enpIoyed as a naikei, vhich Ciahan (2OO8a:85) iefeis lo as a IexicaI
IaleI, foi peopIe vho face significanl difficuIlies, such as Iack of concenlialion,
inpuIsiveness, exliene IeveIs of aclivily and Iack of conlioI (aikIey, 2OO5:36).
ADHD prctai|s in eveiy counliy and elhnic gioup (aikIey, 2OO5:91). Occuiience in Soulh
Afiica coiiesponds vilh lhal in lhe USA and Luiope, vheie il is eslinaled lhal up lo 12 of
schooI-age chiIdien (SandIei, CIesne & CeIIeil, 2OO8:111, Well, Anend, Well, Coeiss,
eIjan, & OIenchek, 2OO5:42), up lo 8 of coIIege sludenls (Weyandl & DuIauI, 2OO8:312),
and up lo 5 of aduIls (IIunei & Slonei, 2OO5:29O, Svailz, Iievall & Iiocloi, 2OO5:647)
suffei fion ADHD.
In lhe Iallei gioup il nanifesls in inallenlion, inpuIsivily, disoiganisalion and a Iack of
seIf-ieguIalion (Svailz, c| a|., 2OO5:647). The nunlei of nev cases iepoiled each day,
knovn as lhe incidence of ADHD, aIso seens lo le on lhe inciease, lul lhis nay le due lo
noie nedia allenlion of Iale (Cones, 2OO8:39). Hovevei, Cooding (2OO7l:37) cIains lhal
cuiienlIy 8O of aduIls vilh ADHD aie undiagnosed and unliealed.
ADHD has inpaiiing ccnscqucnccs foi lhe eveiyday psychoIogicaI, acadenic and sociaI
funclioning (Weyandl & DuIauI, 2OO8:312), as veII as lhe lehavioui of lhe individuaI, lhese,
in luin, fuilhei infIuence lhe individuaIs gioving expeiiences (Sheinan, c| a|., 2OO8: 347,


212
IIunei & Slonei, 2OO5:29O, Well, c| a|., 2OO5:36). The synplons of ADHD aie lhoughl lo le
aggiavaled ly lhe individuaIs expeiiences, neuioIogicaI and nuliilionaI faclois and
enviionnenlaI vaiialIes (Sonna, 2OO5:36).
The piolIens expeiienced incIude cognilive, enolionaI, sociaI, lehaviouiaI and
nolivalionaI deficils (Rief, 2OO5:4, Sleenkanp, 2OO1:72, Svailz, c| a|., 2OO5: 647). These
piolIens iesuIl in Ieaining disaliIilies, seIf-ieguIalion piolIens, exleinaI Iocus of conlioI,
peiceplion, speech and sIeep piolIens, disoiganisalion, Iack of line-nanagenenl skiIIs, lhe
inaliIily lo piioiilise lasks and pooi sliess-nanagenenl skiIIs (aikIey, 2OO5:2OO5, Cooding,
2OO7l:37, OIiviei, c| a|., 2OO9:238) The nanifesling lehavioui piolIens aie ieIaled lo lhe
individuaIs inaliIily lo nainlain lhe IeveI of allenlion necessaiy lo inleinaIise infoinalion,
a highei IeveI of inpalience, lhe inaliIily lo conlioI novenenl and aclivily, and loiedon.
Accoiding lo Svailz, c| a|. (2OO5:647), aduIl ADHD-suffeieis aie pione lo acadenic
undeiachievenenl, diug aluse, pooi occupalionaI adjuslnenl, anli-sociaI lehavioui,
ieIalionship difficuIlies, nood and affeclive disoideis, and peisonaIily disoideis. This is
confiined ly Weyandl and DuIauI (2OO8:312), vho nainlain lhal lhe .iisk foi Iovei
achievenenl scoies, pooi acadenic coping skiIIs in geneiaI, lul especiaIIy in viiling, aie
lhe pievaIenl chaiacleiislics of ADHD-diagnosed coIIege sludenls. They aIso find il difficuIl
lo adjusl lo coIIege Iife and lo foin sociaI ieIalionships.
In oidei lo counleiacl lhe diIennas faced ly ADHD, lhe piesence of ADHD needs lo le
eslalIished lhiough piopei diagncsis. The Aneiican Isychialiic Associalions DSM-IV RT
(2OOO) diffeienliales lelveen lhe foIIoving lhiee sul-lypes: ADHD-I: lhe piedoninanlIy
inallenlive lype, ADHD-HI: lhe piedoninanlIy hypeiaclive-inpuIsive lype, and ADHD-C:
lhe conlined lype. They aIso piovide cIeai indicalois of fuilhei synplons foi diagnosis.
These aie cIusleied aiound lhe lhiee coies of: pooi suslained allenlion, pooi inpuIse conlioI
and apalhy (Cones, 2OO8:27). The diagnosis nusl le done piofessionaIIy ly an expeil and is
nol a sinpIe nallei. Il is leIieved lhal in sone cases paienls conliilule lo lhe diagnosis - in
oidei lo aIIeviale lheii ovn iesponsiliIily and lIane foi lhe chiIds lehavioui, and lo gain
access lo schooI suppoil seivices (Ciahan, 2OO8l:7).
Nuneious dcfini|icns of ADHD in lhe Iileialuie aIso iefei lo lhe specific syndione
chaiacleiislics of inallenlion, hypei-iesponsiveness, inpuIsivily, pooi inhililion and
lediousness (Rief, 2OO5: 4). Iuilheinoie, lhe Iileialuie nenlions chaIIenges such as
enolionaI oulluisls, enlhusiasn shoilages, Iov seIf-esleen, and difficuIly vilh piolIen-
soIving (Aleison, Shuie & CoIdslein, 2OO7: 291, OIiviei, c| a|., 2OO9: 237).
Hovevei, in lhis chaplei ve aigue lhal a definilion lhal focuses on lhe chiIds diffeiences as
s|rcng|ns, ialhei lhan as deficiencies, indicales lhal ADHD is lhe iesuIl of high
iesponsiveness and sliong aIeilness. In luin, lhe individuaIs ciealivily and expiession aie
enhanced, vhich nay le fuilhei conpIenenled ly incieased noloi novenenl, inlensified
heaiing capacily, lacliIe sensilivily, alove-aveiage peiipheiaI vision and vuIneialIe
enolionaI laIance (Cones, 2OO8:31).
The diagnosis can aIso shed Iighl on lhe specific slienglhs of lhe individuaI lo diiecl and
ieinfoice duiing lhe nanagcncn| of ADHD. Seen fion such a vievpoinl, ADHD lhen
lecones noie nanagealIe lhan vhen il is peiceived as a deficiency (Well, c| a|., 2OO5:1OO).
This is pieciseIy vhal viII deleinine and diiecl lhe nanagenenl appioach.
The Value of Coached Behaviour Modification
in the Effective Management of Attention Deficit Hyperactivity Disorder (ADHD)

213
The foIIoving peilinenl qucs|icn, lheiefoie, lecones ieIevanl:
Hcu can ADHD-rc|a|cd ocnaticur oc cffcc|itc|q nanagcd?
2. Management of ADHD
Againsl lhe lackgiound discussed alove, il lecones appaienl lhal lhe individuaI diagnosed
vilh ADHD expeiiences najoi chaIIenges, vhich nake il difficuIl lo nanage lhe
individuaIs lehavioui (Aleison, Shuie & CoIdslein, 2OO7, aikIey, 2OO5, Rief, 2OO5, OIiviei,
c| a|., 2OO9: 237). The individuaIs ieguIai unacceplalIe and/oi inappiopiiale conducl oflen
iesuIls in fuilhei aggiavaled piedicanenls foi vhich soIulions nusl conslanlIy le found
(}ohnslon & Mash, 2OO1, Khanis, 2OO6).
ADHD is a conlinuing, chionic disoidei, vhich is nol cuialIe, lul il is liealalIe and
nanagealIe - lhiough lhe iighl inleivenlion and nanagenenl appioach (}ackIyn &
Ravichandian, 2OO9:1O57, Cooding, 2OO7a:4O). Many diffeienl slialegies foi inleivenlion and
appioaches lo lhe liealnenl of ADHD exisl. When iefeiiing lo lhe nanagenenl of ADHD,
lhis inpIies, nol onIy finding lhe lesl possilIe nelhod of inleivenlion, lul aIso lhe
inpIenenlalion and noniloiing lheieof (Cones, 2OO8:55, Rief, 2OO5: 29).
Iiogiannes foi nanaging ADHD shouId le fIexilIe, lo aIIov foi fiequenl adjuslnenl lo
lhe individuaIs specific needs. A piogiannes puipose and effecliveness shouId aIso le
assessed and inpioved conlinuousIy, in oidei lo ensuie lhal il ienains effeclive and
ieIevanl (Cones, 2OO4:126).
No singIe appioach exisls lhal can soIve lhe difficuIlies of ADHD (Heiiol, Lvans & Ioslei,
2OO7:121). Accoiding lo Ciahan (2OO8l:17), ADHD cones lo le undeislood lhiough a lio-
psycho-sociaI lheoielicaI fianevoik. The nanagenenl of ADHD shouId lheiefoie le
nu||incda| in naluie (Ciahan, 2OO8l: 2O, Sheinan, c| a|., 2OO8:348, Cooding, 2OO7a:4O,
Heiiol, c| a|., 2OO7:121), lecause a conlinalion of appioaches seens lo le noie effeclive
vilh lhe lioIogicaI, as veII as lhe sociaI-enolionaI aspecls of ADHD. Il incIudes lhe
foIIoving:
2.1 PhysicaI assessment
efoie any nanagenenl of lhe disoidei can connence, lhe individuaI has lo undeigo a
lhoiough physicaI check-up ly a cIinician, lo asceilain lhe individuaIs geneiaI heaIlh
condilion in conpaiison vilh lhe noin, and lo fuilhei ensuie lhal lhe synplons leing
expeiienced aie nol caused ly olhei iIInesses oi deficiencies (Young & Anaiasinghe,
2OO9:116).
2.2 MedicaI/pharmacoIogicaI approaches
Il is usuaIIy leIieved lhal ADHD can lesl le nanaged ly neans of liochenicaI liealnenl,
depending on lhe needs, nass and age of lhe individuaI invoIved (HaIIoveII & Raley,
1995:238). This is iefeiied lo as lhe fiisl-Iine appioach (Ciahan, 2OO8a:92, Ciahan,
2OO8l:19). Medicalion is consequenlIy oflen piesciiled lo inpiove allenlion and lo ieduce
hypeiaclivily. Hovevei, nedicalion liealnenl is usuaIIy noie effeclive vhen coupIed vilh
coached lehavioui nodificalion.


214
ased on lhe nedicaI nodeI (Ciahan 2OO8a: 85, Ciahan, 2OO8l:19) and lecause il is
leIieved lhal lhe nedicalion viII inciease lhe IeveI of dopanine and noiepinephiine
lelveen lhe synapses oi neuioliansnilleis of lhe liain, piesciiplions foi slinuIanls, such
as RilaIin and Conceila, have incieased ovei line (Ciahan, 2OO8a:86.87). Ciilicisn againsl
lhe nedicaI nodeI is lhal il appeais lo accepl lhe 'disoideied chiIdien as having IillIe oi
no conlioI ovei lheii aclions (Ciahan, 2OO8l: 21).
Many voices of concein aie spiinging up againsl lhe use of nedicalion (Lakoff, 2OOO: 15O,
SandIei & odfish, 2OO8:1O5, Weyandl & DuIauI, 2OO8:316) and lhe oveiuse of slinuIanl
lheiapy (SandIei c| a|., 2OO8:111), as il is nol guaianleed lo lenefil aII cases in a siniIai oi a
posilive vay (IIunei & Slonei, 2OO5:29O). In lhis iegaid, (2OO8a:9O) iefeis lo lhe
(dis)iIIusion and lhe paiadoxicaI effecl of nedicines.
The Iong-lein posilive effecls of nedicalion have nol leen indispulalIy pioven (Heiiol, c|
a|., 2OO7:121, SandIei, c| a|., 2OO8:111, Young & Anaiasinghe, 2O1O:127), and aie nol
necessaiiIy Iong-Iasling, as lhey cease vilhoul lhe nedicalion, oflen iesuIling in noie
agilalion and anxiely (Cones, 2OO8:94). Iuilheinoie, in lhe case of lhe aluse of nedicine,
addiclion lecones a dangei (Covan, 2OO2). These slinuIanls aIso have iepoiled noninaI
liealnenl-eneigenl side-effecls (SandIei, c| a|., 2OO8:111), such as sIeep disluilance, appelile
suppiession and veighl changes, enolionaI inslaliIily, giovlh ielaidalion and headaches
(aikIey, 2OO5:269, Ciahan, 2OO8:9O).
Yel, despile aII lhe concein, lhe consunplion of nedicine foi ADHD-ieIaled synplons is
sliII incieasing (Ciahan, 2OO8a: 86). Sone physicians suggesl lhal lhe nedicalion shouId nol
le used conlinuousIy, in oidei foi lhe individuaI lo Ieain lo nanage ADHD vilhoul il
(MehI-Madiona, 2OO5: 1). This conliilules lo lhe gioving use of conpIenenlaiy and
aIleinalive appioaches in lhe liealnenl of ADHD (SandIei, c| a|., 2OO8a:111)
Ncurc|ncrapq, aIso knovn as LLC liofeedlack oi neuiofeedlack liaining, is an allenpl lo
noinaIise ADHD liainvave iesponses lo slinuIi, and il is seen as, an effeclive aIleinalive
lo slinuIanl nedicalion (Sleenkanp, 2OO1:95). Il leaches lhe individuaI lo focus on his/hei
liainvave nolions, appIying svifl conpuleis, vhich nake avaiIalIe lolh audiloiy and
visuaI feedlack, unfoilunaleIy al high cosl, lecause of lhe expensive equipnenl used
(Sonna, 2OO5:143).
Dic|arq inleivenlion is aIso an allenpl lo heIp deciease lhe synplons of ADHD, especiaIIy
lhe aspecl of ieslIessness (DAdano, 2OO1:133). Iuilheinoie, nu||iti|anins aie used lo
suppIy vhal lhe liains needs foi piopei funclioning (Sonna, 2OO5:41). Hcnccpa|nic
ncdica|icn is aIso uliIized in an allenpl lo conlioI lhe synplons of ADHD, lul il lakes a
Iong line lo shov effecls, and is lheiefoie Iess popuIai (aikIey, 2OO5: 269). Iuilheinoie,
csscn|ia| fa||q acids, such as fish oiI, can conliilule lo lhe individuaIs veIIleing (Sonna,
2OO5:39), vhiIe speciaIIy coIouied cqcg|asscs can inpiove lhe visuaI peiceplion (Cones,
2OO8:1O4) of lhe individuaI diagnosed vilh ADHD.
Il is a veII-knovn facl lhal nedicalion aIone is insufficienl in lhe nanagenenl of ADHD,
and has faiIed lo piovide a soIulion lo lhe 'piolIen il vas neanl lo soIve (Ciahan,
2OO8a:92). Lach individuaI is a unique leing vilh unique needs and slienglhs. Thal is vhy a
nuIlinodaI appioach, naneIy a conlinalion of appioaches ly a nuIlidiscipIinaiy lean of
speciaIisls, usuaIIy piovides lhe lesl iesuIls (Young & Anaiasinghe, 2OO9:116).

215
2.3 RemediaI and educationaI measures
ased on lhe vilhin-lhe chiId deficil-nodeI (Ciahan, 2OO8a:91), schooI-going Ieaineis
diagnosed vilh ADHD aie oflen assisled in deaIing vilh schooI-ieIaled chaIIenges, such as
adjusling lo schooI, oi voiking oul honevoik scheduIes, lhiough ienediaI leaching and
lhe leaching of Ieaining and coping slialegies (Rief, 2OO5:57).
Isycho-educalionaI nanagenenl iefeis lo lhe enphasis of lhe Ieaineis Ieaining aliIilies in
ieIalion lo his/hei oveil lehavioui (Riding & Raynei, 2OO5:1OO). CIassioon acconnodalions
incIude neasuies, such as iecoided lexllooks and nole-laking seivices, as veII as suppoil
gioups and individuaI counseIIing (Svailz, c| a|., 2OO5:648). The assislance of a ienediaI
speciaIisl, speech lheiapisl and an occupalionaI lheiapisl can le vaIualIe vilh iegaid lo
peicepluaI and co-oidinalion difficuIlies (Rief, 2OO5:233, Sonna, 2OO5:15), again confiining lhe
significance of a nuIlidiscipIinaiy lean and a nuIlinodaI appioach foi lhe nanagenenl of
ADHD (Heiiol, c| a|., 2OO7:121, Cooding, 2OO7a:4O, Ciahan, 2OO8a:92).
2.4 PsychoIogicaI management
The poinl of depailuie of lhe psychoIogicaI nodeI is lhal lhe chiId can exeil oi |carn seIf-
conlioI (Ciahan, 2OO8l: 21). A piofessionaI psychoIogisl usuaIIy undeilakes a piopei
assessnenl lo eslalIish lhe individuaIs enolionaI slaliIily and peiceplion. Theiapy and
counseIIing aie oflen used in an allenpl lo aIIeviale lhe piolIens ieIaled lo lhe disoidei
(MacCiav, 2OO5:15).
This vouId incIude fani|q |ncrapq (HaIIoveII & Raley, 1995:136), as veII as inditidua| |ncrapq
foi lhe diagnosed individuaI and olhei individuaIs invoIved in lhe case, such as lhe paienls.
LnolionaI and sociaI suppoil aie ciuciaI foi lhe piopei undeislanding of ADHD, good
connunicalion, heaIlhy ieIalionships and luiIding lhe individuaIs seIf-esleen, ly focusing
on posilive, ialhei lhan negalive aspecls, as veII as uncoveiing and piaclising exisling
slienglhs (HaIIoveII & Raley, 1995:144, LavIis, 2OO4:249, Rief, 2OO5:84, Sonna, 2OO5:72).
Ccgni|itc ocnaticura| lheiapy (Ciahan, 2OO8a:92), such as ialionaI-enolive lheiapy (RLT),
can le done - in oidei lo nanage lhe synplons of ADHD. This invoIves lhe exaninalion
and inpioving of lehaviouis and inleiaclion lhiough skiIIs leaching and posilive
ieinfoicenenl (MacCiav, 2OO5:64, Rief, 2OO5:61). Cognilive lheiapy is especiaIIy usefuI foi
aduIl suffeieis of ADHD, lecause nol aII peopIe can Ieain effeclive slialegies lo oveicone
lheii chaIIenges (Young & Anaiasinghe, 2OO9:126). Hovevei, lhe success of cognilive
lheiapy is doullfuI vhen appIied ly ilseIf, lecause of ils focus on cognilive, ialhei lhan
educalionaI inleivenlions (Ciahan, 2OO8a:93).
Aflei consideialion of aII lhe alove-nenlioned appioaches, lhis chaplei sliongIy aigues foi
ocnaticur ncdifica|icn lo le doninanl in lhe nuIlinodaI appioach lo ADHD, lo enalIe lhe
individuaI lo Ieain nev sociaIIy appioved lehaviouis - inpIenenled duiing lheiapy and
ieinfoiced al hone, in lhe schooI and in lhe sociaI enviionnenl, as viII le discussed in lhe
nexl seclion.
3. Behaviour modification as a way of managing ADHD
The chaIIenges expeiienced ly lhe individuaI diagnosed vilh ADHD aie a ieaIily lhal nusl
le faced on a daiIy lasis, ly aII peopIe invoIved vilh lhe individuaI. ehavioui cannol


216
easiIy le aIleied, lecause il can le deleinined ly heiedily, oi sliongIy engiained, lul
shouId le nodified lo iendei il noie acceplalIe, in oidei lo heIp lhe individuaI vilh ADHD
lo Iive a fuIfiIIed Iife in sociely, as an accepled hunan leing (Cones, 2OO8:98).
ConsequenlIy, lehavioui nodificalion is oflen appIied lo anend lhe unacceplalIe and/oi
inappiopiiale lehavioui (Sonna, 2OO5:153).
3.1 What is behaviour modification?
ehavioui nodificalion is a lheiapeulic inleivenlion piaclice, invoIving lheiapeulic
lechniques lased on lhe lheoiy of opeianl condilioning of Skinnei and olhei lehavioui-
Ieaining lheoiies (Cales, NeveII & Wiay, 2OO1:86). These lheoiies aie giounded in lhe liulh
lhal Ieaining liings aloul change in lehavioui, ly neans of lhe nelhodicaI and
condilioned uliIizalion of posilive oi negalive ieinfoicenenl.
When a specific slinuIus-iesponse pallein is conlingenlIy ieinfoiced, lhe individuaI is
condilioned lo iespond (Hukandad, Shahzad, AIi, Quadeei & Khan, 2O11:9O4).
Reinfoicenenl is acconpIished ly neans of anylhing lhal viII slienglhen lhe desiied
iesponse, oi veaken lhe undesiied iesponse.
This appioach enlaiIs a lechnique vheiely inpiopei and inappiopiiale conducl is
sulsliluled ly a noie acceplalIe aIleinalive (Cones, 2OO8:99). The foui lasic piincipIes of
lhe lheoiy aie: posilive ieinfoicenenl, negalive ieinfoicenenl, punishnenl and exlinclion
(Hukandad, c| a|., 2O11:9O4). ehavioui nodificalion can le dislinguished fion olhei
lechniques ly lhe facl lhal il focuses onIy on olseivalIe, desciilalIe and neasuialIe
lehaviouis (Snilh, 2O11:1).
Thiough lhis appioach syslenalic allenpls aie nade lo nodify oi slienglhen lhe
piolaliIily of lhe occuiience of lehavioui, ly ieinfoicing desiied lehavioui, and
discouiaging oi ignoiing undesiialIe lehavioui. AII allenlion is consideied lo le
ieinfoicing, vhelhei posilive oi negalive. Hovevei, piaise and ievaids aie noie oflen used
lhan punishnenl and ignoiing - lo acconpIish lhe goaIs of lehavioui nodificalion.
Iunishnenl iefeis lo an unpIeasanl slinuIus aflei undesiialIe lehavioui, vhiIe a ievaid
iefeis lo a pIeasanl slinuIus upon desiialIe lehavioui.
3.2 Why is behaviour modification needed?
ehavioui nodificalion is effecliveIy used lo lieal nany disoideis and can le veiy vaIualIe
in nanaging ADHD (Davies & Wille, 2OOO:135). Il oflen happens lhal peopIe, such as lhose
diagnosed vilh ADHD, aie lianded as voilhIess oi Iessei individuaIs (LavIis, 2OO4:55). As
a iesuIl, lhey deveIop a Iov seIf-concepl and seIf-peiceplion of leing unalIe lo funclion
piopeiIy and leing inconpelenl and palhelic, fuilhei aggiavaling lheii deficienl
chaiacleiislics (Levine, 2OO2:327).
Inslead, lheii s|rcng|ns shouId le uncoveied, focused on and fuilhei ieinfoiced, ly neans of
lehavioui-nodificalion lechniques. Ioi lhal ieason lehavioui nodificalion can le used
effecliveIy.
Iiopei lehavioui and inleiaclion can le laughl (Sonna, 2OO5:153). IeopIe invoIved vilh lhe
ADHD-diagnosed individuaI shouId Ieain lo iespond lo lhe ADHD-diagnosed individuaI
diffeienlIy (aikIey, 2OO5:1O6). Ioi exanpIe, posilive veilaI piaise, vhen juslified and

217
consislenlIy given, can le suipiisingIy effeclive. Accoiding lo IIunei and Slonei (2OO5:291),
lhe leaching of appiopiiale sociaI skiIIs viII advance lhe individuaIs geneiaI sociaI
funclioning.
3.3 How is behaviour modification done?
ehavioui nodificalion can le used in conjunclion vilh any olhei neans foi lhe
nanagenenl of ADHD-ieIaled lehavioui, and il can le ieinfoiced al hone, schooI oi in
olhei sociaI sellings (aikIey, 2OO5:242, LavIis, 2OO4:262, Rief, 2OO5:165, Sheinan, c| a|.,
2OO8:348). Il enlaiIs ceilain neasuies aie used lo lolh ieinfoice and slienglhen lhe
appiopiiale lehavioui, oi lo ieduce and discouiage any lehaviouiaI difficuIlies. LxanpIes
of posilive ieinfoicenenls aie ievaids, such as piaise, appiovaI, nodeIIing, and shaping.
This does nol onIy appIy lo lhe ADHD-diagnosed individuaI, lul aIso lo lhe paienls,
silIings and olhei peopIe invoIved vilh lhe individuaI (NeelhIing, Rulheifoid & Schoenan,
2OO5:32).
The naluiaI lendency lo focus onIy on lhe posilive ievaid, can le laIanced ly a
conlinalion of ievaids and punishnenls, knovn as iesponse cosl (Hukandad, c| a|.,
2O11:9O4), vhich viII assisl in decieasing lhe individuaIs inpuIsive incIinalions. Revaids
shouId le langilIe, especiaIIy foi youngei ADHD-suffeieis, lhey shouId le gianled
fiequenlIy, and lhe feedlack shouId innedialeIy foIIov lhe lehavioui (lhe cIosei, lhe
lellei), in oidei lo aIIov lhe individuaI lo nake lhe necessaiy associalions (Young &
Anaiasinghe, 2OO9:117). Hukandad, c| a|., (2O11:9O8), aIso enphasize lhal ievaids oi
punishnenl shouId innedialeIy foIIov lhe lehavioui, and lhey shouId le consislenl and
faii.
Parcn| |raining foins a ciuciaI pail of lhe appioach (Young & Anaiasinghe, 2OO9:121). This
shouId enhance paienling skiIIs and assisl paienls in deaIing vilh lheii chaIIenges ly neans
of appiopiiale lehaviouiaI lechniques and inleivenlion skiIIs. They need ieIevanl
infoinalion and lehaviouiaI slialegies lo inpIenenl al each IeveI of lhe chiIds
deveIopnenl (Young & Anaiasinghe, 2OO9:118).
This vouId incIude lhe idenlificalion and nanipuIalion of lehaviouis, lhe laigeling and
noniloiing of piolIenalic lehavioui, ievaids foi appiopiiale lehavioui, such as piaise,
posilive allenlion, langilIe ievaids, oi a deciease in unvanled lehaviouis lhiough line-
oul, and effeclive connands, appiopiiale ievaids, innediale feedlack and posilive
ieinfoicenenl (Hukandad, c| a|., 2O11:9O5). Iaienls shouId aIso guaid againsl iisk faclois,
such as depiession, naiilaI luinoiI, and Iack of suppoil, ly neans of open discussion,
appiopiiale infoinalion, lasic coping slialegies, suppoil gioups and counseIIing (Young &
Anaiasinghe, 2OO9:118, Cones, 2OO8).
In lhe scncc| enviionnenl, veII-sliucluied ioulines, iuIes and expeclalions aie iequiied ly
lhe ADHD-diagnosed individuaI, as veII as lhe caiefuI allenlion of lhe leachei (Rief,
2OO5:165). ReaIislic acadenic laigels and lehavioui goaIs can seive as nolivaling faclois
(Young & Anaiasinghe, 2OO9:118). AppiovaI can le as sinpIe as a nod of lhe head, oi a
veilaI sound, such as 'Mnnn, oi a connenl, such as 'veII done. LnviionnenlaI
nanipuIalions can aIso le inpIenenled, foi exanpIe, sealing lhe chiId avay fion any
souice of disliaclions.


218
The co-opeialion lelveen schooI and hone is inpoilanl, and ieguIai conlacl shouId le
scheduIed lo assess lhe specific needs, piogiess and inleivenlion pioceduies. Wheie
possilIe and necessaiy, individuaIised appioaches viII le noie successfuI and a
conlingency conliacl piogianne can le appIied (Hukandad, c| a|., 2O11:9O6). Il is
possilIe foi lhe individuaI lo Ieain lo appIy skiIIs, such as naking eye conlacl, giving
conpIinenls, laking luins, Iislening, piolIen-soIving, veilaI insliuclion ('lhinking oul
Ioud), oleying iuIes, leanvoik, using line scheduIes, seIf-noniloiing, enolionaI conlioI,
and seIf-ieinfoicenenl (Young & Anaiasinghe, 2OO9:119-12O).
ehavioui lhal is slienglhened viII iecui, vhiIe lehavioui lhal is nol ievaided viII
piolalIy fade avay. Accoiding lo Sheinan, c| a|. (2OO8:347), gesluies used ly peopIe
invoIved vilh lhe ADHD-diagnosed individuaI, can infIuence lhe individuaIs peifoinance,
foi exanpIe, vilh acadenic puzzIes. IeopIe vilh noie loIeiance and acquainlance vilh
inleivenlion lechniques, vho can voik veII and co-opeiale vilhin a nuIli-discipIinaiy lean
of speciaIisls and vho have a posilive nindsel, can aIso infIuence lhe deveIopnenl of a
noie posilive oulcone foi lhe individuaI diagnosed vilh ADHD (Sheinan, c| a|., 2OO8:347).
Many skiIIed speciaIisls considei lehavioui nodificalion as leing lhe nosl appiopiiale
insliunenl in lhe nanagenenl of ADHD-ieIaled lehavioui (Davies & Wille, 2OOO:135).
IeopIe invoIved vilh ADHD-diagnosed individuaIs shouId assenlIe as nuch infoinalion
as possilIe aloul lehavioui nodificalion - in oidei lo inciease lheii focus on any exisling
s|rcng|ns, ialhei lhan on lhe deficiencies (Rief, 2OO5:14). Iosilive allenlion can le used
effecliveIy as ieinfoicenenl, foi exanpIe, ly piaising veII-neanl allenpls and iefocusing oi
iediiecling any faiIed effoils (Cones, 2OO8:1OO).
4. Coaching as a way of managing ADHD
ADHD coaching is lased on lhe coaching nodeI used in alhIelics and Iife-skiIIs coaching
(Svailz, c| a|., 2OO5:648). Coaching is an inpoilanl and ieIaliveIy nev piofession (Cales, c|
a|., 2OO1:87, Muiphy, Raley, Maynaid, Sussnan & Wiighl, 2O1O:546, Iaikei & ouleIIe,
2OO9:2O5). Iaienls, caiegiveis and leacheis have leen coaching ADHD-diagnosed chiIdien
foi a Iong line, in oidei lo nanage lheii lehavioui, lul no-one has evei lhoughl of lhis
aclion in leins of a sliucluied slialegy, unliI iecenlIy, vhen lhe lein vas coined vilh
iegaid lo psychoIogicaI supeivision, suppoil and goaI achievenenl.
In 2OO2, a lask foice of coaches oiganized ly lhe Allenlion Deficil Disoidei Associalion
(ADDA) viole: "The Cuiding IiincipIes foi Coaching IndividuaIs vilh Allenlion Deficil
Disoidei" (}aksa & Raley, 1999). This docunenl suggesls eIenenls lhal shouId le consideied
as essenliaI lo ADHD coaching, il eslalIishes slandaids and oulIines lhe elhicaI piincipIes
iequiied lo heIp peopIe lellei undeisland ADHD coaching. Appiopiiale coaching nol onIy
piovides supeivision and suppoil, lul il aIso gives a sense of accounlaliIily and consislency.
The lopic of ADHD coaching cuiienlIy enjoys incieased favoui, even lhough il has nol yel
leen ieseaiched exlensiveIy, and lhe effecliveness has nol pioven ly nany enpiiicaI
ieseaich sludies (Muiphy, c| a|., 2O1O:546). Ioi lhe Iallei ieason, sone scienlisls ienain
sceplicaI aloul lhis appioach (Svailz, c| a|., 2OO5:648). Hovevei, seveiaI ieseaich sludies
(HoIIin & IaInei, 2OO6, }ones & McCaughey, 1992, }oidan, Singh & Repp, 1989, Slevenson,
Whilnonl, oinhoIl, Livesey & Slevenson, 2OO2, Zvail and KaIIenyn, 2OO1,) have pioduced
cIeai evidence of success vilh coaching.

219
4.1 What is coaching?
Davson and Cuaiies coaching nodeI (2OOO) is a pionising, innovalive appioach lo ADHD-
ieIaled difficuIlies (IIunei & Slonei, 2OO5:292, Svailz, c| a|., 2OO5:648). Young and
Anaiasinghe (2O1O:126) see coaching as a deiivalive of cognilive lehaviouiaI paiadigns,
lased on a coIIaloialive nenloiing pailneiship, vhich diavs on an individuaIs peisonaI
slienglhs, and ains lo piovide sliucluie, suppoil and feedlack.
This vouId enlaiI lhe necessaiy enphalic and genlIe psychoIogicaI suppoil and supeivision
(CaiioII, 2OO6:4) foi skiIIs deveIopnenl, piolIen-soIving and lhe nanagenenl of ovn line
and aclions, ly neans of significanl conpIex dyadic inleiaclions (Cales, c| a|., 2OO1:87).
This appioach shouId heIp lo nanage lhe synplons of ADHD, as veII as in pioviding lhe
encouiagenenl lo independenlIy deveIop inleinaI and exleinaI sliucluies foi laking
iesponsiliIily foi ieaching specificaIIy sel goaIs (}aksa & Raley, 1999, Iaikei & ouleIIe,
2OO9:2O5).
IIunei and Slonei (2OO5:292) conlend lhal coaching is lased on coiiespondence liaining,
focusing - as il does - on lhe ieinfoicenenl of lehavioui lhal coiiesponds vilh lhe sel goaIs.
Accoiding lo Svailz, c| a|. (2OO5:648), lhis piocess of olseivalionaI Ieaining slienglhens
lhe individuaIs aliIily lo independenlIy counleiacl any ADHD synplons. Al lhe sane
line, lhe individuaI gains seIf-efficacy, as veII as lhe incieased seIf-confidence needed lo
ieach his/hei goaIs.
Coaching, vilh iefeience lo ADHD, invoIves a coIIaloialive aIIiance (Young &
Anaiasinghe, 2O1O:127). Il invoIves lhe supeivision of lehavioui, slialegies and lasks, ly a
peison lo vhon lhe ADHD-diagnosed individuaI nusl le accounlalIe - vhelhei lhe
ADHD-diagnosed individuaI le an aduIl oi a chiId. CIeaiIy, lhe coaching piincipIes nusl
ienain lhe sane, il is lhe slialegies and lasks lhal have lo le age-appiopiiale, and need-
specific (ADDA, 2OO2, Quinn, Raley & MailIand, 2OOO, WaIIace, 1998).
The lasis of coaching is lhal lhe coach and lhe ADHD-diagnosed individuaI shouId voik
logelhei lo sel goaIs and deveIop lhe looIs, slialegies and confidence necessaiy lo heIp lhe
individuaI oveicone lhe lehavioui difficuIlies encounleied, and lo iepIace any
unacceplalIe lehavioui vilh lhe coiiecl lehavioui foi lhe specific silualion (HaIIoveII &
Raley, 1994, }aksa & Raley, 1999, Svailz, c| a|., 2OO5:648).
4.2 Why is coaching needed?
Accoiding lo lhe Diagnoslic Ciileiia fion DSM-IV-RT (2OOO) and lhe Diagnoslic and
SlalislicaI ManuaI of MenlaI Disoideis (1994), execulive funclioning issues, such as line
nanagenenl, piioiilizalion, piociaslinalion, and ieaIislic vievs of a lask oi silualion aie
anong lhe nany aspecls vhich cause lehaviouiaI difficuIlies foi lhose diagnosed vilh
ADHD (Aneiican Isychialiic Associalion, 2OOO, Aneiican Isychialiic Associalion, 1994).
Olheis in lhe Iisl piovided ly lhe DSM-IV incIude diffeiences in Ieaining slyIes lelveen
paienls and chiIdien, Ieaining disaliIilies iesuIling fion lhe inaliIily lo piocess and ielain
infoinalion, lhe inaliIily lo pay allenlion foi Ienglhy peiiods of line, lhe inaliIily lo ollain
and oiganise infoinalion, lhe inaliIily lo seIf-ieguIale and seIf-noniloi ovn lehaviouis and
lendencies, lhe Iack of accounlaliIily, lhe inaliIily lo foin and nainlain Iasling ieIalionships
(Aneiican Isychialiic Associalion, 2OOO, Aneiican Isychialiic Associalion, 1994).


220
These aieas of concein aie lypicaIIy addiessed ly neans of lehavioui- nodificalion
coaching.
Coaching is an exceIIenl looI foi paienls of snaII chiIdien vho have leen diagnosed vilh
ADHD, and aIso foi lhe aduIl sliuggIing vilh oiganisalionaI and line-nanagenenl aspecls,
lolh in lhe piivale, as veII in lhe piofessionaI seclois of daiIy Iife (}aksa & Raley, 1999,
IIunei & Slonei, 2OO5:292, Svailz, c| a|., 2OO5:648). Coaching heIps lolh chiIdien and aduIls
suffeiing fion ADHD-ieIaled difficuIlies, lo focus on lhe vaiious aspecls of lheii lask,
vilhoul lhe feeIing lhal lhey aie leing iepiinanded oi 'lossed aiound, as in lhe case of
chiIdien, and ciilicized and picked on, as in lhe case of aduIl suffeieis (Chionis, Chacko,
Ialiano, Wynls & IeIhan, 2OO4).
Coaching heIps individuaIs lo concenliale lellei on specific aspecls and peisonaI s|rcng|ns,
oflen nol olvious. IiequenlIy, in such inslances, incoiiecl lehaviouis aie Ieained as
nechanisns foi coping vilh peiceived difficuIl silualions. Coaching can lhen ie-diiecl and
coiiecl incoiiecl lehavioui halils (Quinn, c| a|., 2OOO). Oflen lhe oidei of inpoilance of a
lasks sleps eIudes an individuaI conpIeleIy, iesuIling in eiiois, accidenls and fiuslialing
deIays.
Coaching heIps in lhe eIininalion of lhe fiuslialion of lask ie-diieclion, and il leaches lhe
ADHD-diagnosed hov lo deveIop lhe aliIily lo sel goaIs and keep lo lhe ains iequiied lo
conpIele lhe lask. eai in nind lhal lhe najoi piolIens of ADHD aie lhe Iack of
oiganizalionaI skiIIs and consislency, nuluaI iespecl, liusl and conpaliliIily. These aie key
aspecls of lhe coaching piocess designed lo foslei accounlaliIily and iesponsiliIily, and lo
nininise feai of faiIuie, Iack of seIf-esleen and Iack of seIf-confidence on lhe pail of lhe
ADHD-diagnosed individuaI (}aksa & Raley, 1999).
Coaching heIps individuaIs of aII ages lo nake posilive, Iasling changes lhal viII inpacl
lheii Iives Iong aflei lhey Ieave schooI and enlei aduIl Iife. Chionis, c| a|. (2OO4), confiins
lhal coaching leaches individuaIs diagnosed vilh ADHD hov lo deveIop lhe necessaiy
coiiecl skiIIs lhal lhey viII need lo enpIoy lhioughoul Iife. Thiough coaching, lhe
individuaI gains lhe iesponsiliIily lo funclion independenlIy (IIunei & Slonei, 2OO5:298)
and deveIops lhe seIf-ieguIaling skiIIs needed foi seIf-deleininalion and lhe seIf-
nanagenenl of ADHD-ieIaled chaIIenges (Iaikei & ouleIIe, 2OO9:2O5). Il can aIso
effecliveIy assisl lhe individuaI vilh piolIens, such as piociaslinalion, Iack of
concenlialion, pooi pIanning, anxiely, sociaI inconpelence oi line nanagenenl (Svailz, c|
a|., 2OO5:648).
4.3 How is coaching done?
Coaching noinaIIy invoIves paiiing an individuaI (chiId oi aduIl) diagnosed vilh ADHD
vilh anolhei peison, vho lhen seives as his/hei coach (IIunei & Slonei, 2OO5:292).
Thiough lheii nindfuI invoIvenenl (CaiioII, 2OO6:4) lhey finaIise goaIs, suggesled ly lhe
individuaI diagnosed vilh ADHD, aflei vhich lehavioui noniloiing, supeivision,
encouiagenenl and suppoil, piovision of feedlack, as veII as conlingency nanagenenl
foIIovs, vilh lhe ain of Ieaining nev and appiopiiale lehavioui.
ADHD coaches aie usuaIIy lhose cIosesl lo lhe ADHD-diagnosed individuaI, i.e. lhe
paienls, oIdei silIings, peeis and leacheis, aIlhough lheie nay aIso le sone lheiapisls and

221
olhei piofessionaIs invoIved in lhe individuaIs coaching. The nosl inpoilanl poinl is, lhal
hovevei nany diffeienl peopIe coach any one individuaI al diffeienl lines of lhe daiIy
iouline, lhal lhey shouId aII le synchionised and in agieenenl on lhe lype of coaching, as
veII as on lhe iequiienenls and lhe slialegies leing used. This viII pievenl confusion and
fiuslialion of aII conceined (Cones, 2OO8, }aksa & Raley, 1999, Svailz, c| a|., 2OO5:648).
Togelhei, lhe coach and lhe individuaI diagnosed vilh ADHD undeilake difficuIlies, such
as line-nanagenenl and piolIen-soIving (Svailz, c| a|., 2OO5:648).
IieciseIy hov ADHD coaching is done viII depend on vho is leing coached and vho is
doing lhe coaching. When deaIing vilh cni|drcn diagnosed vilh ADHD, paienls, leacheis
and sonelines oIdei silIings, peeis oi caiegiveis can seive as coaches, and lhe coaching
voik shouId le done on a daiIy lasis, in lhe foin of guidance, ienindeis and supeivision of
lasks, such as ioulines, halils, honevoik, oi househoId choies. Coaching, in lhis inslance, is
an ongoing slialegy lhal seives as guidance foi lhe ADHD-diagnosed chiId lo Ieain lhe
coiiecl lechniques vilh vhich lo voik, lolh al lhal nonenl in line, as veII as in lhe fuluie
(NalionaI Resouice Cenlie on ADHD, 2OO3). Coaching enlaiIs peilinenl queslions lhal
slinuIale iefIeclive lhinking, in puisuil of pIanning lo ieach ones goaIs (Iaikei & ouleIIe,
2OO9:2O5).
This cognilive eIenenl assisls lhe individuaI lo acquiie avaieness of his/hei ovn lehavioui
and lhe iequiied lehavioui changes (Svailz, c| a|., 2OO5:648). Il enalIes lhe individuaI lo
appIy lhe lehavioui vilhoul lhe piesence of lhe coach - in lhe end.
Coaching chiIdien is a IillIe noie invoIved lhan coaching adu||s, lul lhe lasic slialegy
ienains lhe sane. AIlhough lhe ADHD coaching pailneiship is sliII fIexilIe and designed lo
neel lhe needs of lhe ADHD aduIl suffeiei, coaching al lhis IeveI aIIovs noie fieedon of
lhoughl, aclion and decision- naking, vhiIe al lhe sane line, iequiiing a highei IeveI of
connilnenl and accounlaliIily.
Coaching seives as a suppoil syslen lo assisl lhe ADHD-diagnosed aduIl in Ieaining hov lo
nanage line, deveIop oiganisalionaI skiIIs, deleinine piioiily of lask peifoinance, and il
piovides lhe peifecl pIalfoin foi lhe deveIopnenl of peisonaI accounlaliIily and
iesponsiliIily (NalionaI Resouice Cenlie on ADHD, 2OO3).
4.4 Who does the coaching and who gets coached?
Accoiding lo lhe InleinalionaI Coach Iedeialion (2OO3) (ICI) - an inleinalionaI associalion
of peisonaI and lusiness coaching lhal is evoIving as lhe piincipaI goveining lody foi lhis
fieId - lheie is cuiienlIy no speciaIised schooIing oi Iicensing iequiied in leconing a coach
oi a coach vho speciaIises in ADHD (vvv.coachfedeialion.oig). Yel, Muiphy, c| a|.
(2O1O:546), expIain lhal a speciaIisl coach nusl undeigo nelicuIous liaining al an inslilulion,
in oidei lo gain ceilificalion.
Quile a nunlei of piofessionaI inslilulions aie nov liaining coaches lo voik vilh ADHD-
diagnosed individuaIs, such as lhe Associalion foi IiofessionaI Lxeculive Coaching and
Supeivision (AILCS) (CaiioII, 2OO6:4, Muiphy, c| a|., 2O1O:546). This is inpoilanl as iegaids
lhe quaIily conlioI and ieIialiIily of lhis nev piofession. This is vilaI in deveIoping lhe
appiopiiale coaching skiIIs, such as Iislening, iefIeclion, queslioning and enpalhy
(CaiioII, 2OO6:4, Svailz, c| a|., 2OO5:651).


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The designaled coach shouId le connilled and consislenl in his/hei coaching appioach. A
good knovIedge of lhe needs and difficuIlies faced ly lhe ADHD-diagnosed individuaI is
iequiied. KnovIedge of ADHD-ieIaled issues, such as in lhe case of paienls acling as
coaches, is aIso needed in oidei lo coach soneone vho has leen diagnosed vilh ADHD
(CaiioII, 2OO6:4, Svailz, c| a|., 2OO5:648).
Coaching is, geneiaIIy speaking, a lvo-peopIe piocess. AIlhough lhe paienls aie lhe
piinaiy 'coaches foi lheii ADHD-diagnosed chiIdien, lhey nay need oulside heIp, in lhe
foin of piofessionaI coaching, fion a counseIIoi, psychoIogisl oi fion naiiiage and faniIy
lheiapisls lellei veised in lhe noie inliicale aspecls of lhe effecls of ADHD lehavioui on
lhe faniIy in geneiaI (CaiioII, 2OO6:4, Muiphy, c| a|., 2O1O:546).
When ve speak of coaching cni|drcn diagnosed vilh ADHD, lhe coach nay fiequenlIy le a
diffeienl peison in diffeienl sellings, i.e. lhe paienls couId lake luins coaching lhe chiId al
hone and/oi in sociaI sellings, accoiding lo lhe silualion, lhe need, lhe pIace and/oi lhe
lask leing deaIl vilh. Al schooI, lhe leachei vouId le lhe chiIds coach. On lhe pIaygiound,
lhe coach couId le an appoinled noie naluie peei oi fiiend, lo vhon lhe chiId Iooks up
and adniies, oi a sludenl leachei, specificaIIy appoinled lo coach pIay-line lehavioui
(}aksa & Raley, 1999).
ADHD coaching nay le heIpfuI lo adu||s suffeiing fion lhe effecls of ADHD, lul onIy if
lhey iecognise lhe inpoilance of lheii connilnenl lo lhe piocess. ChiIdien aie ieIianl on
lheii paienls lo knov vhal is lesl foi lhen and viII viIIingIy foIIov coaching diieclions,
vilhoul leing seIf-conscious aloul il. AduIls, hovevei, need lo adnil lhal lhey have a
piolIen lhal lhey aie unalIe lo oveicone aIone. To do lhis, lhey have lo enliusl lhe
nanaging of lheii piolIen-soIving slialegies lo anolhei, lheiely, ieIinquishing lheii conlioI
ovei lhe piocess, sonelhing lhal aduIls oflen sliuggIe vilh (NalionaI Resouice Cenlie on
ADHD, 2OO3).
If ADHD-diagnosed aduIls need assislance in deaIing vilh lhese piaclicaI chaIIenges in
daiIy Iife, a coach nay le a good souice of heIp (CaiioII, 2OO6:4, Muiphy, c| a|., 2O1O:546).
Hovevei, if lhe aduIl needs assislance vilh enolionaI, psychialiic, oi inleipeisonaI
piolIens, lhen a piofessionaIIy Iicensed lheiapisl shouId le consuIled. When lolh lypes of
assislance aie needed, as is oflen lhe case, il nay le heIpfuI lo seIecl a coach and a lheiapisl
vho viII agiee lo voik logelhei - lheiely foining a lean gioup lo piovide lhe necessaiy
suppoil and accounlaliIily lo lhe suffeiei (Cones, 2OO8, NalionaI Resouice Cenlie on
ADHD, 2OO3).
5. Coached behaviour modification in the management of ADHD
In lhe najoiily of cases, especiaIIy lhose invoIving aduIls suffeiing fion lhe effecls of
ADHD, coached lehavioui nodificalion is lhe nosl effeclive ioule, lecause il iequiies daiIy
feedlacks, adjuslnenls and ieoiganisalion. Il nol onIy piovides nuch-needed suppoil and
encouiagenenl, lul il aIso iequiies accounlaliIily, connilnenl and liusl, fion lolh lhe
ADHD suffeiei, as veII as fion lhe chosen coach. As a geneiaI iuIe, coaches deaI vilh
piolIens in eveiyday Iiving, such as oiganizalion, line nanagenenl, nenoiy, foIIov-
lhiough, and nolivalion.

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Theii focus is on vhal, vhen and hov, lul nol so nuch on lhe vhy (NalionaI Resouice
Cenlie on ADHD, 2OO3).
AII cases of ADHD aie unique and lhe ADHD coaching invoIves lhe use of diffeienl and
unique inleivenlion skiIIs lo suil each pailicuIai individuaI (Cooding, 2OO7a:41, Muiphy, c|
a|., 2O1O:549). AIlhough lhe synplons nay le siniIai, lhe fiequency, duialion, Iocalion and
conlenl viII diffei foi each individuaI (Svailz, c| a|., 2OO5:649). Thiough coaching, lehavioui
nodificalion can le done noie effecliveIy. Il is a 'genlIei vay of ie-diiecling lehavioui
lhan sinpIy issuing a sel of insliuclions (Cales, c| a|., 2OO1: 86).
Like aII coaching, ADHD-coached lehavioui nodificalion focuses on lhe specific needs of
lhe individuaI vhose lehavioui is leing adjusled and nodified (Young & Anaiasinghe,
2O1O:128).
The nosl connon queslion asked ly ADHD suffeieis is: 'Hov Iong viII I need
coaching` The ansvei lo lhis queslion is once again diffeienl foi each unique individuaI.
The duialion of ADHD coaching depends on lhe difficuIlies leing expeiienced ly lhe
individuaI, as veII as lhe individuaIs goaIs and iale of piogiess, anongsl olhei lhings. The
individuaIs deleininalion and connilnenl aIso pIay an inpoilanl ioIe in lhe Ienglh,
piogiess and concIusion of lhe coaching piocess (CaiioII, 2OO6:4, Muiphy, c| a|., 2O1O:546).
Ioi nosl paienls, lheii chiIds lehavioui nodificalion coach nay Iasl as Iong as lheii chiId
Iives al hone, vhich vouId piolalIy le aloul lhe fiisl 2O+ yeais of lheii chiIds Iife.
Theieaflei, depending on lheii peisonaI ieIalionship, coaching ly lhe paienls couId go on
foi even Iongei lhan lhal. The choice leIongs lo lolh pailies equaIIy. Sone young aduIls
enjoy lhe line lhey spend vilh lheii paienls, especiaIIy sane-sex paienls, and choose lo
conlinue leing accounlalIe foi lheii piogiess lo lhal paienl (Hyde Iaik, Raley, & }aksa,
2OO2).
Many hovevei, Ieain lo cope ly lhenseIves and choose lo ask foi heIp onIy vhen
alsoIuleIy necessaiy. IiequenlIy, lhe individuaIs iesponse lo coaching is affecled ly lheii
ovn sense of seIf-esleen and peisonaI vaIue. The highei lheii seIf-esleen, lhe noie oflen
lhey viII iesoil - ly lhenseIves - lo finding lhe appiopiiale coach foi lheii need (Hyde
Iaik, c| a|., 2OO2).
Coached lehavioui nodificalion usuaIIy piogiesses accoiding lo lhe foIIoving foinal:
An in-deplh discussicn lakes pIace duiing lhe iniliaI neeling (Svailz, c| a|., 2OO5:65O) oi fiisl
session, vheie lhe ADHD-diagnosed aduIl and lhe assigned coach gel lo knov each olhei,
lhe piocess is expIained and lhe coaching ieIalionship is defined in leins of needs,
difficuIlies, iequiienenls, slialegies lo le used, accounlaliIily and iesponsiliIily. olh
individuaIs discuss vhal lhe ADHD-diagnosed individuaI vanls lo achieve, and vhal
his/hei piesenl synplons, difficuIlies and slienglhs aie.
The fiisl inpoilanl aspecl of coaching is lo luiId up a good coIIaloialive ieIalionship and lo
coIIecl a piopei case hisloiy. Theieaflei, one vouId conpiIe an acceplalIe scheduIe foi lhe
coaching piocess. SnaII sleps al a line and diffeienl coaching goaIs lhen lecone lhe oidei
of lhe day. IniliaIIy, one lasic iouline is sliiven foi pei veek, and lhen giaduaIIy noie goaIs
aie added. Theieaflei, lhe diffeienl lechniques, looIs and aclions foi acconpIishing lhe goaIs
viII le liainsloined. These have lo le inpIenenled consislenlIy. Iuilheinoie, lhe


224
neasuies foi supeivision, noniloiing and suppoil need lo le agieed upon. Thioughoul lhe
piocess, ieadjuslnenls viII need lo le nade.
Key aspecls of lhe piocess aie expIained, such as peisonaI phone caIIs, oi e-naiIs as
ienindeis and neans of encouiagenenl, as veII as fuluie face-lo-face conlacl sessions. Nol
noie lhan lhiee Iong-lein goaIs and langilIe, neasuialIe, olseivalIe, specific, ieasonalIe
and possilIe achievenenls shouId le idenlified al lhis slage, and addilionaIIy, a pIan of
aclion, suggesled ly die ADHD-diagnosed individuaI and agieed upon ly lolh pailies, is
sel up (Svailz, c| a|., 2OO5:65O).
The ADHD-diagnosed individuaI usuaIIy deleinines lhe delaiIs of lhe discussion, vilh lhe
coachs encouiagenenl, lul lolh lhe coach and lhe ADHD-diagnosed individuaI laIk aloul
vhals voiking and vhal can le inpioved, and/oi changed. The achievenenl of lhe Iong
lein goaIs can exlend pasl lhe coaching piocess of aloul eighl veeks. This fiisl discussion
session can Iasl aloul 9O ninules (Svailz, c| a|., 2OO5:65O), lul lhis line Iinil is usuaIIy
agieed upon al lhe slail of lhe appoinlnenl.
Theieaflei, rcgu|ar scssicns Iasl appioxinaleIy 3O ninules pei veek, oi li-veekIy, lo assess
goaI-acconpIishnenl (Svailz, c| a|., 2OO5:65O). Il is duiing lhese shoilei sessions lhal shoil-
lein goaIs oi easiIy allainalIe snaIIei slepping slones aie sel, vhiIe Iong-lein goaIs aie
adjusled, and fuilhei sliucluies and slialegies aie deveIoped, vilh lhe ain of luiIding noie
seIf- confidence. Duiing lhese sessions, lhe aclion pIan foi lhe foIIoving veek is aIso
deleinined and agieed upon (}aksa & Raley, 1999, Svailz, c| a|., 2OO5:65O) lhen il shouId le
viillen dovn and signed ly lolh pailies.
Rcuards and punisnncn| (iefeiied lo as consequences ly Svailz, c| a|. (2OO5:651), iniliaIIy
suggesled ly lhe ADHD-diagnosed individuaI and agieed upon, foin an inpoilanl pail of
lhe piocess of coaching, in oidei lo nanage lhe ADHD difficuIlies. These guideIines seive
lhe puipose of ieinfoicenenl of lhe appiopiiale lehavioui, and lhey viII ensuie lhe cIienls
connilnenl lo lhe coaching piocess. The oulcone is lo gel lhe ADHD-diagnosed
individuaI lo evenluaIIy noniloi his/hei ovn lehavioui.
One veiy inleiesling aspecl of coaching lhal is inlioduced al a highei IeveI of iesponsiliIily
lhan lhal found in lhe coaching of snaII chiIdien, is lhe inpoilance of cncc|-ins (NalionaI
Resouice Cenlie on ADHD, 2OO3). These aie a ciuciaI pail of lhe coaching piocess and
iequiie lhal lhe ADHD-diagnosed individuaI send lhe coach a liief slalus updale on each
pIanned aclion - eilhei ly c-nai| oi ly leIephone. This fosleis accounlaliIily and
iesponsiliIily on lhe pail of lhe ADHD-diagnosed individuaI, and aIso conliilules lo
eIininaling any piociaslinalion, and heIps lo keep lhe individuaI on liack lelveen sessions.
The coach and lhe individuaI agiee on hov oflen lhese 'check-ins shouId occui. AIlhough
such 'check-ins shouId foin pail of lhe daiIy piocess, in line, lhese shouId have Iongei
line Iapses in lelveen, depending on lhe individuaIs piogiess, connilnenl and
liuslvoilhiness (Svailz, c| a|., 2OO5:65O).
Thiough coaching, lhe individuaI is heIped lo focus on lhe lask al hand, lo nanage line
noie effecliveIy, lo piioiilise iesponsiliIilies and nanage lension, and lo conlioI
unacceplalIe lehavioui (Cooding, 2OO7a:4O). This can le done lhiough iepealed
noniloiing, lhe piovision of ieguIai feedlack and piaise. TangilIe success aIvays has a
poveifuI effecl (Muiphy, c| a|., 2O1O:55O). AcconpIishnenls and eslalIishing a good halil
seive lo giaduaIIy luiId noie confidence, seIf-avaieness and seIf-nanagenenl.

225
UIlinaleIy, lhe goaI of coaching is lo piovide suppoil - unliI lhe individuaI Ieains lhe
necessaiy skiIIs lo le alIe lo funclion independenlIy (IIunei & Slonei, 2OO5: 292), and slay
on liack ovei line - le lhal individuaI an aduIl oi a chiId. The puipose of lehavioui
nodificalion coaching is lo piovide lhe iesouices, slialegies and skiIIs needed lo equip lhe
individuaI foi Iife (NalionaI Resouice Cenlie on ADHD, 2OO3, Quinn & Raley, 2OO2).
5.1 Does coaching take the pIace of therapy?
No, coaching is nol a sulslilule foi lheiapy. olh coaching and lheiapy aie lased on a
veIIness nodeI (Iaikei & ouleIIe, 2OO9:2O5), and addilionaIIy, lased on liusl. This invoIves
conpIex ieIalionships and change, giving feedlack, and Ieaining nev skiIIs (SunneifieId,
2OO6:24). Hovevei, lhe coachs lask is neilhei counseIIoi noi advisoi, lul a coIIaloialoi
(Svailz, c| a|., 2OO5:648).
Coaching ains lo inpiove peifoinance and lo nake lhe ADHD-diagnosed individuaI noie
independenl and iesponsilIe foi his/hei ovn lehavioui and aclions lhiough supeivision
(Muiphy, c| a|., 2O1O:547). Il is inpoilanl lhal coaching le appioached vilh lhe fuII co-
opeialion of lhe individuaI needing heIp. ADHD-diagnosed individuaIs need lo undeisland
lhe inpoilance of voiking vilh a lehaviouiaI coach foi lhe coaching piocess lo le
successfuI and effeclive (Hyde Iaik, c| a|., 2OO2, ShinleI & Keysai, 2OO7).
The ADHD-diagnosed individuaI shouId le ieIaliveIy heaIlhy, psychoIogicaIIy speaking, as
coaches aie nol expecled lo give lheiapy foi seiious psychialiic oi nenlaI disluilances. The
individuaI shouId aIso accepl lhal he/she is suffeiing fion ADHD-ieIaled piolIens and
needs assislance and coaching lo nanage lhese piolIens. The individuaI aIso needs lo
connil hin/heiseIf lo lhe coaching inleivenlion (Muiphy, c| a|., 2O1O:551).
Theiapy is lased on lhe pienise lhal ienediaI change and enolionaI heaIing aie needed
(Muiphy, c| a|., 2O1O:547). Wheie enolionaI piolIens, such as depiession oi olhei
psychoIogicaI issues hindei daiIy funclioning, lhese need lo le addiessed ly piofessionaIs,
such as lhe faniIy docloi, lhe psychoIogisl oi lhe psychialiisl (HaIIoveII & Raley, 1994,
Muiphy, c| a|., 2O1O:551, Quinn & Raley, 2OO2). If lhese issues ienain unliealed, coaching
viII nol le successfuI. In such cases, il is advisalIe foi lhe coach lo voik in landen vilh lhe
individuaIs vaiious heaIlhcaie piovideis lo oveicone lhese olslacIes (WaIIace, 1998).
The puipose of ccacning is lo suppoil lhe deveIopnenl of nelhods lo nanage lhe day-lo-day
ADHD-ieIaled chaIIenges (Cooding, 2OO7a:4O). Il is lased on aclion Ieaining (Muiphy, c|
a|., 2O1O:547), lhal is lo say, Ieaining lhal suppoils lhe individuaI up lo lhe poinl vheie
he/she can nanage ly hin/heiseIf. Coaching is a foin of veilaI ienindei, a guiding of lhe
nelhods foi caiiying oul a lask, oi of adjusling lehavioui, especiaIIy vheie chiIdien aie
conceined. Ioi lhe aduIl suffeiei il assisls vilh lhe peisonaI and piofessionaI giovlh and
deveIopnenl, lased on lhe puisuil of specific oulcones. These, in luin, aie Iinked lo
peisonaI oi piofessionaI success (Cones, 2OO8, Quinn & Raley, 2OO2, Quinn, c| a|., 2OOO,
WaIIace, 1998).
The nain ain of coaching is lo shov lhe individuaI hov lo achieve lhese goaIs in lhe nosl
piaclicaI nannei possilIe (Quinn & Raley, 2OO2, Quinn, c| a|., 2OOO). In coaching lhe
enphasis is on lhe individuaIs aliIily lo |a|c ac|icn cn |ifc gca|s in a laIanced and fuIfiIIing
vay (Iaikei & ouleIIe, 2OO9:2O5). The ADHD-diagnosed individuaI is seen as iesouicefuI


226
and ciealive. The individuaI is heIped lo deveIop his/hei ovn syslens of effeclive
funclioning in puisuil of his/hei goaIs.
Tncrapq, on lhe olhei hand, deaIs vilh lhe heaIing of pasl expeiiences of pain lhal have
iesuIled fion lhe sligna allached lo lhe ADHD diagnosis (Muiphy, c| a|., 2O1O:547).
Whelhei in a faniIy silualion oi oulside il in sociaI sellings, such as schooI oi voik
silualions, ADHD is hugeIy nisundeislood (HaIIoveII & Raley, 1994, }aksa & Raley, 1999).
This faiIuie lo undeisland, coupIed vilh lhe iesuIling dysfunclion and confIicl vilhin an
individuaI, can so easiIy cause pain and insecuiily. Such liauna is lesl addiessed in lheiapy
(Cones, 2OO8).
Accoiding lo lhe InleinalionaI Coach Iedeialion (2OO3), lheie aie seveiaI issues lhal can
inleifeie vilh lhe coaching piocess. These viII oflen iequiie iefeiiaI lo a nedicaI oi nenlaI
heaIlh piofessionaI, foi exanpIe, in cases vheie lhe ADHD-diagnosed individuaI is nol alIe
lo use sinpIe seIf-nanagenenl oi oiganizalionaI slialegies lo achieve lhe desiied goaIs,
despile lhe coach's suppoil, encouiagenenl and ienindeis, in cases vheie lhe ADHD-
diagnosed individuaI has a co-exisling psychialiic condilion, such as depiession, lipoIai
disoidei, anxiely disoidei, sulslance aluse, oi peisonaIily disoidei, vheie lhe ADHD-
diagnosed individuaI has sliessfuI Iife ciicunslances, such as naiilaI piolIens, divoice, oi
lhe dealh of a Ioved one, oi vheie lhe ADHD-diagnosed individuaI has a seiious physicaI
iIIness oi olhei chionic nedicaI condilion (HaIIoveII & Raley, 1994, Quinn & Raley, 2OO2,
WaIIace, 1998).
Undei such ciicunslances, coaching shouId le caiiied oul in coIIaloialion vilh lhe nedicaI
oi nenlaI heaIlh piofessionaIs invoIved in lhe ADHD-diagnosed individuaIs caie. In such
cases, lhe ADHD-diagnosed individuaI nay lenefil fion lhe addilion of liadilionaI
liealnenls, such as nedicalion and psychoIogicaI lheiapy, as is oflen lhe case vheie a
nuIlinodaI appioach lo liealnenl vouId voik lesl (HaIIoveII & Raley, 1994).
The focus of lheiapy is oflen on iesoIving difficuIlies aiising fion lhe pasl vhich hanpei an
individuaI's enolionaI funclioning in lhe piesenl. Coaching, on lhe olhei hand, is foivaid-
noving and fuluie-focused, pioviding suppoil, hope and encouiagenenl (Hyde Iaik, c| a|.,
2OO2, ShinleI & Keysai, 2OO7). WhiIe posilive feeIings/enolions nay le lhe naluiaI oulcone
of coaching, lhe piinaiy focus is on ciealing voikalIe slialegies foi achieving specific goaIs
in lhe individuaIs voik oi peisonaI Iife. Coaching enphasises aclion, accounlaliIily and
foIIov-lhiough. Theiapy, on lhe olhei hand piovides a pIalfoin foi iefIeclion, and voiking
lhiough difficuIl enolionaI feeIings lhal iesuIl fion lhe confIicl associaled vilh ADHD
(HaIIoveII & Raley, 1994).
6. A possibIe coached behaviour-modification programme
The Ccping S|i||s Prcgrannc of ehavioui Modificalion (Cones, 2OO8) is a vaIualIe
piogianne lo use in a coaching silualion, as il piovides nany fIexilIe aIleinalives foi aII
ages and silualions. The Coping SkiIIs Iiogianne guides lhe designaled coach lhiough a
piocess of iniliaI invesligalion of lhe piesenling difficuIlies, in oidei lo define lhe nosl
appiopiiale vay lo deaI vilh and iesoIve piolIenalic silualions and lehaviouis. Used
coiieclIy, syslenalicaIIy and consislenlIy, lhe Coping SkiIIs Iiogianne is one of lhe nosl
piaclicaI and effeclive piogiannes lo use. Ils fIexiliIily nakes il ideaI foi aII age gioups,
silualions and needs (Cones, 2OO8).

227
Sone of lhe slialegies used ly lhe Coping SkiIIs Iiogianne incIude an iniliaI invesligalion
inlo lhe specific needs of lhe faniIy oi individuaI faced vilh ADHD-ieIaled issues and
piolIens. This invesligalion is done ly neans of olseivalion and diaIogue, and il is nol jusl
lased on lhe exisling infoinalion avaiIalIe via lhe nedia and olhei iesouices. This nelhod
of invesligalion encouiages paienls and olhei designaled coaches lo olseive lehavioui
lased on aliIily and slienglhs, ialhei lhan sinpIy lo focus on deIileiale nislehavioui. Il
iequiies lhal lhe paienl ieaIIy olseive lhe chiIds lehavioui and deleinine vhal il is lhal
piovokes such lehavioui. Once lhis facl has leen eslalIished, slialegies nay le sel in pIace
lo iepIace lhe undesiialIe lehavioui vilh a noie desiialIe aIleinalive (Cones, 2OO8,
Hukandad, c| a|., 2O11).
Theieaflei, olhei slialegies and skiIIs can le sel in pIace, such as coaching conliacls, vheie
appIicalIe, lhe selling of ieasonalIe and allainalIe goaIs, accounlaliIily and iesponsiliIily,
posilive feedlack fion lhe paienls and designaled coaches, lhe seIeclion of looIs and
slialegies lo assisl vilh execulive funclioning issues, such as caIendais, lineis, pIanneis,
sludy luddies/coaches, jouinaIing foi oIdei chiIdien and aduIl individuaIs, and line
nanagenenl.
A Ieaining slyIes invenloiy is sonelines aIso inpIenenled, lo shov paienls vhy lheii
chiIdien so fiequenlIy have difficuIly in paying allenlion in cIass and duiing honevoik
sessions al hone. Oflen lhe confIicling Ieaining slyIes of leacheis and Ieaineis, as veII as
lhose of paienls and lheii chiIdien aie aII lhal sland lelveen doing veII and sliuggIing
lhiough lhe schooI day (Cooding, 2OO7a:4O, Ciahan, 2OO8a:92, Heiiol, c| a|., 2OO7:121).
CIassioon aiiangenenls aie aIso discussed and adjusled, vheie possilIe, in conjunclion
vilh leacheis and olhei schoIaslic slaff, in oidei lo inpiove lhe focus and deciease
disliacliliIily, and aIso lhe eslalIishing of consislenl daiIy ioulines foi aII nenleis of lhe
faniIy, exlended faniIy and caie giveis (Cones, 2OO8, Rief, 2OO5:57).
Pcricdica| adjus|ncn|s of Ieained skiIIs have lo le caiiied oul as soon as each nev skiII has
leen nasleied, lhal is lo say, a nev skiII shouId ienain in pIace, in ils oiiginaI foin, onIy as
Iong as il sliII seives ils puipose foi lask execulion. As soon as lhe skiII slops leing effeclive,
il needs lo le upgiaded oi adjusled, lo heIp vilh lhe nexl difficuIly. Ioi exanpIe, a laly
Ieains hov each lype of food 'lehaves in his/hei pIale, ly handIing il vilh his/hei fingeis
fiisl (skiII 1) - a naluiaI skiII lhal aII lalies have. Soon, nonny pIaces a spoon in lhe lalys
hand and leaches hin/hei hov lo use lhe spoon (skiII 2). This is nol a naluiaI skiII, and il
viII, lheiefoie, lake a IillIe Iongei lo naslei.
The spoon nay, al fiisl, le used as an addilion lo feeding vilh lhe fingeis, il nay even le
used as a loy, lul il viII evenluaIIy le used piopeiIy, al vhich poinl lhe skiII needs lo le
upgiaded lo using a foik, and so on. Il is sliII lhe sane skiII, lul is leing upgiaded
conlinuousIy lo lhe nexl IeveI, in snaII sleps one al-a-line (Cooding, 2OO7a:4O, Ciahan,
2OO8a:92).
If peiiodicaI adjuslnenls aie caiiied oul ieguIaiIy and efficienlIy, lhe chiId viII inleinaIise
lhe 'skiII, and Ialei Ieain lo adapl il lo aduIl Iife silualions, having Ieained hov lo exhausl
aII lhe possiliIilies in one specific skiII, changing il and lhen using lhe adaplalion foi a
diffeienl difficuIly. Non-ADHD-diagnosed peopIe do il aulonalicaIIy aII lhe line, il is hov
hunans suivive, lhey adapl lo lheii suiioundings and lheii needs. Hovevei, lhis is nol a


228
naluiaI lehavioui nechanisn foi ADHD-diagnosed individuaIs, peihaps, lecause eaiIy on
in lheii Iives lheii nolheis liied lo conpensale foi lheii eveiy difficuIly.
Ioi ADHD-diagnosed chiIdien, skiIIs have lo le Ieained and inlegialed. When skiII
adjuslnenl is caiiied oul speediIy, lhe chiIds confidence in his/hei aliIily lo adapl lo
changes - lhe liggesl difficuIly foi ADHD suffeieis - is loosled, and ADHD-ieIaled
difficuIlies lecone Iess pioninenl and piolIenalic. This is lhe funclion of coaching: lo heIp
find, inlegiale, noniloi and adjusl lhe appiopiiale skiIIs leing Ieained and used (Hyde
Iaik, c| a|., 2OO2).
Chionis, Chacko, Ialiano, Wynls and IeIhan (2OO4) discoveied in lheii ieseaich lhal
lehaviouiaI paienl liaining (IT), in vhich paienls aie guided in hov lo coach lheii
chiIdiens lehavioui nodificalion, is one of lhe nosl effeclive lehavioui-nodificalion
piocesses in lhe liealnenl of ADHD-ieIaled nislehavioui. They found lhal, lecause so
nany aspecls infIuence lhe chiIds lehavioui and affecl lhe paienls ieaclions lo lhal
lehavioui, conlinuous piogianne adjuslnenls aie needed in lhe vay paienls leach lheii
chiIdien, lhe slyIe lhal lhey use, and hov lhe chiIdien inleipiel vhal is leing laughl.
This is liue in aduIl coaching aIso, in lhal aduIls have a lendency lo assune vaiious
peinulalions in lhe oulcones of lheii aclions. Il is lhis aspecl lhal iesuIls in lhe difficuIlies
faced ly aduIls vilh ADHD-ieIaled difficuIlies, lhe una|-if-fac|cr. Ioi exanpIe: 'Whal if I
do lhe voik iequiied, lul nolhing changes` If lhal is so, lhen vhy do lhe voik` I nighl as
veII caiiy on as I have lefoie. ChiIdien donl queslion lheiapy in lhis vay. AduIls aie lhe
ones vho viII do lhis noie fiequenlIy (Cones, 2OO8).
Iiogianne fc||cu-up peiiods shouId lake pIace fion line lo line, aflei lhe conpIelion of
lhe Coping SkiIIs Iiogianne, (Cones, 2OO8), in oidei lo nake any necessaiy adjuslnenls
and deaI vilh any difficuIlies lhal lhe paienls nighl expeiience aIong lhe vay, and vhich
nighl nol have leen pieviousIy coveied ly lhe Coping SkiIIs Iiogianne. The paienls, as
and vhen lhey feeI il is necessaiy, usuaIIy iniliale lhese foIIov-up peiiods, and in sone
inslances, lheie nay le a shoil succession lelveen foIIov-up peiiods, and lhen a Iongei gap
unliI heIp is iequesled again. In olhei inslances, foIIov-up peiiods nay le Iess fiequenl and
fevei in nunlei (Cones, 2OO8).
Iiogianne foIIov-up peiiods aie inpoilanl foi lolh lhe ADHD-diagnosed individuaI and
lhe paienls, and/oi designaled coach, as lhese piovide lhe oppoilunily lo nake
adjuslnenls lo lhe piogianne fion line lo line. Likevise, lhe paienls/coaches lenefil,
lecause lhe up-dale sessions seive as a foin of suppoil syslen vheie lheii queslions nay
le ansveied, ieassuiance piovided and nev infoinalion ollained (Cones, 2OO8).
7. ConcIusion
The nanagenenl of lhe chaIIenging and difficuIl lehavioui associaled vilh ADHD piesenls
a piolIen lhal causes sliess foi aII peisons invoIved, in lhe hone, schooI and sociely al
Iaige. The nanagenenl of ADHD-ieIaled piolIen lehavioui is lheiefoie a veII-ieseaiched
lopic, and iefeis lo an aiiay of appioaches.
In lhis chaplei ve have, hovevei, aigued foi lhe use of a genlIei appioach, naneIy coached-
lehavioui nodificalion, vhich is exlieneIy poveifuI (ScouIai & LinIey, 2OO6:11) in
nodifying unacceplalIe oi inappiopiiale lehavioui. This is done lhiough a nuluaI-

229
nenloiing pailneiship, giounded on an individuaIs peisonaI slienglhs. Il invoIves lhe
piovision of enphalic psychoIogicaI supeivision, suppoil, encouiagenenl and feedlack. Il
ains al confidence, inleinaI sliucluie, goaI-diiecled aclion, lask peisislence and iesponsilIe
funclioning of lhe ADHD-diagnosed individuaI.
Oui conlenlion is aplIy sunned-up ly Iaikei and ouleIIe (2OO9:212): The suggesled
appioach is appiopiiale lo heIp individuaIs diagnosed vilh ADHD lo deveIop seIf-
ieguIalion skiIIs foi nanaging chaIIenges caused ly lheii execulive funclion difficuIlies
lhiough nelhods lhal enphasise seIf-deleininalion. Il is inpoilanl lo conslanlIy leai in
nind lhal il is lhe lehavioui lhal is undesiialIe and nol lhe peison.
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34(1):111-12O.
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Tnc Ccacning Psqcnc|cgis|, 2(1):9-11.
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achievenenl and lehaviouiaI oulcones of chiIdien vilh allenlion
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Rcscarcn, 5O(4): 347-36O.
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Mcncrq, and Ccgni|icn. 33(2) Maich: 357-369.
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232
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12
Distractor or Noise?
The InfIuence of Different Sounds
on Cognitive Performance in
Inattentive and Attentive ChiIdren
Cian SdeiIund
1,2*
and Sveikei Sikslin
3
!
"#$%&'(#)' +, -#.%/+/0123 4+/).%5 6)07#&20'8 9+55#/#3
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1. Introduction
Il is a veII knovn and ceilified facl lhal noise undei nosl ciicunslances inleifeie vilh
cognilive piocessing of vaiious kinds, e.g. vigiIance (e.g. ioadlenl, 1951), aiilhnelics
(ioadlenl, 1958), and iesponse speed (ioadlenl, 1957). This effecl is assuned lo le due lo
lhe conpelilion of allenlionaI iesouices lelveen lhe laigel and lhe disliacling slinuIi. This
finding is oflen iepIicaled and found vaIid anong diffeienl lasks and pailicipanl
popuIalions (eIIeviIIe, RouIeau, Van dei Linden, & CoIIelle, 2OO3, onan, 2OO4, KIalle,
Meis, Sukovski, & Schick, 2OO7, RouIeau & eIIeviIIe, 1996). Mosl ieseaich since ioadlenls
days has deaIl vilh lhe negalive effecls of noise and diffeienl kinds of audiloiy disliaclion.
In Iine vilh lhis eaiIiei ieseaich has denonslialed lhal inallenlive peisons, such as chiIdien
vilh ADHD (allenlion deficil /hypeiaclivily disoidei) aie even noie susceplilIe lo
disliaclion as conpaied vilh lheii allenlive peeis. This has leen shovn in nuneious of
sludies (e.g. Coilell & Slanczak, 1999, Ceffnei, Luckei, & Koch, 1996, Ricknan, 2OO1).
Hovevei, in conliasl lo lhe nain lody of evidence, lheie have leen a fev iepoils of
conliadicloiy findings. SpecificaIIy, il has leen shovn lhal undei ceilain ciicunslances,
chiIdien vilh allenlionaI piolIens, ialhei lhan leing disliacled, acluaIIy lenefil fion
enviionnenlaI noise piesenled vilh lhe concuiienl laigel lask. UnliI iecenlIy, lhis faciIilaling
effecl of non-lask ieIaled enviionnenlaI audiloiy slinuIalion has leen Iiniled lo lhe effecls of
lackgiound nusic on aiilhnelic lask peifoinance ly chiIdien vilh ADHD (Alikoff,
Couilney, SzeileI, & KopIevicz, 1996, Ceijels, Ciav, Heise, Wesleinann, & Rolhenleigei,
2OO2). In addilion, ioad liaffic noise vas found lo inpiove episodic nenoiy anong chiIdien
fion househoIds vilh Iov socio-econonic slalus, a gioup lhal is IikeIy lo le dislinguished ly
allenlionaI piolIens and acadenic undei-achievenenl (Malheson el aI., 2O1O, SlansfeId el aI.,
2OO5). Hovevei, lhese sludies have nol piovided a salisfacloiy lheoielicaI accounl foi vhy
noise, undei ceilain ciicunslances, can le leneficiaI foi cognilive peifoinance.

Theie aie sone eaiIy sludies lhal piovide a lheoielicaI accounl foi noise enhancenenl. In
lhese sludies, hypeiaclive chiIdien inpioved lheii peifoinance in denanding allenlion
lasks vheie noise vas inlioduced ly visuaI slinuIalion (ZenlaII, 1986, ZenlaII & Dvyei,
1989, ZenlaII, IaIkenleig, & Snilh, 1985), oi audiloiy slinuIalion (ZenlaII & Shav, 198O). In
lhese expeiinenls lhe posilive effecl vas alliiluled lo a geneiaI inciease of aiousaI,
foinuIaled in a lheoielicaI fianevoik naned lhe oplinaI slinuIalion lheoiy (ZenlaII &
ZenlaII, 1983). Hovevei, lhis oplinaI slinuIalion lheoiy has nol leen expIoied oi deveIoped
fuilhei.
The ain vilh lhe piesenl chaplei is lo piesenl a pIausilIe lheoielicaI expIanalion as lo vhy,
vhen, and hov noise can inpiove execulive funclions and cognilive peifoinance in vaiious
lasks. Oui ieseaich has iecenlIy exlended lhese findings and foi lhe fiisl line viII heie le
suggesled a lheoielicaI fianevoik foi undeislanding vhich condilions aie necessaiy foi
noise induced cognilive enhancenenl lo occui. We have shovn lhal audiloiy noise has
diffeienl effecls on lhe nenoiy peifoinance of chiIdien vilh an ADHD diagnosis
conpaied lo noinaIIy deveIoped chiIdien (SdeiIund, Sikslion, & Snail, 2OO7). These
effecls have leen iepIicaled, and found vaIid in fuilhei sludies conpiising sul-cIinicaI,
inallenlive pailicipanls (SdeiIund, MaikIund, & Laceida, 2OO9, SdeiIund, Sikslin,
Loflesnes, & Sonuga-aike, 2O1O). In lhe foIIoving seclion ve inlioduce a nodeI and
findings lhal denonsliale a Iink lelveen noise slinuIalion and cognilive peifoinance. This
has leen naned lhe Modeiale iain AiousaI (MA) nodeI (Sikslin & SdeiIund, 2OO7),
vhich suggesls a Iink lelveen allenlion, dopanine liansnission, and exleinaI audiloiy
noise (vhile noise) slinuIalion.
2. The phenomenon of Stochastic Resonance
IeicepluaI slochaslic iesonance (SR) is lhe counleiinluilive phenonenon ly vhich veak
sensoiy signaIs lhal cannol le delecled lecause lhey aie piesenled leIov lhe deleclion
lhieshoId, lecone deleclalIe vhen addilionaI iandon (slochaslic) noise is added (Moss,
Waid, & Sannila, 2OO4). SignaIing in lhe liain is chaiacleiized ly noisy inpuls and oulpuls.
The ciuciaI lask of lhe cenliaI neivous syslen is lo dislinguish lelveen lhe signaI, lhe
infoinalion-caiiying conponenl, and noise lhal conslilule neaningIess neuiaI inpuls. The
paiadox is lhal lhe liain can acluaIIy use noise lo diffeienliale lhe signaI in lhe laigeled
slinuIi fion noise, so noise acluaIIy inpioves oi incieases lhe signaI-lo-noise ialio. The
iequiienenl foi lhis phenonenon lo occui is lhe inlioduclion of non-Iineaiily in lhe
iesponse, foi exanpIe lhiough a lhieshoId funclion. This is shovn in Iiguie 1, vheie lhe
noise and lhe signaI inleiacl. The noise adds lo lhe signaI and liings lhe neuion ovei lhe
aclivalion lhieshoId, and eIicils a neuiaI iesponse (aclion polenliaI), giving lhe audiloiy
syslen a iepiesenlalion of lhe signaI (a sinus lone).
SR is veII eslalIished acioss a iange of sellings, and exisls in any lhieshoId-lased syslen.
The concepl of SR vas oiiginaIIy inlioduced lo expIain cIinale changes (enzi, Iaiisi,
Suleia, & VuIpiani, 1982), lul has leen idenlified in a nunlei of naluiaIIy occuiiing
phenonena, sone exanpIes aie: in li-slalIe oplicaI syslens (Cannailoni, Hnggi, }ung, &
Maichesoni, 1998), in nechanoieceplois of lhe ciayfish (DougIass, WiIkens, IanlazeIou, &
Moss, 1993), and in lhe feeding lehavioi of lhe paddIefish (RusseII, WiIkens, & Moss, 1999).
SR is in pailicuIai found in lhe neivous syslen, dislinguished ly ils aII-oi-none naluie of
aclion polenliaIs.
Distractor or Noise? The nfluence of Different Sounds
on Cognitive Performance in nattentive and Attentive Children 235

Iig. 1. Slochaslic iesonance vheie a veak sinusoidaI signaI goes undelecled as il does nol
liing lhe neuion ovei ils aclivalion lhieshoId. Wilh added noise, lhe sane signaI iesuIls in
aclion polenliaIs.
In hunans SR has leen found in diffeienl nodaIilies: in louch, vheie lacliIe iandon
slinuIalion nade skin ieceplois noie sensilive (WeIIs, Waid, Chua, & Tinolhy IngIis,
2OO5), in audilion, vheie vhile noise inpioves audiloiy deleclion in a gioup vilh noinaI
heaiing (Zeng, Iu, & Moise, 2OOO), and in pailicipanls vilh cochIeai inpIanls (ehnan &
Zeng, 2OO3), in vision, vheie visuaI (fIickeiing) noise inpioved deleclion of veak signaIs
(Sinonollo el aI., 1999). InleieslingIy, cioss nodaI SR has leen found, vheie veak visuaI
signaIs lecane deleclalIe vhen pailicipanls vheie exposed lo Ioud audiloiy vhile noise
(Manjaiiez, Mendez, Mailinez, IIoies, & Miiasso, 2OO7). SR can inpiove noloi conlioI and
laIance as veII. LIdeiIy, dialelics, and Iaikinson palienls peifoinance vas enhanced
lhiough slochaslic noise liansnilled ly vilialing soIes (Novak & Novak, 2OO6, IiipIala,
Nieni, Haiiy, Lipsilz, & CoIIins, 2OO3, IiipIala el aI., 2OO6). In neuiodegeneialive disoideis
gaIvanic slinuIalion of lhe vesliluIai oigans inpioved noloi conlioI consideialIy (Ian,
Sona, Kvak, & Yananolo, 2OO8, Yananolo, Sliuzik, Sona, Ohashi, & Kvak, 2OO5). To sun
up, SR is piesenl in lhe enliie neivous syslen in aII nodaIilies, and il seens lhal lhe
neivous syslen can lake advanlage of noise lolh in sensoiy disciininalion and noloi
conlioI. SR is usuaIIy quanlified ly pIolling deleclion of a veak signaI, oi cognilive
peifoinance, as a funclion of noise inlensily. This ieIalion exhilils an inveiled U-cuive,
vheie peifoinance peaks al a nodeiale noise IeveI. Thal is, nodeiale noise is leneficiaI foi
peifoinance, vheieas loo nuch, oi loo IillIe noise allenuales peifoinance.
WhiIe Iess knovn, enpiiicaI evidence aIso suggesl lhal SR inpioves cenliaI piocessing in
lhe liain and lhus inpioves cognilive peifoinance. Ioi exanpIe a faciIilaling effecl of
cognilive SR has leen found vheie audiloiy noise inpioved lhe speed of aiilhnelic
conpulalions in a noinaI gioup of schooI pupiIs (Ushei & IeingoId, 2OOO). In a visuaI lask,
face iecognilion, iesponse lines gol shoilei vhen lhe vesliluIai oigans vheie slinuIaled ly
a veak slochaslic gaIvanic cuiienl (WiIkinson, NichoIIs, Iallenden, KiIduff, & MiIleig,
2OO8) finaIIy, figuie copying lecane noie accuiale vhen exposed lo gaIvanic slinuIalion

(WiIkinson, Zulko, Degulis, MiIleig, & Iollei, 2OO9). This indicales lhal aIso highei
cognilive piocessing is susceplilIe foi SR.
3. IndividuaI differences in SR and the Moderate Brain ArousaI ModeI (MBA)
Mosl of lhe alove-iefeiied iefeiences of lhe SR-effecl aie nade vilh noinaI popuIalions,
and lhe ieveaIed effecls of noise aie found lo le vaIid foi lhe enliie popuIalion. Oui ieseaich
gioup has focused on cognilive effecls of SR in pailicuIai gioups vilh allenlionaI piolIens,
Iike in ADHD, vheie ve have found diffeienliaI effecls of noise on cognilive peifoinance.
Sone gioups of pailicipanls inpiove lheii peifoinance, vheieas lhe peifoinance olhei
gioups deleiioiale vhen exposed lo noise. The queslion is hov lhese diffeienlialions can le
expIained. We piopose lhe Modeiale iain AiousaI nodeI (MA) vhich is deveIoped lo
addiess and expIain lhese diffeiences (Sikslin & SdeiIund, 2OO7). The MA nodeI vas
deveIoped lo iespond lo lhe Iinilalion of slandaid psychophysicaI nodeIs in expIaining lhe
noise faciIilaling effecl in chiIdien vilh allenlion piolIens. The nodeI is lased on
eslalIished facls conceining SR, ,0&2', lhal lhe SR phenonenon is highIy sensilive lo lhe
inlensily of lhe signaI and, 2#1+)., lhe inlensily of lhe noise, vheie lhe cognilive oi
peicepluaI peifoinance shovs an inveiled U-shaped cuive vhen pIolled againsl noise
inlensily (e.g. Moss, el aI., 2OO4). Thus, a nodeiale IeveI of noise is leneficiaI foi
peifoinance. Too IillIe noise does nol add sufficienl inpul lo liing lhe signaI ovei lhe
aclivalion lhieshoId, and loo nuch noise oveipoveis lhe signaI - in lolh cases Ieading lo
deleiioialion in allenlion and peifoinance. The ciuciaI and innovalive insighl of lhe MA
nodeI is lhal lheie aie individuaI diffeiences in lhe lenefil of noise, sone peopIe need jusl a
snaII anounl of noise and sone need a Iol of noise lo achieve oplinaI peifoinance (see
Iiguie 2). This is lecause individuaIs diffei in inleinaI IeveIs of lackgiound noise and signaI
IeveIs in lheii neuiaI syslens. Thal is, vheie noise IeveIs aie Iov, exleinaI noise has lo le
added lo ieach an oplinaI peifoinance, and lo achieve a nodeiale liain aiousaI IeveI.
Iuilheinoie, iequiied noise IeveIs aie Iinked lo neuioliansnillei funclion and in pailicuIai
lo dopanine. A hypo-funclioning dopanine syslen is Iinked lo inallenlion, and iecenl
ieseaich suggesls lhal ADHD possess Iov IeveIs of exliaceIIuIai dopanine (SoIanlo, 2OO2,
VoIkov el aI., 2OO9, VoIkov el aI., 2OO7). The MA nodeI pioposes lhal noise, as an
aIleinalive lo slinuIanl nedicalion, can conpensale foi Iov dopanine IeveIs (Sikslin &
SdeiIund, 2OO7).
In sunnaiy, lhe MA nodeI posils lhal cognilive peifoinance in ADHD and inallenlive
chiIdien lenefils fion noisy enviionnenls lecause lhe dopanine syslen noduIales lhe SR
phenonenon. Il suggesls lhal lhe slochaslic iesonance cuive is iighl shifled in peisons vilh
a ADHD diagnose due lo Iovei gain oi Iovei dopanine. IeveIs The MA nodeI piedicls
lhal foi a given cognilive lask ADHD chiIdien and inallenlive chiIdien iequiie noie
exleinaI noise oi slinuIalion conpaied lo conlioI chiIdien, in oidei lo ieach oplinaI (i.e.
nodeiale) liain aiousaI IeveI (see Iiguie 2). This piediclion has leen lesled and confiined
in seveiaI diffeienl sellings vilh vaiious pailicipanl gioups and lasks. Woid iecaII lesls in
chiIdien vilh ADHD (SdeiIund, el aI., 2OO7), non-cIinicaI, inallenlive schooI chiIdien
(SdeiIund, el aI., 2O1O), and Iov peifoining schooI chiIdien (SdeiIund & Sikslin, 2OO8).
The effecl has aIso leen found in a dicholic Iislening lask, and in a visuo-spaliaI voiking
nenoiy lask in a noinaI sludenl popuIalion, vheie haIf of lhe pailicipanls ialed
lhenseIves as inallenlive (SdeiIund, el aI., 2OO9). Al lhe nonenl ve have pieIininaiy dala
shoving significanl effecls of noise on lhiee diffeienl cognilive lasks in paiily vilh, oi even
Iaigei, lhan lhe effecls of slinuIanl nedicalion (SdeiIund el aI., in piogiess).

Iig. 2. The ieIalionship lelveen noise IeveIs, allenlion aliIily, and cognilive peifoinance.
Sul-allenlive pailicipanls (e.g. ADHD) iequiie noie noise foi naxinaI peifoinance
accoiding lo lhe MA nodeI.
4. The difference between distractors and noise
As shovn in nuneious expeiinenls, enviionnenlaI audiloiy noise exeils a negalive
infIuence on schooIvoik and on cognilive peifoinance in geneiaI. Conpaiisons have leen
nade vilh vaiious sounds lhal aie pioposed lo have a negalive inpacl on diffeienl kinds of
inleIIecluaI voik. olh iiieIevanl neaningfuI speech and ioad liaffic noise have leen found
la have a deliinenlaI effecl on lolh senanlic and episodic nenoiy iecaII in aduIls (Hygge,
onan, & Lnnaikei, 2OO3). AIso schooI chiIdien veie susceplilIe lo lhese kinds of
disliaclois vhen peifoining nalhenalicaI conpulalions (Ljung, Siqvisl, & Hygge, 2OO9).
Aiiciafl noise seens lo le deliinenlaI duiing nosl kinds of voik lhal iequiie allenlion
(Hygge, Lvans, & uIIingei, 2OO2, Malheson, el aI., 2O1O, SlansfeId, el aI., 2OO5), even lhe day
aflei lhe noise exposuie (SlansfeId, Hygge, CIaik, & AIfied, 2O1O). SenanlicaIIy neaningfuI
iiieIevanl infoinalion is found lo le disliacling, lul does aIso inleiacl vilh voiking
nenoiy capacily, peisons lhal possess a high voiking nenoiy capacily veie Iess
disliacled ly iiieIevanl speech lhan peeis vilh Iovei capacily (Siqvisl, 2O1Oa, 2O1Ol,
Siqvisl, Ljungleig, & Ljung, 2O1O).
In lhe piesenl sludy ve fuilhei invesligaled diffeienl enviionnenlaI soundscapes lhal have
ecoIogicaI ieIevance oul of a schooI peispeclive, and lheii inpacl on a denanding voiking
nenoiy lask. Ioi lhis puipose ve ciealed foui diffeienl lackgiound noises oi soundscapes
lhal couId occui in a cIassioon selling: 1) speech oi cIassioon noise, 2) vhile noise, 3) a nix
of speech + vhile noise, and finaIIy 4) a siIenl condilion. We posed lhe queslion vhelhei
puie noise is lhe lesl vay of inlioducing cognilive enhancenenl in inallenlive chiIdien, oi
vhelhei ecoIogicaIIy vaIid soundscapes couId pioduce siniIai cognilive enhancenenl.
We piedicled lhal audiloiy enviionnenlaI slinuIi vouId have a posilive effecl on inallenlive
peisons and le deliinenlaI lo lhe allenlive peisons. In pailicuIai, lased on pievious dala, ve

piedicled lhis effecl lo occui foi vhile noise. Hovevei, ve posed no diiecl piediclion on
vhelhei speech nighl pioduce cognilive enhancenenl effecls on inallenlive chiIdien.
5. Methods
5.1 Participants
Tvenly-lvo piinaiy schooI chiIdien lelveen 7 and 1O yeais oId (M = 8.3 yis) pailicipaled in
lhe piesenl sludy (14 loys and 8 giiIs). The lvenly-lvo pailicipanls veie scieened and
seIecled oul of a gioup of 33 pailicipanls accoiding lheii allenlion aliIily as iepoiled ly lheii
leacheis. The eIeven lhal scoied Iovesl on lhe allenlion scaIe vheie seIecled foi lhe inallenlive
gioup vhiIe lhe ones lhal scoied high on allenlion foined lhe allenlive gioup. Whal vas
consideied noinaI oi alove aveiage in allenlion vas decided accoiding lo lheii leacheis
judgnenls. Ioi lhis puipose a SNAI scoie vilh 18 queslions veie used (Svanson el aI., 2OO7).
Mean scoie foi lhe inallenlive gioup vas 28.8 and foi lhe allenlive 1.5. 28 poinls is sIighlIy
leIov lhe cul off poinl foi ADHD diagnosis (36). None of lhe pailicipanls veie consequenlIy
diagnosed vilh ADHD oi any olhei neuiopsychialiic diagnoses. Iailicipanls veie aIso
consideied lo le vilhin a noinaI iange vilh iegaid lo geneiaI schooI peifoinance.
5.2 MateriaIs
A visuo-spaliaI voiking nenoiy (vsWM) lesl vas used (spanloaid, Wesleileig,
Hiivikoski, Ioissleig, & KIingleig, 2OO4). This lesl is a sensilive neasuie of cognilive
deficils in ADHD. The lesl deleinines voiking nenoiy capacily vilhoul leing affecled ly
pievious skiIIs oi knovIedge. The visuo-spaliaI WM lask consisls of ied dols (nenoiy
slinuIi) lhal aie piesenled one al a line al a conpulei scieen in a foui ly foui giid. Inlei-
slinuIus-inleivaIs veie 4 seconds, laigel is shovn foi 2.225 sec and a 1.725 sec pause is
given lefoie lhe nexl laigel luins up. Iailicipanls aie asked lo iecaII Iocalion, as veII as lhe
oidei in vhich lhe ied dols appeai. The voiking nenoiy Ioad incieases aflei eveiy second
liiaI, and lhe voiking nenoiy capacily is eslinaled lased on lhe nunlei of coiieclIy
iecaIIed dols. Dependenl vaiialIe vas lolaI nunlei of coiieclIy iecaIIed dols.
AII noise condilions veie iecoided and iepioduced on a CD pIayei. The speech pail of lhe
speech and noise condilion vas iecoided al a cafe al SlockhoIn Univeisily, vheie five
sludenls discussed fiIns, looks, and vhal lhey did ovei lhe veekend. The equivaIenl
conlinuous sound IeveI of lhe vhile noise vas sel lo 78 d(A) in lhe lhiee noise condilions, in
accoidance vilh findings fion eaiIiei sludies (SdeiIund, el aI., 2OO7, SdeiIund, el aI., 2O1O).
5.3 Design
We used a 2 x 4 design, vheie sound enviionnenl (siIence vs. vhile noise, siIence vs.
speech, siIence vs. speech + vhile noise) vas lhe vilhin gioup vaiialIe. The lelveen gioup
vaiialIe vas leachei ialed cIassioon allenlion IeveI (allenlive vs. inallenlive)
5.4 Procedure
The lesling vas conducled al lhe chiIdiens schooI, foIIoving peinission fion paienls and
chiIdien. The iegionaI elhic loaid in SlockhoIn appioved lhe sludy. The pailicipanls veie
lesled individuaIIy in a ioon duiing lhe schooI day.
The pailicipanls veie lesled individuaIIy in a ioon duiing lhe schooI day. AII pailicipanls
used lhe sane 15 Iaplop IC foi lhe visuo-spaliaI lesl (span-loaid). Headphones piovided lhe
noise, and d IeveIs vheie checked foi aII pailicipanls ahead of eveiy session. efoie slailing
lhe expeiinenl piopei, lvo piaclice liiaIs veie conducled. The line laken lo conpIele each
lesl vas appioxinaleIy 5 ninules, depending on lhe peifoinance IeveI (lhe lellei
peifoinance lhe Iongei line). AIlogelhei, lhe lesling sessions Iasled appioxinaleIy 3O ninules
incIuding insliuclions and lesl liiaIs. The noise condilions veie piesenled in iandon oidei so
each condilion appeaied equaIIy nany lines in each posilion (fiisl, second, lhiid, and foilh).
6. ResuIts
A 2 x 4 nixed ANOVA vas conducled incIuding aII noise condilions. No nain effecl of
noise vas found, lul a significanl oveiaII inleiaclion vas found lelveen noise and gioup
(I(18,3)= 3.44, p= .O39, ela
2
= .365). The diffeience lelveen gioups vas aIso significanl,
vheie lhe allenlive gioup oulpeifoined lhe inallenlive gioup in aII condilions (I(2O,1) =
12.63, p = .OO2, ela
2
.387)
Theieaflei ve conducled lhiee sepaiale 2 x 2 nixed ANOVAs, one foi each noise condilion.
Il conpiised one lelveen-suljecl facloi, /&+<$ (allenlive vs. inallenlive) and one vilhin-
suljecls facloi, #)1+.0)/ 2'0(<5%'0+) 1+).0'0+) (siIence vs. vhile noise, siIence vs. speech,
siIence vs. speech + vhile noise). The dala fion lhese lesls aie piesenled in lhe lhiee giaphs
leIov. In neilhei of lhe lhiee noise condilions ve found a nain effecl of noise, lul in lvo
oul of lhiee condilions ve found a iolusl noise x gioup inleiaclion.
In lhe fiisl ANOVA, (siIence vs. vhile noise, Iiguie 3) ve found an inleiaclion lelveen
gioup and noise. The inallenlive gioup inpioved ils peifoinance vheieas lhe allenlive

Iig. 3. Nunlei of coiieclIy iecaIIed ilens in a visuo-spaliaI voiking nenoiy lask as a
funclion of noise condilion, siIence vs. vhile noise in lvo gioups: allenlive (N=11) and
inallenlive (N=11).
15
20
25
30
35
40
45
silence noise
P
e
r
f
o
r
m
a
n
c
e
Inattentive
Attentive

gioup decIined undei lhe vhile noise condilion (I(2O, 1)= 8.17, p = .O1O, ela
2
= .29O). A one-
vay ANOVA shoved lhal lhe diffeience lelveen gioups in lhe siIenl condilion
disappeaied in lhe noise condilion (p < .OO1 vs. p= .222)

funclion of noise condilion, siIence vs. speech noise in lvo gioups: allenlive (N=11) and
inallenlive (N=11).

funclion of noise condilion, siIence vs. speech noise in lvo gioups: allenlive (N=11) and
inallenlive (N=11).
15
20
25
30
35
40
45
silence speech
P
e
r
f
o
r
m
a
n
c
e
Inattentive
Attentive
15
20
25
30
35
40
45
silence speech
P
e
r
f
o
r
m
a
n
c
e
+ noise
Inattentive
Attentive
A paiied sanpIes lesl, lesling gioups sepaialeIy, ieveaIed lhal lhe deciease foi lhe allenlive
gioup vas significanl (l(1O)= -2.95, p = .O15), vheieas lhe inciease in peifoinance foi lhe
inallenlive gioup did nol ieach significance (l(1O)= 1.O2, p = .333, Iiguie 3).
The second ANOVA (siIence vs. speech, Iiguie 4) aIso shoved a significanl inleiaclion, in
lhis case, lelveen gioup and speech (I(2O, 1)= 6.15, p = .O19, ela
2
= .246). The inallenlive
gioup peifoined lellei and lhe allenlive gioup peifoined voise in lhe speech condilion as
conpaied lo peifoinance in lhe siIenl condilion.
A paiied sanpIes lesl, lesling gioups sepaialeIy, ieveaIed lhal lhe inciease foi lhe
inallenlive gioup vas significanl in lhe speech condilion (l(1O)= 3.O1, p = .O13) vheieas lhe
decienenl foi lhe allenlive gioup vas nol (l(1O)= .981, p = .35O). IinaIIy, lhe one-vay
ANOVA shoved lhal, despile lhe inpiovenenl foi lhe inallenlive gioup, in lhe speech
condilion lhe diffeience lelveen gioups ienained significanl (I(2O, 1)= 5.43, p = .O3O).
In lhe Iasl ANOVA (siIence vs, speech + noise, Iiguie 5) lheie vas no inleiaclion lelveen
lhe gioup and noise condilion The iolusl diffeienl lelveen gioups ienained in lhe speech
+ noise condilion (I(2O, 1)= 16.94, p = .OO1). Neilhei did a paiied sanpIe l-lesl ieveaI a
diffeience lelveen gioups as an effecl of noise, lolh gioups peifoined al lhe sane IeveI in
siIence as in lhe speech + noise condilion (p= .766 vs. p = .368)
7. ConcIusions and future chaIIenges
As piedicled, lhe iesuIls shovn alove confiin eaiIiei findings shoving diffeienl effecls of
vhile noise on allenlive and inallenlive chiIdien seIecled fion a noinaI popuIalion. The
sul-cIinicaI inallenlive gioup did indeed lenefil fion noise, vhiIe lheii allenlive peeis did
nol. InleieslingIy, lhe speech (cIassioon noise) condilion did nol Iead lo any deliinenlaI
effecls foi lhe inallenlive gioup, lul inpioved lheii peifoinance as veII. These iesuIls
suggesl lhal lhe leneficiaI effecls of audiloiy enviionnenlaI slinuIalion on inallenlive
peopIe aie found nol onIy in puie noise condilions, as has leen found pieviousIy, lul
geneiaIize lo lioadei sels of enviionnenlaI sounds. In pailicuIai, lhis sludy denonsliales
lhal noise enhancenenl can le found foi speech. To vhal exlenl noise enhancenenl effecls
geneiaIize lo olhei audiloiy slinuIi is sliII unexpIoied. Hovevei, lhese iesuIls suggesl lhal
ve need lo le open lo lhe idea lhal videi sels of enviionnenlaI slinuIalion nay seive lhe
lenefil of cognilive enhancenenl in inallenlive peopIe. The cafeleiia/cIassioon noise
condilion inpioved voiking nenoiy peifoinance foi lhe inallenlive gioup, vheieas lhe
allenlive pailicipanls peifoinance decieased.
The ievieved Iileialuie has found inconsislenl iesuIls iegaiding lhe effecl of noise on
peifoinance in cognilive lasks. Sludies have shovn deliinenlaI effecls, no effecls, and lhal
noise inleiacls vilh olhei vaiialIes such as gendei oi line of lhe day (akei & HoIding,
1993, akei, HoIding, & Loel, 1984, eIIeviIIe, el aI., 2OO3, onan, Lnnaikei, & Hygge, 2OO5,
RouIeau & eIIeviIIe, 1996). Il is pIausilIe lhal conlioIIing foi pailicipanl chaiacleiislics such
as age, allenlion aliIily and voiking nenoiy capacily vouId piovide olhei iesuIls.
DiffeienliaI effecls of noise can le hidden in gioup neans, veie sone pailicipanls inpiove
vhiIe lhe peifoinance of olheis is inpaiied.
Oui findings suggesl a need foi fuilhei sludies of psychoacouslics on diffeienl soundscapes.
Iievious ieseaich has focused on lesling diffeienl noise IeveIs (anpIiludes in d) ovei
Iaigei sanpIes of pailicipanls. Hovevei, lhe dala piesenled heie piopose lhal diffeienl

sounds need lo le invesligaled in ieIalion SR. While noise nighl le liiing lo Iislen lo foi
exlended peiiods. Iuluie ieseaich needs lo addiess lhe queslion of vhelhei sounds fion
valeifaIIs, shiveiing Ieafs oi sounds fion lanloo giass couId le leneficiaI as veII. These
noise-Iike sounds possilIy incIude sufficienl vaiialiIily in lolh anpIilude and fiequencies
lo induce lhe iequiied inciease of vaiialiIily inlo lhe neivous syslen.
Iuluie sludies shouId invesligale lhe neuiophysioIogicaI liaces sel ly noise ly LLC
neasuies. LaiIiei sludies have shovn lhal ADHD palienls dispIay eIevaled ieIalive lhela
povei, lhela/aIpha, and lhela/lela ialios duiing iesl (aiiy, CIaike, & }ohnslone, 2OO3). We
have ieason lo leIieve lhal noise exposuie couId noinaIize lhese anonaIies, and inciease
lhe IeveI of lela and ganna aclivily pailicuIaiIy. ela and ganna aclivily is ciuciaI foi
highei nenlaI aclivilies, such as focused allenlion. Iuilheinoie, lhe expanding fieId of
neuio-feedlack is pioviding /invesligaling inleiesling looIs lo inpiove allenlion, hovevei,
snaII effecl sizes have leen shovn lhis fai (Ains, de Riddei, SliehI, ieleIei, & Coenen,
2OO9, CevensIelen el aI., 2OO9). The oulcone effecls of neuio-feedlack nighl gel loosled if
conlined vilh noise exposuie and nay, in pailicuIai, shoilen lhe line needed lo ollain
iolusl and Iong-Iasling effecls. The fieId of noise-induced inpiovenenl is sliII in ils infancy,
and a Iol of ieseaich is needed lo gel a good picluie of lhe polenliaI conliilulions fion lhis
nev fieId. NeveilheIess, ve find lhe iesuIls veiy pionising lhis fai, and foiesee a gioving
fieId of possilIe appIicalions. In Svedish educalion and eIsevheie, schooI faiIuies inciease.
Cuiienl figuies shov lhal aloul 25 do nol achieve a conpIele exan fion conpuIsoiy oi
uppei secondaiy schooI (SkoIveikel, 2OO5). IndividuaIIy adapled sludy enviionnenls,
uliIizing lhe lenefils of noise, nay le one possiliIily lo luin lhis dovnvaid liend.
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Svanson, }. M., Schuck, S., Mann, M., CaiIson, C., Hailnan, K., Seigeanl, }., . . . McCIeaiy, R.
(2OO7). CalegoiicaI and dinensionaI definilions and evaIualios of ADHD: The
SNAI and lhe SWAN ialing scaIes. J#'&0#7#. "#1#(C#& :GGH ,&+(
hllp://vvv.ADHD.nel.
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Cognilive Ieifoinance Undei Ceilain Condilions: LxanpIes fion Visuo-SpaliaI
Woiking Menoiy and Dicholic Lislening Tasks. -&+1##.0)/2 ,&+( V_?AMY94 :GGD3
"#$' +, >0)/<02'0123 4'+1`;+5( 6)07#&20'83 4'+1`;+5(3 4@#.#).
SdeiIund, C. . W., Sikslion, S., & Snail, A. (2OO7). Lislen lo lhe noise: Noise is leneficiaI
foi cognilive peifoinance in ADHD. |ConlioIIed CIinicaI TiiaIj. B+<&)%5 +, 1;05.
$281;+5+/8 %). $281;0%'&83 %). %550#. .0210$50)#23 FK(8), 84O-847. doi: 1O.1111/j.1469-
761O.2OO7.O1749.x
SdeiIund, C. . W., & Sikslin, S. (2OO8). Iosilive effecls of noise on cognlive peifoinance:
LxpIaining lhe Modeiale iain AiousaI ModeI. -&+1##.0)/2 ,&+( Y9ZA?3
Y)'#&)%'0+)%5 9+(0220+) +) ';# Z0+5+/01%5 A,,#1'2 +, ?+02#.
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lackgiound vhile noise on nenoiy peifoinance in inallenlive schooI chiIdien.
Z#;%70+&%5 %). Z&%0) V<)1'0+)23 L(55). doi: doi:1O.1186/1744-9O81-6-55
Siqvisl, I. (2O1Oa). High voiking nenoiy capacily allenuales lhe devialion effecl lul nol
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1O.1OO1/jana.2OO9.13O8
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?#<&+$281;+5. doi: jnp194 |piij 1O.1348/1748664O9X4682O5

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slinuIalion inpioves aulononic and noloi iesponsiveness in cenliaI
neuiodegeneialive disoideis. P)) ?#<&+53 NK(2), 175-181.
Zeng, I. C., Iu, Q. }., & Moise, R. (2OOO). Hunan heaiing enhanced ly noise. Z&%0) J#2#%&1;3
KLD(1-2), 251-255.
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159-165.
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Hypeiaclive ChiIdien. B+<&)%5 +, 41;++5 -281;+5+/83 :H(2), 165-173.
ZenlaII, S. S., IaIkenleig, S. D., & Snilh, L. . (1985). Lffecls of coIoi slinuIalion and
infoinalion on lhe copying peifoinance of allenlion-piolIen adoIescenls. B+<&)%5
+, PC)+&(%5 9;05. -281;+5+/83 !=(4), 5O1-511.
ZenlaII, S. S., & Shav, }. H. (198O). Lffecls of cIassioon noise on peifoinance and aclivily of
second-giade hypeiaclive and conlioI chiIdien. B+<&)%5 +, #.<1%'0+)%5 $281;+5+/83
H:(6), 83O-84O.
ZenlaII, S. S., & ZenlaII, T. R. (1983). OplinaI slinuIalion: A nodeI of disoideied aclivily
and peifoinance in noinaI and devianl chiIdien. -281;+5+/01%5 Z<55#'0)3 DF(3), 446-
471.
Part 4
EEG Biofeedback

13
QEEG Characteristics and Biofeedback
ModaIities in ChiIdren with ADHD
Nada Iop-}oidanova
!"#$%&'"(& *+% ,-./0+#0.-1+2+3.4 5(16"%-1&. ,"71$&%1/ 821(1/4 9:+#;"4
<= >$/"7+(1$
1. Introduction
Allenlion Deficil Hypeiaclivily Disoidei (ADHD) is one of lhe nosl fiequenl
neuiopsychialiic diagnoses duiing chiIdhood, vaiying lelveen 2 and 1O depending on
counliy oi cuIluiaI aiea. In oui counliy (R. Macedonia), lhe incidence of ADHD is aloul 2.
The olhei IaleIs of lhe disoidei inlioduced in lhe pasl aie hypeiaclivily, hypeikinesis,
hypeikinelic syndione, nininaI liain dysfunclion and nininaI liain danage. Accoiding
lo DSM - IV (Aneiican Isychialiic Associalion, 1994) lheie aie lhiee nain cIinicaI foins of
lhis disoidei: inallenlive, hypeiaclive/inpuIsive and conlined. Luiopean diagnoslic
ciileiia foi hypeikinelic disoidei as defined ly lhe ICD-1O (InleinalionaI CIassificalion of
Diseases, 1O
lh
ievision, 1993) incIude chiIdien dispIaying deveIopnenlaIIy inappiopiiale
IeveIs of allenlion, hypeiaclivily and inpuIsivily lhal legin in chiIdhood and cause
inpaiinenl lo schooI peifoinance, inleIIecluaI funclioning, sociaI skiIIs, diiving and
occupalionaI funclioning. CeneiaIIy, ICD-1O ciileiia aie noie iesliiclive lhan DSM-IV
diagnosis lecause lhey need a giealei degiee of synplon expiession.
The oveiIapping of aII lhiee foins vilh Ieaining disaliIilies is veiy high (up lo 7O), as veII
as vilh conducl piolIens. The inallenlive (ADD) foin nainIy oveiIaps vilh anxiely
disoideis and Ieaining disaliIily, vhiIe hypeiaclive foin (ADHD) noslIy oveiIaps vilh
conducl disoidei. Sone chiIdien vilh ADHD have novenenl disoideis oi lics and
occasionaIIy lhey nay have seizuie disoideis (aikIey, 199O). Sliong genelic conponenl
ieIaled lo defecl in chionosone 11 is shoved in sone sludies (Anokhin el aII. 2OO6).
Conceining lhe invoIvenenl of specific neuioliansnillei syslens in lhe palhophysioIogy of
ADHD sone aulhois suggesl lhal lhe calechoIanineigic dysieguIalions aie cenliaIIy
invoIved.
This chaplei is nainIy devoled lo lhe QLLC chaiacleiislics of ADHD in chiIdien, connecled
lo endophenolypes, evenl ieIaled polenliaIs, liain iale and liofeedlack liealnenl. IiislIy, il
viII le expIained vhy QLLC iecoiding is inpoilanl foi lhe exacl diagnoslics and lhe
lheiapy pIanning foi ADHD chiIdien. ased on QLLC diffeienlialion, lhe endophenolypes
cIusleiing enalIes noie piecise diagnoslics. In addilion, il viII le shovn lhal evenl ieIaled
polenliaIs (LRIs) aie ieIaled lo lhe possilIe dysfunclion of execulive syslen, as a pail of lhe
liain lhe nosl invoIved in lhis disoidei. The appIied caIcuIalion of liain iale is oui oiiginaI
pioposaI foi lhe evaIualion of geneiaI nenlaI aclivalion IeveI, consideiing undei oi ovei-
aiousaI slales, so lhal lhe pIanning of lhe liealnenl piolocoIs lecones noie easy.


250
IinaIIy, liofeedlack viII le offei as lhe non-phainaceulicaI liealnenl foi ADHD, vilh
Iong-lein effecls.
2. QEEG recording
The LLC iecoiding is a noninvasive, painIess, and safe neasuienenl using digilaI
lechnoIogy of eIecliicaI palleins al lhe suiface of lhe scaIp vhich piinaiiIy iefIecl coilicaI
eIecliicaI aclivily oi liainvaves. The Quanlilalive LLC pioceduie uses nuIli-eIecliode LLC
iecoiding vheie lhe dala aie piocessed vilh vaiious aIgoiilhns and lhan slalislicaIIy
anaIyzed conpaiing vaIues vilh noinalive dalalase iefeience vaIues. The piocessed LLC
couId le aIso conveiled inlo coIoi naps of liain funclioning caIIed liain naps.
The pIacenenl of eIecliodes fion lhe fiisl iecoiding (inlioduced in 1924) vas sliongIy
piecise and lhe syslen vas caIIed lhe1O-2O InleinalionaI Syslen of LIecliode IIacenenl.
This syslen of iecoiding is used unliI nov. The "1O" and "2O" iefei lo lhe facl lhal lhe acluaI
dislances lelveen adjacenl eIecliodes aie eilhei 1O oi 2O of lhe lolaI fionl-lack oi iighl-
Iefl dislance of lhe skuII (Iig.1).

Iig. 1. The 1O-2O InleinalionaI Syslen

QEEG Characteristics and Biofeedback Modalities in Children with ADHD

251
Lach sile has a Iellei lo idenlify lhe Iole and a nunlei lo idenlify lhe henispheie Iocalion.
The Ielleis I, T, C, I and O sland foi IionlaI, TenpoiaI, CenliaI, IaiielaI, and OccipilaI,
iespecliveIy. Nole lhal in facl lheie exisls no cenliaI Iole, lhe "C" Iellei is onIy used foi
idenlificalion puiposes onIy. The Iellei "z" (zeio) iefeis lo an eIecliode pIaced on lhe
nidIine. Lven nunleis (2, 4, 6, 8) iefei lo eIecliode posilions on lhe iighl henispheie,
vheieas odd nunleis (1, 3, 5, 7) iefei lo lhose on lhe Iefl henispheie.
One inpoilanl eIenenl of lhe LLC signaI is ils ihylhnicily. Rhylhns diffei in fiequency,
Iocalion, nechanisn of geneialion and funclionaI neaning. They evoIve in line, so lhal a
iepiesenlalive LLC iecoiding usuaIIy lakes lhiee oi noie ninules (in oui palienls ve use
five ninule iecoiding). Ioi conpiessing lhe infoinalion aloul ihylhnicily ovei line, as a
nosl poveifuI nelhod, lhe Iouiiei anaIysis is used. The paianeleis of Iouiiei anaIysis can
le adjusled lo lhe goaI of a specific lask.
When LLC is iecoided fion nany eIecliodes lhal covei lhe vhoIe coilex, il is possilIe lo
conpule a 2D iepiesenlalion of a neasuied LLC chaiacleiislic. The chaiacleiislics couId le
eilhei polenliaI oi povei laken al a pailicuIai fiequency.
Conpuleiized anaIysis of LLC signaIs invoIve a nunlei of faclois: fiequency disliilulion,
voIlage (as anpIilude of lhe signaI), Iocus of lhe phenonena, vave shape noiphoIogy,
inlei-henispheiic synneliies, chaiaclei of vavefoin occuiience and ieaclivily (changes in
an LLC paianelei vilh changes in slale).
The pallein of neuionaI osciIIalions pIays an inpoilanl ioIe in lhe evaIualion and liealnenl
of chiIdien (and aduIl as veII) vilh ADHD. These palienls aie chaiacleiized vilh QLLC
alnoinaIilies in up lo 8O. In lhis popuIalion, fionlaI iegions aie nosl IikeIy lo shov
devialions fion noinaI deveIopnenl, vilh disluiled lhaIano-coilicaI and seplaI-
hippocanpaI palhvays, aIlogelhei naned as execulive syslen.
The lein execulive funclions iefeis lo lhe cooidinalion and conlioI of noloi and cognilive
aclions lo allain specific goaIs. In neuiopsychoIogy, lhe lein execulive funclions has
Iong leen used as a synonyn foi fionlaI Iole funclion. A nodein viev posluIales seveiaI
sul-conponenls in lhe hypolhelicaI execulive nechanisn. In a fiequenlIy ciled
cIassificalion, Snilh and }onides (1999) dislinguished lelveen nechanisns ieIaling lo (a)
allenlion and inhililion, (l) lask nanagenenl, (c) pIanning, (d) noniloiing and (e)
coding. Theie is, hovevei, no consensus on lhe nunlei and lhe piecise naluie of
funclionaI sulconponenls.
As ve said pieviousIy, il is supposed lhal lhe nain liain syslen inpaiied in ADHD is lhe
execulive syslen. The execulive syslen is chaiacleiized ly lvo paianeleis: geneiaI
aclivalion of lhe syslen (aiousaI = A) and lhe iesponse associaled vilh diffeienl opeialions
such as voiking nenoiy, aclion seIeclion, aclion inhililion and aclion noniloiing (focused
aclivalion = Al).
Il is veII knovn lhal LLC iecoided in eyes open (LO) and eyes cIosed (LC) iesling slale is
good indicaloi of nelaloIic aclivily in lhe liain coilex. Lov nelaloIic aclivily in lhe aiea
lhal geneiales lhe coiiesponding LLC is chaiacleiized ly inciease of sIov aclivilies (deIla
and lhela vaves) and deciease of lela aclivilies. Il neans lhal in lhis condilion, lhe IeveI of
aclivalion is Iov (Iov A), as veII as lhe anpIilude of iesponses ve naned focused aclivily
(Al) is aIso Iov.


252
The eaiIy sludies of LLC alnoinaIilies in chiIdien vilh nininaI liain dysfunclion aie
nade in lhe peiiod 193O-195O. asicaIIy, LLC sludies shoved lhe inciease of deIla and lhela
lands in cenliaI and fionlaI iegions duiing LLC iecoiding. This finding vas confiined ly
quanlilalive LLC anaIysis in lhe 197Os and Ialei. These sludies aie suppoiled ly iecenl ILT
(posilion enission lonogiaphy) and SILCT (singIe pholon enission conpuleiized
lonogiaphy) scan sludies, vhich aIso indicale alnoinaIilies in ceieliaI nelaloIisn in lhese
pailicuIai liain aieas.
The nosl sludies of QLLC in ADHD popuIalion confiin eIevaled IeveIs of sIov vave
povei in fionlaI iegion indicaling fionlaI Iole deaclivalion, in conpaiison lo noinaI
chiIdien. These chiIdien expeiience decieased nelaloIisn in piefionlaI iegions of lhe liain
and have leen good candidales foi lhe use of slinuIanl nedicalion oi neuiofeedlack. Olhei
chiIdien shov deficils in Iinlic syslen aclivily and aie chaiacleiized as having opposilionaI
lehavioi, enolionaI oulluisls, and inpuIsiveness. These chiIdien aIso shov significanl
decieased nelaloIisn in lhe piefionlaI Ioles and lhe anleiioi cinguIaled gyius. They aie
good candidales foi lhe use of liicycIic anlidepiessanls. The lhiid sulgioup conpiises
individuaIs vho have incieased aclivily in lhe nediaI supeiioi fionlaI gyius. AIlhough
lhese chiIdien expeiience ADD lhey aie oflen chaiacleiized as having an allenlion deficil
vilh olsessive-conpuIsive disoidei. They have a veiy shoil allenlion span and aie oflen
inpuIsive and opposilionaI. These palienls sonelines iespond lo cIonipianine. y fai lhe
nosl connon gioup of chiIdien vilh ADD consisls of lhose vilh excessive sIov aclivily in
fionlaI and cenliaI liain iegions.
Having in nind lhal lhe alsoIule vaIues of LLC speclia depend on sone liain unieIaled
fealuies, such as lhickness of lhe skuII, a ieIalive paianelei defined as lhe lhela-lela ialio is
inlioduced. MuIli-cenliic sludies in USA (Monaslia el aI. 2OO1, Lulai 1991, 1997, Mann el aI
1992) used lhe lhela-lela ialio as an index of inallenlion. This so caIIed 1($&&"(&1+( 1(7"? is
defined as a ialio of lhela LLC povei (neasuied vilhin lhe 4-8 Hz fiequency land) and
lela LLC povei (neasuied vilhin 13-21 Hz fiequency land). UsuaIIy lhis index is
caIcuIaled ly LLC iecoiding al a singIe pIace Cz in iefeience lo Iinked eais. Il vas found
lhal lhis index is lhiee lines highei in inallenlive and conline lypes of ADHD chiIdien al
lhe age of 6-1O yeais conpaied vilh noinaI gioup. Monaslia el aI. (2OO1) found lhal lhe
sensilivily of lhis index vas 86 and his specificily is 98.
Opposile lo lhese findings Russian scienlisls fion lhe Hunan iain Inslilule in Sl
Ieleisluig (Kiopolov, 2OO9) shoved lhal lhis index is a good neasuie onIy foi a pail of
ADHD popuIalion. Mapping lhis index in noinaI popuIalion shoved lhal lhe Iocalion of
lhe naxinun of lhis index changes significanlIy vilh age. Ioi exanpIe, lhe naxinun of
lhela-lela index nove fion cenliaI-paiielaI Iocalion al 7-8 yeais oId chiIdien lo fionlaI-
cenliaI Iocalion in aduIls. The concIusion vas lhal foi lellei iesuIls in disciininaling lhe
ADHD popuIalion fion heaIlhy suljecls lhis index nusl le neasuied in diffeienl eIecliode
posilion depending on age.
CeneiaIIy, ve can infei lhal QLLC iecoiding is needed foi noie piecise diagnoslics of
ADHD, in addilion lo lhe cIinicaI ciileiia. The nelhod is a non invasive, ieIaliveIy easy foi
nanipuIalion vilh slandaidized Iocalions of lhe eIecliodes ovei lhe scaIp. The iecoiding is
peifoined in diffeienl condilions: eyes open, eyes cIosed and duiing sone cognilive lasks
(Co/ NoCo paiadign, visuaI oi audilive peifoinance lasks, ieading oi nalh lasks). QLLC
is usefuI if neuiofeedlack liealnenl is pIanned lo le appIied.


253
3. Endophenotypes
Lndophenolypes aie chaiacleiislics indicaling lioIogicaI naikeis of lhe liain disease.
Lndophenolype nusl oley sone iequiienenls: a) lo le slalIe and iepioducilIe in line
inleivaIs duiing vhich lehavioiaI palleins associaled vilh lhe slale of lhe liain ienain
unchanged, l) endophenolype nusl iefIecl a funclion of a ceilain liain syslen lhal in a
specific vay deleinine lhe hunan lehavioi, and c) il nusl le inheiiled. LLC speclia, oi
anpIilude of lhe lackgiound LLC in ceilain fiequency lands, oley lhese iequiienenls and
consequenlIy can le consideied as endophenolypes.
We said in lhe pievious lexl lhal LLC osciIIalions (expiessed as e.g. aIpha oi lhela ihylhn)
vane and vax in line. The degiee of vaiialiIily of lhe lasic osciIIalion depends on lhe
fiequency land and lhe slale (eyes open, eyes cIosed, lask elc) of lhe suljecl. Ioi exanpIe,
aIpha spindIes in lhe posleiioi iegions vaiy vilh peiiods of fev seconds, and luisl of lhe
fionlaI nidIine lhela appeai vilh inleiluisl peiiods of fev deco-seconds. Hovevei, if
aveiaged ovei significanlIy Iong line inleivaIs lhe iesuIling speclia lecone quile slalIe
chaiacleiislics of lhe liain. So, lhese chaiacleiislics of LLC speclia couId le consideied as a
ieIialIe and slalIe eslinalion of lhe liain funclionaI slale.
Diffeienl osciIIalions iefIecl diffeienl nechanisns: aIpha ihylhns iefIecl lhe slale of lhaIano-
coilicaI palhvays, fionlaI nidIine lhela ihylhns iefIecl funclioning of lhe Iinlic syslen, lela
ihylhns aie noie IocaI iefIecling slale of specific coilicaI aieas. So, defining alnoinaI
ihylhnic aclivilies in LLC and associaling lhese alnoinaIilies vilh dislincl syslens fil lhe
second iequiienenl foi endophenolypes as lhe lioIogicaI naikeis of disease. IinaIIy, lheie is
sliong expeiinenlaI evidence lhal specliaI chaiacleiislics of LLC aie inheiiled.
CeneiaIIy, il can le said lhal endophenolype is leconing an inpoilanl concepl in lhe sludy
of diffeienl nenlaI disoideis such as ADHD, schizophienia elc. The lein vas coined in 1966
and appIied in psychialiy ly Collesnan and ShiIeds in 1972. Il is giaduaIIy sulsliluling
sone siniIai leins such as lioIogicaI naikeis, vuIneialiIily naikei, sulcIinicaI liails
oi inleinediale phenolype. An endophenolype nay le neuiophysioIogicaI, liochenicaI,
endociinoIogicaI, neuioanalonicaI, oi neuiophychoIogicaI in naluie. Lndophenolype
iepiesenls sinpIei cIue lo genelic nechanisn lhan lhe lehavioiaI synplons.Theiely,
endophenolypes can heIp lo define sullypes of a pailicuIai disoidei and can le used as a
quanlilalive liail in genelic anaIyses of piolands and faniIies.
Ioi exanpIe, sone ieseaicheis suggesl a lioIogicaI ialionaIe foi Iack of inhililion as an
endophenolype foi ADHD. Inhililoiy lasks aclivale lhe piefionlaI coilex and lasaI gangIia,
iegions in vhich lhe dopanine syslen is associaled vilh execulive funclioning. Tesls of
inhililoiy funclion, such as lhe slop signaI lask, oflen consisls of lvo concuiienl lasks (a "Co"
lask and NoCo lask) in vhich lhe suljecl is signaIed lo pioduce a pailicuIai iesponse. An
individuaI vilh a pooi inhililoiy syslen viII have a Iong ieaclion line. This deficil, leing
iepIicaled seveiaI lines, is conceined lo le specific lo ADHD. Inaging sludies have shovn
lhal lhis inhililoiy lask aclivales lhe piefionlaI coilex and lasaI gangIia. Inhililion aIso
coiieIales vilh faniIy hisloiy, so lhal 48.1 suljecls vilh pooi inhililion have a faniIy hisloiy
of ADHD conpaied vilh onIy 7.7 of noinaI conlioIs. (Cioslie, Schachai, 2OO1).
Lndophenolypes nay aIso le usefuI in expIoiing diffeienl palhvays Ieading up lo lhe
disoidei. Ialienls having lhe sane diagnosis nay diffei sliongIy in lhe nunlei and seveiily
of synplons lhey poiliay, suggesling heleiogeneily in lhe causaI palhvays. Ciealing noie


254
honogeneous sulgioups of palienls lased on lheii endophenolypic funclioning, nay
faciIilale uniaveIing lhese diffeienliaI causaI palhvays.
RecenlIy, a QLLC specliun cIassificalion of ADHD popuIalion has leen deveIoped defining
foui nain sullypes: I sullype (alnoinaI inciease of deIla-lhela fiequency iange cenliaIIy oi
cenliaIIy-fionlaIIy), II sullype (alnoinaI inciease of fionlaI nidIine lhela ihylhn), III
sullype (alnoinaI inciease of lela aclivily fionlaIIy), and IV sullype (excess of aIpha
aclivilies al posleiioi, cenliaI, oi fionlaI Ieads).
In lhe foIIoving, I viII shov (on Iigs. 2-8) sone oui exanpIes of QLLC speclia fion
diffeienl sullypes of ADHD chiIdien (Iop-}oidanova 2OO7, 2OO9, Zoicec 2OO7, 2OO8).
The fiisl and second sullypes aie chaiacleiized cIinicaIIy vilh inallenlion, vhiIe in lhe lhiid
sullype nainIy hypeiaclivily, inpuIsivily and sociaI inadaplalion aie pievaIenl. The Iov
allenlion span is aIso lhe nain conpIain of chiIdien vilh aIpha excess.
Anong lhe invesligaled Macedonian ADHD chiIdien (ovei 25O), veiy sIov aIpha excess
(sullype 4) vas shoved in 25 of chiIdien, and high lhela/lela ialio in fionlaI-cenliaI
coilex (sullype 1) in olhei 25 of chiIdien. The najoiily of 48 leIong lo lhe conlined 1
and 2 sullypes. Veiy iaieIy (undei 2) ve found sullype III veie oveiaclive coilex is
lypicaI finding (Iop-}oidanova el aI. 2OO7, Zoicec el aI. 2OO7, 2OO8).

Iig. 2. Sullype I - High deIla and lhela anpIiludes in fionlaI-cenliaI coilex


255
As can le seen on Iig. 1, in fionlaI and cenliaI iegion of liain coilex lhe doninanl fiequencies
aie in lhe iange of deIla and lhela vaves, vhiIe aIpha and lela vaves aie piaclicaIIy alsenl.

Iig. 3. Sullype II Lxcess of fionlaI-nidIine lhela
On Iig.3 ve can see a pick of lhela aclivily (I 6.54 Hz) in fionlaI-nidIine aiea as lhe nosl
inpoilanl finding. Il is aIso conlined vilh geneiaIIy sIov aclivily (Iack of aIpha and lela
aclivily). The sane is visilIe on lhe iov LLC iecoid shovn in Iig. 4.
olh Iig.5 and 6 shov ovei aclivalion of lhe coilex expiessed ly lhe pionounced lela liain
vaves.
In addilion lo lhe QLLC, SILCT (Anen, 1997, Anen el aI. 1998@ shovs lhe coiiesponding
specifics in ADHD chiIdien vhich can le sunnaiized as:
fionlaI Iole deaclivalion (piesenled cIinicaIIy as ADD, vhich usuaIIy iespond lo
lheiapy vilh RilaIin)
lenpoiaI Iole dysfunclion (veiy Iike lenpoiaI epiIepsy, iespond lo lheiapy vilh
anliconvuIsanl)
honogenous coilicaI suppiession (iespond lo conlinalion anlidepiessives + RilaIin)
incieased aclivily in lhe anleiioi nediaI aspecls of lhe fionlaI Ioles - gyios ieclus
(iesponds lo aIpha adieneigic lIockeis Iike cIonidine)
hypofionlaIily al iesl, lul noinaI fionlaI aclivily in inleIIecluaI sliess (iespond lo RilaIin)


256

(Nole sIov deIla/lhela vaves in fionlaI and cenliaI aiea)
Iig. 4. Sullype II - iov LLC iecoiding

Iig. 5. Sullype III - ovei aclivaled lela in fionlaI, cenliaI and paiielaI coilex


257

(Nole fasl liain vaves ovei aII coilex)
Iig. 6. Rov LLC iecoiding - oveiaclive coilex

Iig. 7. Sullype IV - aIpha excess


258

Iig. 8. Sullype IV- Rov iecoiding aIpha excess
The evidence is nol sufficienl lo peinil concIusions aloul lhe lenefils of SILCT inaging in
lhe diagnosis and liealnenl of ADHD. A significanl nunlei of pulIished sludies aie
focused on invesligaling diffeiences in iegionaI ceieliaI peifusion in iesponse lo diug
lheiapy and on seiolonin and dopanine ieceploi and lianspoilei aclivily. These sludies aie
onIy pieIininaiy. On lhe olhei side, lhe iisks associaled vilh SILCT inaging incIude
exposuie lo Iov-dose iadialion vhich is nol ieconnendalIe in chiIdien.
4. Event reIated potentiaIs
As ve said pieviousIy, lhe lein execulive funclions iefeis lo lhe cooidinalion and conlioI
of noloi and cognilive aclions lo allain specific goaIs. The execulive conlioI is needed foi
oplinizing lehavioi. The need foi an execulive conlioI nechanisn has leen posluIaled foi
non-iouline silualions iequiiing a supeivisoiy syslen (e.g. seIeclion of appiopiiale aclion
fion vaiiely of oplions, inhililion of inappiopiiale aclions, and keeping in voiking
nenoiy lhe pIan of lhe aclion as veII as lhe oulcone).
The execulive syslen conpiises a conpIex liain syslen such as seveiaI coilicaI and sul
coilicaI sliucluies inleiconnecled vilh each olhei. The coilicaI sliucluies incIude lhe
piefionlaI aieas inleiconnecled vilh lhe coiiesponding lhaIanic nucIei. The sliialun is lhe
nosl inpoilanl in lhe sulcoilicaI ciicuils and il is consideied as a cognilive nap of coilicaI
iepiesenlalions of aclions. Togelhei vilh lasaI gangIia lhe piefionlaI coilex peifoins
execulive funclions associaled vilh engagenenl, disengagenenl, noniloiing opeialions and
voiking nenoiy.
These opeialions of execulive syslen aie iefIecled in evenl ieIaled polenliaIs (LRIs) evoked
in diffeienl paiadigns Iike Co/NoCo, oddlaII and voiking nenoiy lasks. In oui piaclice
vilh ADHD chiIdien, ve use lhe Hunan iain Inslilule (HI) noinalive dalalase foi
conpaiing lhe ollained LRIs fion lhe palienls and noins.


259
The foIIoving execulive conponenls in lhe Co/NoCo slinuIus lasks couId le ollained:
- lhe noloi and aclion suppiession conponenls associaled vilh fionlaI negalivivilies al
2OO niIIisecond (lhe convenlionaI N2 inhililion conponenl)
- lhe engagenenl conponenl associaled vilh paiielaI posilivily al 3OO niIIisecond (lhe
convenlionaI I3l conponenl)
- lhe noniloiing conponenl associaled vilh fionlaI-cenliaI posilivily al 4OO niIIisecond
(I4OO).
The N2 noloi inhililion conponenl is geneialed in lhe ipsi-IaleiaI pienoloi coilex, lhe I3l
conponenl is geneialed in lhe paiielaI coilicaI aiea, and lhe I4OO noniloiing conponenl is
geneialed in lhe cinguIaled coilex. Il is supposed lhal dopanine is lhe nain nedialoi of lhe
execulive syslen.
Ioi lhe psychoneliic assessnenl of lhe execulive funclions in ADHD palienls nosl
fiequenlIy ve use lhe Slioop CoIoi Woid Task - SCWT (Slioop 1935), and Wisconsin Caid
Soiling Tesl - WCST (eig 1948).
The ollained iesuIls foi a gioup of 3O chiIdien diagnosed as conlined foin of ADHD, aged
7-14 yeais aie piesenled on TalIe 1 and TalIe 2 (Zoicec and Iop-}oidanova, 2O1O).

WCST
T-scoie
ADHD
Significance
of lhe lesl
T-scoie
conlioIs
Significance
of lhe lesl
I
A /$&"3+%1"- 42 Lov aveiage 55 aveiage O,32
A #"%-"6"%$&1+(- 31 leIov aveiage 51 aveiage O,OOOO1*
A '1-&$:"- 32 leIov aveiage 5O aveiage O,OOOOO*
/$%&- &+&$2 3O leIov aveiage 52 aveiage O,OOOO1*
> /$&"3+%1"- 31 leIov aveiage 51 aveiage O,OOOO1*
* slalislicaI significance
TalIe 1. T-scoie and slalislicaI significance foi WCST ollained foi ADHD chiIdien
conpaied vilh heaIlhy conlioI
SCWT
T-scoie
ADHD
Significance of lhe lesl
T-scoie
conlioIs
Significance of lhe lesl I
>1-&$:"- B9&@ CC 5O aveiage 55 aveiage O,1
>1-&$:"- CCC 29 Veiy Iov 5O aveiage O,OOOO1*
>1-&$:"- CCCDCC 28 Veiy Iov 53 aveiage O,OOOOO*
9& CCCE9& CC 5O aveiage 53 aveiage O,O2
*slalislicaI significance
TalIe 2. T- scoie and slalislicaI significance foi SCWT ollained foi ADHD chiIdien
conpaied vilh heaIlhy conlioI
In lhe eIecliophysioIogicaI evaIualion of ADHD chiIdien ve used VCIT (visuaI cognilive
peifoinance lask) vilh lvo slinuIus Co/NoCo lask deveIoped specificaIIy foi lhe HI
dalalase. The lask consisled of 4OO liiaIs. The duialion of slinuIi is equaI lo 1OO ns. TiiaIs
consisled of piesenlalion of a paii of slinuIi vilh inlei slinuIus inleivaI of 1.1 sec. InleivaI
lelveen liiaIs is equaI lo 3,1OO ns and iesponse inleivaI fion 1OO lo 1,OOO ns. Suljecls veie


260
insliucled lo piess a lullon vilh index fingei of lheii iighl hand as fasl as possilIe eveiy
line vhen aninaI oi angiy face vas foIIoved ly an aninaI oi angiy face (Co condilion),
iespecliveIy, and lo vilhhoId lhe suppiessing on lhe olhei lhiee liiaIs (NoCo condilion).
The VCIT duiing QLLC foi ADHD chiIdien shoved veiy high onnission and connission
eiiois, shoilei ieaclion line (RT) and highei vaiialion of lhe ieaclion line (vai RT),
conpaied vilh lhe iesuIls ollained foi conlioI heaIlhy chiIdien.(TalIe 3)

VCIT ADHD Noin &-lesl I
+'1--1+( "%%+%- BF+@ 32, 25 4 15, 65 O, OOOO1*
/+''1--1+( "%%+%- BA+F+@ 4, 75 1 7, 58 O, OOOO*
<G B'-@ F+ 456, 89 486 - 9, 17 O, OOOO1*
6$% <G 18, 97 11, 7 8, 78 O, OOOOO*
TalIe 3. SlalislicaI significance foi VCIT foiADHD chiIdien conpaied vilh lesls noins
Ioi lhe I3Co conponenl (aclivalion piocesses) ve did nol ollained significanl diffeiences
foi lhe Ialency as veII as foi lhe anpIilude, vhiIe foi I3NoCo conponenl (inhililion
piocesses) ve ollained nol significanl diffeiences foi lhe Ialency, lul significanl diffeiences
conceined lo lhe anpIidude. (TalI. 4)

ADHD noin &-lesl p
,HF+ B'-@ 327, 15 327, 89 - O, 12 O, 9
,HF+ B'I@ 9, 73 8, 55 O, 77 O, 44
,HA+F+ B'-@ 4O2, O5 415, 78 - O, 69 O, 49
,HA+F+ B'I@ 4, 67 6, 23 - 2, 89 O, OO6*
TalIe 4. SlalislicaI significance foi I3Co and I3NoCo foi ADHD chiIdien conpaied
vilh lesls noins
CeneiaIIy, oui ieseaich (Zoicec and Iop-}oidanova 2O1O) dedicaled lo lhe psychoneliic and
eIecliophysioIogicaI evaIualion of chiIdien diagnosed as ADHD shoved significanl
piesence of lhe peiseveialive nislakes and difficuIlies in lhe nenlaI fIexiliIily. The iesuIls
ollained foi VCIT shoved significanlIy highei onnission and connission eiiois, Iovei
ieaclion line (RT) as veII as highei vaiialion of line ieaclion (vai RT) conpaied lo lhe lesls
noins. The I3Co conponenl vaIues in lIe Ialency and anpIilude did nol diffei fion lhe
noins, lul lhe I3NoCo conponenl shoved significanl diffeience in lhe anpIilude.
5. Brain rate evaIuation
Revieving lhe LLC sludies of palienls vilh ADHD il can le concIuded lhal nosl of lhen
have geneiaIized oi inleinillenl specliun shifl. Il is lhe ieason lhal ve inlioduced lhe liain
iale caIcuIalion (Iop-}oidanova and Iop-}oidanov, 2OO5) in addilion lo lhela/lela ialio foi
lolh ains, in lhe assessnenl pioceduie and as a neuiofeedlack paianelei.


261
The liain iale (LLC specliun veighled fiequency) can le consideied as an inlegiaI slale
alliilule coiieIaled lo liain eIecliic, nenlaI and nelaloIic aclivily. In pailicuIai, il can seive
as a pieIininaiy diagnoslic indicaloi of geneiaI nenlaI aclivalion (i.e. consciousness IeveI),
in addilion lo heail iale, lIood piessuie oi lenpeialuie as slandaid indicalois of geneiaI
lodiIy aclivalion.
In oui ieseaich il vas shovn lhal liain iale can le used lo disciininale lelveen lhe gioups
of undei-aiousaI (UA) and ovei-aiousaI (OA) disoideis, lo assess lhe quaIily of sIeep, as
veII as lo indicale lhe IQ changes caused ly sone enviionnenlaI loxins (Iop-}oidanova
2OO9, Iop-}oidanov and Iop-}oidanova 2OO9, 2O1O). iain iale is aIso suilalIe lo ieveaI lhe
palleins of sensilivily/iigidily of LLC specliun, incIuding fiequency lands ieIaled lo
peinealiIily of coiiesponding neuionaI ciicuils. ased on aII lhis findings, lhe individuaIIy
adapled neuiofeedlack piolocoIs can le eIaloialed.
The nain chaiacleiislic of lhe inlegiaI (poIychionalic) LLC specliun is ils nean fiequency,
veighled ovei lhe vhoIe specliun (liain iale - *
J
), defined as
"
J
1
J 1 1 1 1
1 1 1
* *I * 7* I I * 7*
I
+%
I
* * , * I I
I
( ) , ( )
,
= =
= = =

vheie, 1 denoles lhe fiequency land (foi deIla 1KL, lhela 1KM, elc.), and I
1
- lhe
coiiesponding nean anpIilude of lhe eIecliic polenliaI. (Iop-}oidanova N., Iop-}oidanov }.,
2OO5)
In lhe foIIoving I viII piesenl sone iesuIls ollained foi liain iale (Deneidzieva, 2O11)
caIcuIaled foi a gioup of 5O palienls diagnosed as ADHD (age 119. 98, SD = 25.32 nonlhs,
lvo fenaIes and 48 naIes) conpaied vilh a gioup of 5O heaIlhy conlioIs (nean age 117.84,
SD = 24.89 nonlhs, and lhe sane gendei ialio as lhe ADHD gioup) (TalIe 5).

IionlaI CenliaI Iosleiioi Lefl MidIine Righl
C
i
o
u
p

e
f
f
e
c
l

NoinaIs vs.
ADHD

O.OOOOOO O.OOOOOO O.OOOOOO O.O29686 O.OOOO82
C
o
n
d
i
l
i
o
n

e
f
f
e
c
l

LC vs. LO O.O33569 O.O15872 O.OOOOOO O.OOOO83 O.OOOOOO O.OOOO14
LO vs. VCIT O.OOOOO1
LC vs. VCIT O.OOOOOO O.OO753O O.OOOOOO O.O14954 O.OOOOOO
LC vs. ACIT O.OOOOO5 O.OOO196 O.OOOOOO O.OOOOO4 O.OOOOOO O.OOOO89
VCIT vs.ACIT
O.OOOOO5

TalIe 5. Sunnaiy of significanl inleiaclions lelveen gioups, condilions and iegions foi
liain iale iesuIls (evaIualed vilh posl hoc onfeiioni lesl)


262
Maxinun vaIues of *
J
foi sagillaI lopogiaphy veie ollained in cenliaI and posleiioi iegions,
vhich is slalislicaIIy significanl, I (3, 39O) = 24.849, p =.OOOOO (Iig. 9, Iefl paneI). Anyvay lhese
iesuIls aie Iovei lhan lhose in heaIlhy conlioIs. Accoiding lo lhe diffeienl condilions, ollained
iesuIls veie aIso slalislicaIIy significanl, I (9, 949.31) = 72.294, p = O.OOOO. Maxinun vaIues foi
*
J
veie ollained in lhe posleiioi iegion duiing LC and nininun vaIues in lhe fionlaI iegion
again duiing LC condilion foi lolh ADHD and heaIlhy gioups..

Iig. 9. ResuIls foi f
l
vaIues foi sagillaI lopogiaphy accoiding gioups-Iefl paneI and
accoiding condilions-iighl paneI (LC-eyes cIosed, LO-eyes opened, VCIT- visuaI
conlinuous peifoinance lesl, ACIT- audiloiy conlinuous peifoinance lesl)
Maxinun vaIues of *
J
foi IaleiaI lopogiaphy aie ollained in lhe Iefl and iighl sides (Iig.1O, Iefl
paneI), vhich indicales highei excilaliIily of IaleiaI iegions. The iesuIls aie again significanlIy
highei in noinaI gioup vhich indicales undei aiousaI (UA) in chiIdien vilh ADHD
(coiiesponding lo sullype I pievaIence). Accoiding diffeienl condilions in IaleiaI lopogiaphy
lhe Iovei *
J
vaIues veie ollained in nidIine foi aII foui condilions (Iig.1O, iighl paneI).

Iig. 1O. ResuIls foi f
l
vaIues foi IaleiaI lopogiaphy accoiding gioups - Iefl paneI and
accoiding condilions - iighl paneI (LC-eyes cIosed, LO-eyes opened, VCIT-visuaI
conlinuous peifoinance lesl, ACIT- audiloiy conlinuous peifoinance lesl)


263
The liain iale cocepl is shovn lo le usefuI in lhe case of ADHD aduIls as veII (Maikovska-
Sinoska and Iop-}oidanova, 2O11). Maxinun vaIues of *J foi sagillaI lopogiaphy aie
ollained in cenliaI iegion, vhiIe lhe nininun in fionlaI iegion, coiiesponding lo incieased
aiousaI (vhich is in agieenenl vilh lhe neuiophysioIogicaI consideialions). Maxinun
vaIues of *J foi IaleiaI lopogiaphy aie ollained in lhe Iefl and iighl sides, vhiIe lhe
nininun in lhe nidIine iegion, vhich indicales highei excilaliIily of IaleiaI iegions. As
expecled, a posilive coiieIalion lelveen *J vaIues and lhe QLLC speclia sullypes vas
ollained. Lovei vaIues veie found foi fiisl and second sullype, and highei foi lhe lhiid
and fouilh sullype. This can le expIained ly lhe conpaialIe aiousaI IeveI foi fiisl and
second sullype, and highei aiousaI in lhe lhiid and fouilh sullype. On lhe olhei hand,
lheie vas no coiieIalion lelveen lehavioiaI synplons (ollained vilh aikIeys scaIe) and
*J vaIues (i.e. specliun giavily), as veII as lelveen QLLC ADHD sullypes and lehavioiaI
synplons, iIIuslialing lhe heleiogeneous and nuIlifacloiiaI chaiaclei of ADHD.
CeneiaIIy ve can sunnaiize lhal lhiough diffeienl cIinicaI expeiinenls and pedialiic
piaclice conceining liain iale il vas shovn lhal:
iain iale nay seive as an indicaloi of geneiaI nenlaI aiousaI IeveI, siniIai lo heail iale
(Kaniusas el aI, 2OO7), lIood piessuie and lenpeialuie as slandaid indicalois of geneiaI
lodiIy aclivalion.
y conpaiing eyes cIosed and eyes open liain iale vaIues lhe diagnoses of innei
aiousaI can sinpIy le achieved (Iop-}oidanov and Iop-}oidanova, 2OO9).
As a neasuie of aiousaI IeveI, liain iale can le appIied lo disciininale lelveen
sulgioups (cIusleis) of nixed disoideis (e.g. ADHD, OCD, headache) (Iop-
}oidanova, 2OO7, 2OO8, 2OO9).
iain iale can le noie usefuI foi seIecling palienls vhich need neuiofeedlack liaining
(Iop-}oidanova, 2OO9).
6. Biofeedback treatment
Mosl pievaIenl appioaches in lhe liealnenl of ADHD invoIve lhe use of slinuIanls,
occasionaIIy suppIenenled ly liicycIic anlidepiessanls, aIpha-lIockeis and, in iaie cases,
anlipsycholic diugs oi seIeclive seiolonin ieuplake inhililois. In addilion, lhe exlensive
lehavioi nanagenenl, cognilive-lehavioiaI lheiapy, individuaI psycholheiapy and faniIy
syslen appioaches have leen appIied. In lhe Iasl lvo decades, liofeedlack nodaIilies have
leen offeied in lhe liealnenl of diffeienl condilions and diseases (#$%&'()* "+,-).
iofeedlack nodaIilies can le divided inlo peiipheiaI (lased on eIeclionyogiaphy,
eIecliodeinaI iesponse, heail iale, lenpeialuie, lIood voIune puIse) oi cenliaI i.e.
neuiofeedlack (lased on eIeclioencephaIogiaphy). In vhal foIIovs, ve viII concenliale on
eIecliodeinaI iesponse and neuiofeedlack.
LIecliodeinaI iesponse (LDR) is a conpIex ieaclion vilh a nunlei of conlioI cenleis in
CNS. Thiee syslens ieIaled lo aiousaI, enolion and Ioconolion aie iesponsilIe foi lhe
conlioI of eIecliodeinaI aclivily (ouscin 1992). The ielicuIai foinalion conlioIs LDR in
conneclion lo slales of aiousaI, lhe Iinlic sliucluies (hypolhaIanus, cinguIaled gyies and
hippocanpus) aie invoIved in LDR aclivily ieIaled lo enolionaI iesponses and
lheinoieguIalion, vhiIe lhe noloi coilex and pails of lhe lasaI gangIia aie invoIved in
Ioconolion. In pailicuIai, skin polenliaI and skin conduclance used as paianeleis in LDR


264
liofeedlack aie ieIaled lo lolh synpalhelic and paiasynpalhelic aiousaI (Andieassi 2OOO,
Mangina 1996).
Tiealnenl ly LDR liofeedlack is geneiaIIy lased on liaining palienls in slialegies foi
Ioveiing aiousaI and nainlaining a heaIlhfuI synpalhelic/paiasynpalhelic lone.
ConsequenlIy, LDR liofeedlack nodaIily is a fiisl choice foi inlioveil peisons, vheie high
innei aiousaI is a lypicaI finding and liofeedlack liaining is supposed lo Iovei synpalhelic
aclivily.

Changes in eIecliodenaI aclivily can le ieIialIy delecled vilhin one second of
slinuIus piesenlalion, oflen foIIoving a singIe evenl. Il is inpoilanl lo knov lhal
eIecliodeinaI conduclance piecede any olhei signaIs ieIaled lo neuioinaging such a
posilion enission lonogiaphy (ILT), lIood oxygen IeveI-dependenl funclionaI nagnelic
iesonance (OLD), singIe pholon enission conpuleiized lonogiaphy (SILCT) elc. In olhei
voids, lhe changes of eIecliodeianaI aclivily can le iegisleied lefoie lhe changes ollained
ly lhe olhei neuioinaging lechniques.
Neuiofeedlack (NI) i.e. LLC liofeedlack iefeis lo a specific opeianl-condilioning paiadign
vheie an individuaI Ieains hov lo infIuence lhe eIecliicaI aclivily (fiequency, anpIilude oi
synchionizalion) of his liain. Il invoIves leaching skiIIs lhiough lhe ievaiding expeiience of
inducing LLC changes iefIecled in a peiceivalIe signaI (Iighl oi sound). Neuiofeedlack has
leen shovn lo le pailicuIaiIy usefuI in iefeience lo palhoIogies chaiacleiized ly
dysfunclionaI ieguIalion of coilicaI aiousaI, such as epiIepsy and allenlion deficil
hypeiaclivily disoidei (Lulai 1991, 1997, iilaunei 1999, Mann el aI. 1992, Monaslia 2OO1,
Iop-}oidanova el aI 2OO5). Oui lean aIso used LLC liofeedlack in anoieclic giiIs (Iop-
}oidanova 2OOO, 2OO3), poslliaunalic sliess disoidei - ITSD (Iop-}oidanova 2OO4),
headaches (Iop-}oidanova 2OO8), as veII as foi oplinaI schooI (Iop-}oidanova, CakaIaioska,
2OO8) and nusic peifoinance (Maikovska-Sinoska el aI. 2OO8).
As ve expIained pieviousIy, lhe appIicalion of specliaI anaIysis lo LLC shovs lhal in sone
liain dysfunclions lhe LLC anpIilude in ceilain fiequency lands significanlIy diffeis fion
lhe LLC anpIilude of heaIlhy suljecls. Ioi exanpIe, a ieIaliveIy Iaige gioup of chiIdien
vilh ADHD ieveaIs an excess of lhe lhela/lela ialio i.e. deciease of *J in cenliaI - fionlaI
Ieads. This LLC alnoinaIily is associaled vilh hypo aclivalion of fionlaI Ioles.
Neuiofeedlack piovides a lesl looI foi coiiecling such devialions fion noinaIily.
Neuiofeedlack is lased on lhiee scienlific facls. Iiisl, LLC paianeleis iefIecl liain
dysfunclion in a pailicuIai disease (in lhe case of specific sulgioup of ADHD chiIdien lhis
neans lhe coiiesponding changes of lhela lela ialio and of *J). Second, suljecl can
voIunlaiiIy change lhe slale of his/hei liain so lhal changes can le associaled vilh
incieasing oi decieasing lhe ieIevanl paianelei. Thiid, lhe liain can nenoiize lhis nev
slale and keep il foi Iongei line nol onIy in Ial condilions lul aIso in olhei enviionnenls,
such as schooI, hone elc.
Ioi appIying neuiofeedlack lheiapy, QLLC evaIualion of each palienl is needed. In oui
sludies lhe QLLC is ollained ly slandaid MITSAR LLC iecoidings (21 eIecliodes), vilh lhe
adninislialion of slandaidized lesls: eyes-open (LO), eyes-cIosed (LC), visuaI conlinuous
peifoinance (VCIT), audiloiy conlinuous peifoinance (ACIT), ieading lesl and nalh lesl.
LLC dala aie anaIyzed foi fiequency conlenl using lhe fasl Iouiiei liansfoinalion.
SlalislicaI anaIysis conpaies suljecls dala vilh a noinalive dalalase coiiecled foi line-of-
day vaiialions. Dala aie aIso evaIualed foi peicenlage change acioss slales and conpaied


265
vilh a noinalive dalalase foi slale noduIalion. The ollained lopogiaphic naps shov
covaiiance lelveen aII siles al ieIevanl fiequencies conpaied vilh a noinalive dalalase,
iIIuslialing funclionaI coilicaI inleiaclions.
Many sludies of QLLC foi lhe ADHD gioup confiined an incieased lhela aclivily
piedoninanlIy in fionlaI iegions, and a decieased lela aclivily in conpaiison lo noinaI
chiIdien (Mann el aI 1992). In lhis conlexl incieased lhela/lela ialio is iepoiled as a lypicaI
finding in ADHD chiIdien (Lulai 1991, Monaslia el aI. 2OO1, MuIIei, 2OO6). So, lhe lypicaI
ADHD finding can le undeiaiousaI. As ve said pieviousIy, lhe iecenl cIuslei anaIysis
idenlified seveiaI sulgioups of ADHD lased on diffeienl LLC lopogiaphies. As a
consequence, nanIy foui dislincl sulgioups of ADHD vilh iegaid lo eIecliophysioIogy aie
defined (Kiopolov, 2OO9).
Neuiofeedlack liealnenl is pailicuIaiIy indicaled in ADHD palienls vho shov excessive
LLC sIoving in lhe supeiioi fionlaI coilex oi lhe nidIine cenliaI coilex (i.e. lhe fiisl lvo
sullypes) The nosl ieIevanl neuioIogicaI LLC coiieIale in lhese ADHD cases is usuaIIy
assuned in lhe pIace vheie lhe highesl ialio of lhela/lela aclivily oi Iovesl *J is seen, so
lhal pIacenenl of lhe eIecliode lelveen Cz and Iz is lhe lesl foi liaining. We foIIoved lvo
conseculive liealnenl piolocoIs. (1) Tiaining lo inciease lhe SMR LLC ihylhn (11 - 13 Hz)
and al lhe sane line, slailing lo inhilil (deciease) sIov aclivily in lhe lhela iange (4 - 8 Hz),
lhis appioach is piinaiiIy used foi lhe hypeiaclive conponenl of ADHD. (2) Tiaining lo
focus allenlion aining al incieasing highei lela aclivily (16 - 2O Hz), vhiIe liaining foi
decieasing lhe sIov aclivily conlinued. The liaining is peifoined vilh 4O sessions, 6O nin
duialion pei session, one pei veek. To ollain sliess dininishing, lefoie neuiofeedlack ve
use peiipheiaI liofeedlack foi aII chiIdien.
IiaclicaIIy aII neuiofeedlack inleivenlions can le ioughIy ieduced lo lhe need of nasleiing
fIexiliIily in incieasing oi decieasing lhe geneiaI nenlaI aclivalion, i.e. nenlaI aiousaI
(vhich is sonehov coupIed vilh nelaloIic aclivily). Theiely, in piaclice, vhenevei a
ceilain land is liained, lhe olhei lands aie affecled loo (il nay even appeai lhal e.g. ".lhe
changes lhal occuiied as a iesuIl of slinuIaling in lhe aIpha fiequency veie nol in aIpha lul
veie in lela."(Lulai 1997). Theiefoie, lhe inlioduced liain iale !
l
couId le enpIoyed as a
conpIenenlaiy liofeedlack paianelei, chaiacleiizing lhe vhoIe LLC specliun (as dislincl
fion e.g. lhela-lela ialio). The ialionaIe is lhal, accoiding lo lhe nenlioned enpiiicaI
iesuIls, lhe LLC fiequency shifls aie ieIaled lo nenlaI aclivalion / deaclivalion, as lhe nain
oljeclive of lhe liealnenl.
Using liain iale as a neuiofeedlack paianelei foi a gioup of ADHD chiIdien (N=5O nean age
11.11 yeais) Iop-}oidanova el aI. (2OO5 and 2OO8) ollained lhe shifling of lhe specliun fion
undei-aiousaI lo noinaI nenlaI aiousaI, and il coiiesponded lo inpioved allenlion and
cognilion as veII as lellei schooI peifoinance. Theiely ollained change of liain iale (i.e.
aiousaI IeveI) appeaied lo le noie ieaIislic in iespecl lo lhe changes of psychoIogicaI slale of
chiIdien lhan lhe diaslic ieduclion of lhela/lela ialio, vhich appeaied lo le even haIved.
If ve inlioduce liain iale as a geneiaI indicaloi of nenlaI aiousaI in ADHD exanpIe, ve
can see lhal lhe fiisl lvo sullypes aie coiieIaled vilh Iovei liain iale, (undeiaiousaI-UA)
lhe lhiid sullype vilh highei liain iale (oveiaiousaI-OA), vhiIe lhe foui sullype is ieIaled
lo excess of aIpha aclivily and noinaI aiousaI slale. In lhe fiisl lhiee sullypes of ADHD
lhe piolocoI foi UA and OA is cIeai, vhiIe foi lhe noinaI aiousaI il is nol.


266
The delaiIed anaIysis of QLLC aflei lhe neuiofeedlack liaining vilh liain iale as a
paianelei couId delecl vhich lands have leen nosl changed. Ioi inslance, in sone cases
shifling lhe liain iale lo highei vaIues couId iesuIl in incieasing high aIpha oi lela
fiequencies, in olhei, lhe sane change can appeai due lo dininishing lhe povei of lhela oi
deIla lands. As a iesuIl, lhe QLLC conpaiison lefoie and aflei lhe liain iale liaining can
le infoinalive foi assessing lhe individuaI specliun land sensilivily.
7. ConcIusions
The fionlaI iegions aie nosl IikeIy lo shov devialions fion noinaI deveIopnenl in lhe case
of ADHD, vilh disluiled lhaIano-coilicaI and seplaI-hippocanpaI palhvays, aIlogelhei
naned as execulive syslen.
AppIicalion of specliaI anaIysis lo LLC shovs lhal lhe LLC anpIilude in ceilain fiequency
lands significanlIy diffeis fion lhe LLC anpIilude of heaIlhy suljecls. Ioi exanpIe, a
ieIaliveIy Iaige gioup of chiIdien vilh ADHD ieveaIs an excess of lhe lhela/lela ialio i.e.
deciease of liain iale in cenliaI - fionlaI Ieads. This LLC alnoinaIily is noslIy associaled
vilh undei aclivalion of fionlaI Ioles.
Ioi lhe exacl diagnosis of ADHD, il is ieconnendalIe QLLC lo le conlined vilh DSM-IV
(oi ICD-1O) lehavioiaI lased appioach.
Theie aie foui nain endophenolypes in ADHD popuIalion: I sullype (alnoinaI inciease of
deIla-lhela fiequency iange cenliaIIy oi cenliaIIy-fionlaIIy), II sullype (alnoinaI inciease of
fionlaI nidIine lhela ihylhn), III sullype (alnoinaI inciease of lela aclivily fionlaIIy), and
IV sullype (excess of aIpha aclivilies al posleiioi, cenliaI, oi fionlaI Ieads). Theiely, ve
considei lhe second sullype as a sulgioup of lhe fiisl sullype.
The dysfunclion of lhe execulive syslen can le evaIualed ly evenl ieIaled polenliaIs (LRIs)
as veII. ChiIdien vilh ADHD shoved significanl piesence of lhe peiseveialive nislakes
and difficuIlies in lhe nenlaI fIexiliIily. The iesuIls ollained foi visuaI cognilive
peifoinance lesl (VCIT) shoved significanlIy highei onnission and connission eiiois,
Iovei ieaclion line (RT) as veII as highei vaiialion of line ieaclion (vai RT) conpaied lo
lhe lesls noins.
Disliilulion of liain iale vaIues foi sagillaI and IaleiaI lopogiaphies iefIecls lhe aiousaI
IeveIs in lhe coiiesponding condilions. Theie is a posilive coiieIalion lelveen liain iale
vaIues and lhe QLLC speclia sullypes.
Neuiofeedlack piovides a looI foi coiiecling devialions fion noinaIily, especiaIIy foi lhe
sullypes I, II and III. Ioi ollaining lellei lheiapeulic iesuIls, lefoie neuiofeedlack, lhe use
of peiipheiaI liofeedlack (such as eIecliodeinaI aclivily) aining lo ollain slaliIizalion of
synpalhelic/paiasynpalhelic syslen is ieconnended foi aII palienls.
iain iale can le used as a nuIliland liofeedlack paianelei in nedialing lhe undei aiousaI
oi ovei aiousaI slales, conpIenenlaiy lo fev-land paianeleis and lhe skin conduclion
IoIIov-up ieseaich is needed in oidei lo deleinine noie pieciseIy lhe specificily and
sensilivily of QLLC and liain iale appioach ieIaled lo neuiophysicaI sulsliales of
ADHD.


267
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liain SILCT inaging in oIdei palienls, N ,-./0+$/&16" !%O3-. 4O(2):139-46.
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Anokhin, AI, Healh AC, Myeis L. (2OO6) Cenelic and enviionnenlaI infIuences on fionlaI
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cIinicaI olseivalions and palienl peispeclives. N !"6 ,"71$&% 17(5):342-35O
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Disoidei in chiIdhood, Q#12"#-1;$S 124-136
Collesnan I I. and ShieIds }., (1972) Schizophienia and Cenelics: A Tvin Sludy Vanlage
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Lulai }I. (1991) Discouise on deveIopnenl on LLC diagnoslics and liofeedlack liealnenl
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neuiofeedlack and ieIaled lechniques foi lhe enhancenenl of allenlion. R##2
,-./0+#0.-1+2 P1+*""7J$/: 22(2):111-126
Mann, C., Lulai }., Zinneinan A., MiIIei C., and Muenchen R. (1992) Quanlilalive anaIysis
of LLC in loys vilh allenlion-deficil/hypeiaclivily disoidei: A conlioIIed sludy
vilh cIinicaI inpIicalions. ,$"71$&%1/ A"O%+2+3., 8: 3O-36
Mangina CA, euzeion-Mangina }H. (1996) Diiecl eIecliicaI slinuIalion of specific hunan
liain sliucluies and liIaleiaI eIecliodeinaI aclivily. C(& N ,-./0+#0.-1+2 22:1-8
Maikovska-Sinoska S, Iop-}oidanova N, Ceoigiev D. (2OO8) SinuIlaneous LLC and LMC
liofeedlack foi peak peifoinance in nusician. ,%12+T1 1:239-253
Maikovska-Sinoska S., Iop-}oidanova N. (2O11) Quanlilalive LLC Specliun-veighled
Iiequency (iain Rale) Disliilulion in AduIls vilh ADHD, 8A9 -#"/&% 16 (5): 579-587
Monaslia V}, Lulai }I, Linden M. (2OO1) The deveIopnenl of quanlilalive
eIeclioencephaIogiaphic scanning piocess foi allenlion deficil-hypeiaclivily
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268
MuIIei A. (2OO6) NeuiolioIogicaI diagnoslics and lheiapy in ADHD, in: A"U- 1( ,"71$&%1/-=
Univeisily of Skopje, Skopje, pp 135-147
Iop-}oidanova N. (1999) LIecliodeinaI iesponse lased liofeedlack in pedialiic palienls.
,$"71$&% 8%+$& 43:117-12O
Iop-}oidanova N. (2OOO) iofeedlack niligalion foi ealing disoideis in pieadoIescenls. C(&
,"71$&% 1:76-82
Iop-}oidanova N. (2OO3) Laling disoideis in lhe pieadoIescenl peiiod: psychoIogicaI
chaiacleiislics and liofeedlack niligalion, Chaplei III. In: Svain I (Ld) Iocus on
ealing disoidei ieseaich. Nova ionedicaI looks, Nev Yoik .
Iop-}oidanova N, Zoicec T. (2OO4) ChiId liauna, allachnenl and liofeedlack niligalion.
,%12+T1 1-2:1O3-114
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chiIdien vilh allenlion deficil hypeiaclivily disoidei. ,%12+T1 1:71-8O
Iop-}oidanova N, Iop-}oidanov }. (2OO5) Specliun-veighled LLC fiequency (liain iale)
as a quanlilalive indicaloi of nenlaI aiousaI. ,%12+T1 2:35-42
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I. (Ld) Nev ieseaich on liofeedlack. Nova ionedicaI ook, Nev Yoik.
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Nijnegen, NelheiIands, ook of alsliacls, p.6O
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Iop-}oidanova N, CakaIaioska I. (2OO8) iofeedlack nodaIilies foi lellei achievenenl in
high schooI sludenls schooI sludenls. >N> 2:25-3O, aIso <"61-&$ Q-#$(+2$ 7"
A"O%+#-1/+2+31$, 1:97-98
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8+3( ,%+/"--. 1O(SuppI.1), S71-S79
Iop-}oidanova N. (2OO9) iofeedlack appIicalion foi sonalofoin disoideis and allenlion
deficil hypeiaclivily disoidei (ADHD) in chiIdien. C(& N >"7 9/1 1(2):17-22
Iop-}oidanov }. Iop-}oidanova N. (2O1O) Quanlun liansilion piolaliIilies and lhe IeveI of
Consciousness. N+O%($2 +* ,-./0+#0.-1+2+3., 24(2):136-14O
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,-./0+2+3., 18: 643-662
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Q#12"#-.: 111-12O
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14
EEG Findings in ADHD and the AppIication
of EEG Biofeedback in Treatment of ADHD
Mohannad AIi Nazaii
!"#$%&'#() +, -./&#01 -./&#01
2&."
1. Introduction
As defined in lhe 4lh edilion of Diagnoslic and SlalislicaI ManuaI of MenlaI Disoideis
(Aneiican Isychialiic Associalion, 1994), Allenlion deficil hypeiaclivily disoidei (ADHD)
is chaiacleiized ly a peisislenl pallein of inallenlion, hypeiaclivily, and inpuIsiveness,
lhough il can piesenl vilh oi vilhoul hypeiaclivily. ADHD is lhe nosl connon chiIdhood
nenlaI heaIlh disoidei, vilh an eslinaled pievaIence of 7 lo 1O in loys and 3 in giiIs
aged 4-11 yeais (Sgiok el aI., 2OOO). This disoidei sulslanliaIIy affecls lhe individuaIs
noinaI cognilive and lehavioiaI funclioning. Ioi exanpIe, chiIdien vilh ADHD can have a
gieal deaI of difficuIly focusing on Iessons piesenled ly lheii leacheis and ienenleiing
hov lo do lheii honevoik. They nay oflen le easiIy disliacled vheiely lhey pay allenlion
lo olhei lhings lhan vhal lhey shouId.
The nuneious sludies suppoil a nodeI lhal defines ADHD as an inheiiled disoidei vhose
coie synplons aie founded in neuioanalonic, neuiochenicaI, and neuiophysioIogic
alnoinaIilies of lhe liain (Monaslia, 2OO5). Deficils associaled vilh ADHD suppoil a
hypolhesis lhal analonicaI and liochenicaI alnoinaIilies of lhe piefionlaI coilex conslilule
lhe physicaI lasis of lhis disoidei (aikIey, 1997). In lhis Iine, neuiodiagnoslic pioceduies
(e.g., posilion enission lonogiaphy |ILTj, singIe pholon enission lonogiaphy |SILCTj
and nagnelic iesonance inaging |MRIj) sludies have piovided evidence of lhe neuioIogicaI
lasis of ADHD (oulios, el aI., 2OO9). NeveilheIess, nev lheoiies on lhe palhogenesis of
psychopalhoIogicaI phenonena concepluaIize as a consequence of lhe faiIuie lo inlegiale
lhe aclivily of diffeienl liains' aieas (oulios el aI., 2OO9). Il needs lechniques lapping lhe
dynanics of conpIex inleiaclion ovei line anong ceieliaI iegions invoIved in lhe
inlegialion of cognilive piocessing.
LIecliophysioIogicaI lechniques enalIe noniloiing liain piocessing in ieaI line, pioviding lhe
lesl nelhods lo desciile lhe line couise of liain eIecliicaI aclivilies. Ciovlh of lhis fieId cane
fion lhe nevei and quanlifialIe lechniques such as quanlilalive eIeclioencephaIogiaphy
(QLLC). QLLC nelhods piovide a sel of non-invasive looIs lhal aie capalIe of quanlilaliveIy
assessing iesling and evoked aclivily of lhe liain vilh sensilivily and lenpoiaI iesoIulion
supeiioi lo lhose of any olhei inaging nelhods (Hughes & }ohn, 1999).
QLLC sludies have expIoied liainvave piofiIe in chiIdien vilh ADHD, conpaied lo
noinaI chiIdien. These liainvaves couId le liained via opeianl condilioning (caIIed LLC


270
liofeedlack oi neuiofeedlack) and il is cIained lhal seIf ieguIalion of liain eIecliicaI
aclivily iesuIl in a lheiapeulic lenefil in ADHD. The nain puipose of lhis chaplei is lo Iook
al one aIleinalive nelhod of liealing chiIdien vilh ADHD. To fuIfiII lhis puipose, lhe
piesenl chaplei viII ieviev:
desciiplion of eIeclioencephaIogiaphy and QLLC
QLLC findings in ADHD
liief hisloiy and ialionaIe foi neuiofeedlack deveIopnenl
desciiplion of neuiofeedlack in piaclice
neuiofeedlack findings in lhe liealnenl of ADHD as suppoiled ly conlioIIed sludies.
Oui liain is nade up of nany ceIIs, incIuding neuions and gIiaI ceIIs. Theie aie aloul 1OO
liIIion neuions in lhe liain. Neuions aie ceIIs lhal send and ieceive infoinalion lo and fion
lhe liain and neivous syslen. The Ianguage of lhese connunicalions lhioughoul lhe
neivous syslen is eIeclio-chenicaI signaIs. An eIeclioencephaIogiaphy (LLC) is a looI foi
neasuiing eIecliicaI aclivily geneialed in lhe liain. These eIecliicaI aclivilies of neuions aie
veiy liny. Hence, LLC aclivily aIvays iefIecls lhe sunnalion of lhe synchionous aclivily of
lhousands oi niIIions of neuions, vhen nany neuions shifl lovaids leing noie ieady lo
fiie (excilaloiy) oi lo nol fiie (inhililoiy) al lhe sane line. The LLC signaIs aie iecoided
using sensois (eIecliodes) pIaced on lhe scaIp. LIecliodes aie allached lo oui head and
hooked ly viies lo a conpulei and lhen lhe conpulei iecoids oui liain's eIecliicaI aclivily
on lhe scieen. Ialleins of neuionaI eIecliicaI aclivily iecoided aie caIIed liainvaves.
An LLC signaI is chaiacleiized ly lhiee najoi conponenls: phase, fiequency and
anpIilude. TiadilionaI LLC dispIays vavefoins in lhe line donain, and lhe inleipielalion
is lased on anpIilude and doninanl fiequency. Lach liainvave fiequency is expiessed in
Heilz (Hz). One Hz neans 1 cycIe pei second, il is lhe ihylhn of lhe vave. AnpIilude
iepiesenls lhe heighl (inlensily) of lhe liainvave, and is expiessed in niciovoIl (nV).
iainvaves have liadilionaIIy leen sepaialed inlo diffeienl fiequency lands (DiongeIen,
2OO7):
DeIla ihylhn (): O.1-4 Hz
Thela ihylhn (O): 4-8 Hz
AIpha ihylhn (u): 8-12 Hz
Sensoiy-noloi ihylhn (SMR): 12 lo 15 Hz
ela ihylhn (|): 15-3O Hz
Canna ihylhn (): lhe highei LLC fiequencies, usuaIIy 3O~7O Hz.
ConvenlionaI inleipielalion of lhe LLC is done visuaIIy ly a liained speciaIisl. The speciaIisl
viII exanine lhe LLC, ly delecling fealuies of vaveshapes (noiphoIogy) of lhe liainvaves
lo idenlify ceilain chaiacleiislics lhal nighl indicale oiganic oi neuioIogicaI palhoIogies.
Rouline LLC is lypicaIIy used in lhe foIIoving cIinicaI ciicunslances:
lo dislinguish epiIeplic seizuies,
lo diffeienliale "oiganic" encephaIopalhy oi deIiiiun fion piinaiy psychialiic
syndiones such as calalonia,
lo seive as an adjuncl lesl of liain dealh,
lo IocaIize lhe iegion of liain fion vhich a seizuie oiiginales (Niedeineyei and da
SiIva, 2OO4).

EEG Findings in ADHD and the Application of EEG Biofeedback in Treatment of ADHD

271
A voIuninous Iileialuie allesls lo lhe ioluslness of convenlionaI LLC sludies and lheii
cIinicaI uliIily in disoideis of liain funclion (Hughes & }ohn, 1999). Hovevei, nany
funclionaI chaiacleiislics of liain aclivily couId nol le delecled visuaIIy. Wheieas,
quanlilalive LLC (QLLC) liansfoin lhe LLC inlo a foinal oi donain lhal eIucidales
ieIevanl infoinalion, oi associale nuneiicaI iesuIls vilh lhe LLC dala foi sulsequenl
ieviev oi conpaiison (Nuvei, 1997). Oflen, neuioIogicaIIy lased disoideis do nol invoIve a
sliucluiaI alnoinaIily, Iesion, oi disease piocess, lul alnoinaIilies aie expiessed in lhe
vay lhe liain evaIuales infoinalion. These piocesses can le sludied vilh QLLC lechniques,
lul nol vilh sinpIe visuaI anaIysis of lhe iav LLC (Hoffnan el aI., 1999). Hence, one can
say lhal QLLC nighl piovide addilionaI neasuienenls and dispIays of LLC in nany
diffeienl vays lhal aie nol possilIe vilh visuaI inspeclion.
In facl, QLLC iefIecls lhe aliIily of a nelvoik lo IocaIIy synchionize. Such aliIily lo
synchionizalion is ieIaled lo lhe inlegialive capacilies of a nelvoik and lo lhe chaiacleiislics
of ils inpuls. This can le sliongIy nodified ly lhe aclive slale of lhe liain. Thus, inpaiinenl
of cognilive piocessing (i.e. allenlion) can le noniloied ly QLLC (Nazaii, 2OO8).
Iuilheinoie, QLLC enalIes piecise conpaiison of lhe individuaI palienl's iecoid vilh
noinalive and psychopalhoIogic palienl dalalases (Hughes & }ohn, 1999). QLLC
pioceduies invoIve lhe nalhenalicaI piocessing of digilaIIy iecoided LLC. The nosl
connonIy used nelhod foi LLC quanlificalion is lhe specliaI anaIysis ly neans of Iasl
Iouiiei Tiansfoinalion (IIT) aIgoiilhn. Il piovides neasuies of lhe povei al each
fiequency of lhe LLC lands, knovn as lhe povei specliun. The lesl-ielesl of povei speclia
has leen shovn lo le high (Hughes & }ohn, 1999).
The fiisl slep foi doing a QLLC is digilaI LLC iecoiding, a cap (usuaIIy 19 eIecliodes al
slandaidized posilions) pIaced on lhe head and lvo eIecliodes aie pIaced on lhe eais. The
eIecliodes aie lhen nade lo conducl vilh lhe scaIp and eais ly using a conduclive geI. Once
lhis is achieved, a conpulei inleifaces vilh lhe LLC nachine, and a soflvaie piogian is
used lo dispIay lhe liaces of lhe liainvaves geneialed ly lhe liain, and delecled on lhe
scaIp. Dala is iecoided duiing iesling slales of eyes open, eyes cIosed, and in sone inslances
duiing cognilive lesls such as ieading oi allenlionaI lask. AppioxinaleIy len ninules of
dala aie iecoided in each slale. A QLLC lypicaIIy iequiies aloul an houi lolaI in lhe cIinic lo
conpIele lhe dala galheiing.
Aflei iecoiding lhe LLC dala il is ediled lo ienove ailifacls vhich aie disloilions in lhe LLC
signaI due lo nuscIe novenenl such as coughs, eye novenenl, and leelh cIenching, nuscIe
lension, puIse and olhei souices. Ailifacls aie eIecliic polenliaIs of non-liain oiigin lhal aie
in fiequency and voIlage iange of LLC signaIs and lhal aie delecled ly scaIp eIecliodes
(oulios el aI., 2OO9). CIinicians uliIizing QLLC nusl le skiIIfuI in iecognizing and
nininizing ailifacls, as veII as in caiefuI pie-iecoiding piepaialion pioceduies lo nininize
ailifacls in lhe LLC (Hannond and CunkeInan, 2OO1). Indeed, il needs lo caiefuIIy sludy
lhe iav LLC since alnoinaIilies nay le nasked ly lhe use of a QLLC aIone (Hannond el
aI., 2OO4). Duiing lhe ediling piocess lhe dala is exanined visuaIIy lo idenlify any palleins
lhal nighl le of inleiesl foi liaining puiposes oi vouId suggesl lhe need lo iefei lo anolhei
speciaIisl.
Aflei lhe ediling piocess is conpIeled lhe LLC dala is suljecled lo a vaiiely of nalhenalicaI
and slalislicaI anaIyses. LLC iecoidings shouId le of sufficienl quaIily and of sufficienl
Ienglh so lhal aflei ailifacling lheie is a nininun of 4O-5O seconds of ailifacl-fiee dala


272
avaiIalIe foi anaIysis (Hannond el aI., 2OO4). A sanpIe of ailifacl-fiee LLC dala, usuaIIy 1
lo 2 ninules, is anaIyzed, using lhe IIT lo quanlify lhe povei al each fiequency of lhe LLC
aveiaged acioss lhe enliie sanpIe (Hughes & }ohn, 1999). ResuIls fion each eIecliode can le
iepiesenled as foIIoving neasuies:
alsoIule povei: anounl of anpIilude in each land (lolaI V),
ieIalive povei: in each land peicenlage of alsoIule povei/lolaI povei,
povei ialio: i.e. alsoIule povei of lhela/alsoIule povei of lela (lhela/lela ialio),
coheience: a neasuie of synchionizalion lelveen aclivily in lvo channeIs (siniIaiily of
fiequency lelveen lvo channeIs),
synneliy (lhe ialio of povei in each land lelveen a synneliicaI paii of eIecliodes (no
siniIaiily is caIIed asynneliy).
The finaI anaIysis is lhe dalalase conpaiison. This pioceduie aIIovs foi an individuaIs
LLC lo le conpaied lo an 'aveiage LLC. One can use a iefeience LLC dalalase lo ieveaI
lhe Iocalion and lype of LLC fealuie alnoinaIilies giealei lhan lvo slandaid devialions
fion a noinalive gioup (Thalchei, 1998). This conpaiison dala is deiived fion lhe anaIysis
of LLCs galheied fion hundieds of individuaIs, sane sex, sane handedness, appioxinale
sane age, vho do nol exhilil oi iepoil hisloiicaIIy any significanl nenlaI heaIlh issues.
Oflen lhe LLC viII le conpaied lo nuIlipIe dalalases. The aspecls of an individuaIs LLC
lo le anaIyzed ly lhe QLLC aie:
Does lhe individuaIs LLC fealuies diffei fion lhe 'aveiage LLC`
Hov does il Iook diffeienl (lhe IeveI of slalislicaI significance and lhe degiee of
difficuIly)`
Wheie (vhal aieas of lhe liain) does il Iook diffeienl`
The QLLC dala is used lo geneiale a seiies of anaIyses piesenled in lalIes and giaphics in
liain nap. iain nap is a conpuleiized LLC lopogiaphy lhal enalIes lhe consliuclion of a
li- oi lhiee-dinensionaI naliix foi a lopogiaphic iepiesenlalion of Q-LLC paianeleis, such
as inslanl anpIilude oi land povei (oulios el aI., 2OO9). Diffeienl aIgoiilhns have leen
pioposed lo IocaIize undeiIying liain geneialois. Anong lhe disliiluled souice nodeIs,
Lov ResoIulion iain LIeclionagnelic Tonogiaphy-LORLTA (IasquaI-Maiqui el aI., 1994)
has leen pioven lo piesenl lhe snaIIesl IocaIizalion eiioi (oulios el aI., 2OO9). The
LORLTA is one of lhe QLLC lopogiaphic anaIysis nelhod ly vhich one can piovide a 3-D
anaIysis of lhe LLC idenlifying IocaIized disiuplions in liain aclivily vilhin lhe inleiioi of
lhe liain.
An individuaI vho has ieceived speciaIized liaining in lhese fieIds (see Hoffnan el aI., 1999,
Hannond el aI, 2OO4, Hannond el aI, 2O11) couId exanine lhe QLLC iesuIls. IndividuaIs
conducling assessnenl uliIizing quanlilalive LLC oi any lype of liain napping shouId le
alIe lo galhei ieIialIe dala. A nuch highei slandaid is iequiied foi soneone lo hoId hinseIf
oi heiseIf oul as conpelenl lo anaIyze and inleipiel QLLC dala (Hannond el aI., 2OO4). Il is
sliongIy ieconnended lhal lhe QLLC piovideis '3+456 3+56 6#75+8.(% '(.(4' #" 9::; ,&+8
(3% 94."(#(.(#$% :5%<(&+%"<%73.5+=&.73) >%&(#,#<.(#+" ?+.&6 +& /% <%&(#,#%6 /) (3% ::; ."6 >5#"#<.5
@%4&+'<#%"<% A+<#%() B+& . <+87.&./5% "%4&+5+=) /+.&6 #" (3% <.'% +, 73)'#<#."'C1 +& /% .".5)0#"=
6.(. 4"6%& (3% '47%&$#'#+" +, '4<3 . <%&(#,#%6 7%&'+"1 +& .( . 8#"#848 /% ./5% (+ 6%8+"'(&.(%
(3+&+4=3 %64<.(#+"1 (&.#"#"=1 ."6 D+&E 7&+64<( 6+<48%"(#"= (3%#& <+87%(%"<% (+ #"(%&7&%( 9::;'F
G(3%&D#'%1 (3% 9::; 6.(. '3+456 /% '4/8#((%6 ,+& .".5)'#' /) ." #"6#$#64.5 D#(3 '4<3 <%&(#,#<.(#+"


273
(Hannond el aI., 2O11). Ioi fuilhei delaiIs aloul slandaids and quaIificalions foi doing
QLLC and neuiofeedlack see Hoffnan el aI., 1999, Hannond el aI, 2OO4 and Hannond el
aI, 2O11.
Due lo lhe non-invasive naluie of lhe pioceduie, lhe convenience, nol expensive, and
specificily of lhe dala lhe QLLC has leen used exlensiveIy lo exanine a vaiiely of aspecls of
liain funclion. As nenlioned lefoie, vilh lhe quanlilalive LLC and lopogiaphic liain
naps, il is oflen possilIe lo olseive alliilules of liain funclion lhal cannol le seen in lhe
iav LLC signaI. These piocesses can le olseived and quanlified lhiough sullIe fiequency-
ieIaled and coheience ieIaled aclivilies in lhe QLLC liain naps lhal index lhe degiee of
difficuIly of cognilive lasks (Hoffnan el aI., 1999). Iuilheinoie, il is veII knovn lhal a gieal
nany nedicalions as veII as psychoaclive diugs can pioduce sone aIleialion in lhe LLC
(oulios el aI., 2OO9). The avaiIaliIily of QLLC Iel lo lhe deveIopnenl of a nev ieseaich fieId
lhal naned phainaco-LLC. Ihainaco-LLC nelhods veie incIuded in piecIinicaI sludies lo
idenlify al eaiIy slages of diug deveIopnenl, lhe lheiapeulic indicalions of nev diugs,
deleinining onsel, peak effecl, and duialion of diug effecl on CNS, and piedicl
lheiapeulicaIIy usefuI dosage of psycholiopic diugs (oulios el aI., 2OO9).
In lhe cIinicaI selling, nany sludies have leen iepoiled lhal QLLC can le usefuI foi lhe
evaIualion and undeislanding of niId liaunalic liain injuiy, Ieaining disaliIilies, ADHD,
aIcohoIisn, depiession, and olhei lypes of sulslance aluse (Hoffnan el aI., 1999).
SpecificaIIy, QLLC sludies have iepoiled diffeienl liainvave palleins in chiIdien vilh
ADHD lhan lhose of lhe noinaI popuIalion.
Mosl sludies of lhe eIecliophysioIogicaI coiieIales of ADHD have conpaied lhe QLLC fion
ADHD suffeieis vilh lhose of heaIlhy chiIdien undei iesling condilions (foi a ieviev, see
aiiy el aI., 2OO3, foi a nela-anaIysis, see Snydei & HaII, 2OO6). Hovevei, lhe aIIocalion of
neuiaI iesouices diffeis vhen lhe suljecl diiecls his/hei allenlion lo an expeiinenlaIIy
conlioIIed silualion (Thalchei, 1998). Il is lheiefoie inpoilanl lo evaIuale a neuiaI nelvoik's
aliIily lo change fion a passive lo an aclive condilion. Since inallenliveness and
disliacliliIily aie lhe najoi synplons of ADHD, assessnenl of lhese synplons vouId
iequiie lasks specificaIIy designed lo highIighl allenlionaI deficils, such as lhe conlinuous
peifoinance lask (CIT) oi lhe go/no-go lask. Hence, in a sludy, Nazaii el aI (2O11) sel oul
lo eslalIish lhe funclionaI ieaclivily of fiequency-specific LLC aclivilies duiing eyes-open
iesling and CIT in chiIdien vilh ADHD. High-iesoIulion LLC vas iecoided duiing eyes-
open iesling and CIT peifoinance in 16 chiIdien neeling lhe DSM-IV ciileiia (AIA, 1994)
foi ADHD and 16 age-nalched conlioIs. Significanl CIT vs. eyes-open diffeiences in LLC
aclivilies vas olseived in chiIdien vilh ADHD. In pailicuIai, svilching lo CIT induced an
aIpha povei inciease in chiIdien vilh ADHD and an aIpha povei deciease in conlioIs.
Lovei aIpha povei al laseIine (eyes-open iesling condilion) nighl le inleipieled as
neaning lhal chiIdien vilh ADHD aie unalIe lo allend lo and piocess visuaI slinuIi as
efficienlIy as heaIlhy chiIdien. KIinesch el aI (1996) suggesled lhal aIpha synchionizalion
duiing nenlaI inaclivily nay le inpoilanl foi inlioducing poveifuI inhililoiy effecls,
vhich couId pievenl a nenoiy seaich fion enleiing iiieIevanl pails of neuiaI nelvoiks.
ased on lhis expIanalion, ve suggesled lhal inpaiied inhililion of neuiaI nelvoiks in
chiIdien vilh ADHD al laseIine aIleis nol onIy eneigy denands lul aIso conlioI excilaloiy
piocesses. Opposile aIpha changes nay aIso iefIecl a piinaiy deficil associaled vilh coilicaI
hypoaiousaI in ADHD. These LLC iesuIls agiee vilh lehavioiaI findings Ieading lhe


274
aulhois lo suggesl lhal dynanic changes in neuiaI nelvoik aclivilies aie inpaiied in
chiIdien vilh ADHD (Nazaii el aI., 2O11).
Lulai (1995) conpaied QLLC dala foi ADHD chiIdien vilh conlioIs. He concIuded,
"Lxcessive lhela aclivily and Iack of lela aclivily aie lhe piinaiy neuioIogicaI Iandnaiks of
ADHD" (p. 5O5). Iuilheinoie, "duiing acadenic chaIIenges, lheie veie significanl incieases
in sIov (4-8 Heilz) lhela aclivily aIong lhe nidIine and in lhe fionlaI iegions and decieased
lela aclivily, especiaIIy aIong lhe nidIine posleiioiIy" (p. 5O2). Lulai's ieviev of lhe
Iileialuie ieveaIed lhe foIIoving:
HI/"+&8.5#(#%' #" ::; D%&% &%7+&(%6 #" <3#56&%" "+D <5.''#,#%6 .' IJJ ."6 IJKJ .' %.&5) .'
LMNO BP.'7%&1 A+5+8+" Q ?&.65%)1 LMNOCF -3%&% #' %R(%"'#$% 5#(%&.(4&%1 84<3 +, #( &%$#%D%6 #" (3%
'4775%8%"( (+ (3% P+4&".5 +, >3#56 @%4&+5+=) 74/5#'3%6 #" LMMLF ?.'#<.55)1 ::> '(46#%' '3+D
%R<%''#$% '5+D .<(#$#() #" <%"(&.5 ."6 ,&+"(.5 &%=#+"' +, (3% /&.#"F -3%'% '(46#%' .&% '477+&(%6 /)
&%<%"( S:- T7+'#(&+" %8#''#+" (+8+=&.73)U '<." ."6 AS:>- T'#"=5% 73+(+" %8#''#+"
<+874(%&#0%6 (+8+=&.73)U '<." '(46#%' (3.( .5'+ #"6#<.(% ./"+&8.5#(#%' #" <%&%/&.5 8%(./+5#'8
#" (3%'% 7.&(#<45.& /&.#" .&%.'H B7F VW2CF
ased on Lulai's finding, sludies have iepealedIy iepoiled a QLLC pallein lhal nighl le
piesenl in ADHD lul nol in conlioIs (noinaI chiIdien, adoIescenls, and aduIls). A
consideialIe nunlei of lhese sludies have iepoiled an inciease in Iov-fiequency povei
(piedoninanlIy lhela) and a deciease in high-fiequency povei (especiaIIy lela) in chiIdien
vilh ADHD conpaied vilh lhe age-nalched conlioI gioup (aiiy el aI., 2OO3, Snydei &
HaII, 2OO6). Sone ieseaicheis have liied lo exanine lhe lhela/lela ialio as a neasuie of
ADHD-ieIaled alnoinaIily vilh a highei deleclion povei. As iepoiled ly Snydei & HaII
(2OO6) iesuIls of 9 DSM-IV sludies and lhe iesuIls of 29 pie-DSM-IV sludies suppoil lhal a
lhela/lela ialio inciease is a connonIy olseived liail in ADHD ieIalive lo conlioIs. y
nela-anaIylic slalislicaI exliapoIalion, lhe effecl size of 3.O8 piedicls a sensilivily and
specificily of 94, vhich is siniIai lo vaIues piedicled ly ieliospeclive sludies exanining
ADHD and noinaI conlioIs in gioup conpaiisons (Snydei & HaII, 2OO6).
As enphasized ly lhe connillee of lhe Associalion foi AppIied IsychophysioIogy and
iofeedlack (AAI) and lhe Sociely foi lhe Sludy of NeuionaI ReguIalion (SSNR), QLLC
shouId nol le lhe onIy looI used foi diagnosis of allenlion-deficil/hypeiaclivily disoidei
(Hoffnan el aI., 1999). -3%&% #' "+ '#"=5% (%<3"#X4% (3.( <." /% '+5%5) &%5#%6 47+" ,+& (3% 6#.="+'#'F
Y."#,%'(.(#+"' +, IJJZIJKJ &%,5%<( /%3.$#+& 7&+/5%8'1 5%.&"#"= '()5%1 <+="#(#$% 7&+<%''#"=1 '+<#.5
#"(%&.<(#+"1 ."6 8.") +(3%& 6%$%5+78%"(.5 ,.<(+&'F -3% <4&&%"( 6#.="+'#' +, IJJZIJKJ 6%7%"6'
.5'+ +" (3% 4'% +, <+874(%&#0%6 <+"(#"4+4' 7%&,+&8."<% (.'E'1 6%(.#5%6 3#'(+&)1 '<3++5 7%&,+&8."<%1
."6 %$.54.(#+" ,+& 5%.&"#"= 6#'./#5#(#%' ."6 +(3%& <+8+&/#6#(#%'1 .' D%55 .' +(3%& 8%.'4&%'F 9::;
6.(. <+875%8%"( (3%'% +(3%& ,#"6#"=' /) 7&+$#6#"= ,+& . <+87.&#'+" +, /&.#" .<(#$#() D#(3 6.(./.'%'
,+& /+(3 "+&8.5 ."6 IJJZIJKJ =&+47' (Hoffnan el aI., 1999).
Having diagnosed lhe Iocalions in lhe liain lhal aie pioducing high oi Iov aclivily, il is
nov possilIe lo inleivene vilh liaining lhe liain lo noinaIize lhe aclivily of lhe vaiious
Iocalions in lhe liain. On lhe olhei voids, lhe povei in leing alIe lo define devialions of
liains eIecliicaI palleins vilhin a noinaIIy disliiluled neasuienenl sel is lhal one can
laigel devianl neasuies lo noinaIize ly a vaiiely of inleivenlion nodaIilies. In facl, lhe
LLC (as a physioIogicaI neasuie) is consideied a foin of lehavioi, vhich is suljecl lo
lehavioi nodificalion lhiough lasic "opeianl condilioning" and "shaping" piincipIes vilhin


275
lhe foinvoik of Ieaining lheoiy. This liainvave liaining and Ieaining seIf ieguIalion of
liain aclivily is caIIed LLC liofeedlack oi neuiofeedlack. Neuiofeedlack posluIales lhal
noinaIizing lhe laigel signaI viII iesuIl in a lheiapeulic lenefil. Definilion of neuiofeedlack
ly lhe InleinalionaI Sociely foi Neuiofeedlack and Reseaich (ISNR) is lhe foIIoving:
H"%4&+,%%6/.<E #' . 7&+<%'' #" D3#<3 '%"'+&' .&% 75.<%6 +" (3% '<.57 ."6 6%$#<%' .&% 4'%6 (+
8+"#(+& ."6 7&+$#6% 8+8%"([(+[8+8%"( #",+&8.(#+" (3.( #' ,%6 /.<E (+ (3% #"6#$#64.5 ./+4( 3#'
+& 3%& 73)'#+5+=#<.5 /&.#" .<(#$#() ,+& 74&7+'%' +, #87&+$#"= /&.#" ,4"<(#+"#"=H BK.88+"6 %(
.5F1 \WWL] 7FVVCF Ioi delaiIed infoinalion aloul neuiofeedlack see lhe velsile of lhe
ISNR (hllp://vvv.isni.oig).
Iiguie 1 shovs lhe neuiofeedlack pioceduie. Duiing neuiofeedlack liaining,
neuioeIecliicaI aclivily is delecled via suiface eIecliodes (slep 1). Nole lhal no eIecliicaI
cuiienl is pul inlo lhe liain. This aclivily is lhen anpIified (slep 2) and piocessed ly
soflvaie piogians (slep 3) lhal piovide conlingenl audiloiy oi visuaI feedlack lo lhe
palienl on a conpulei noniloi (slep 4), liain aclivily is noniloied and desiied changes aie
ievaided siniIai lo a videogane. The palienl valches lhe dynanic dispIay of lhe anpIilude
of lhe liainvaves in lhe aieas vheie lhe eIecliodes aie allached ly a geI pasle. The
conpulei piogian gives a ieinfoicenenl each line lhe goaI IeveI of lhe LLC povei (an
oplinaI liain slale) is ieached. This piocessing conlinues duiing lhe neuiofeedlack session
foi a peiiod of 15 lo 4O ninules (slep 5).

Iig. 1. Neuiofeedlack pioceduie
Ioi exanpIe, lheie nighl le aieas of lhe liain vheie lheie is an excess of neuions fiiing
sIovIy duiing lasks iequiiing concenlialion. This is oflen lhe case vilh ADHD. On lhe lasis
of QLLC findings in ADHD, lypicaIIy lhe LLC of a peison vilh ADHD viII ieveaI excess
lhela aclivily, lul dininished lela aclivily. Hence, duiing lhe neuiofeedlack liaining a
puzzIe advances and sounds a lone vhenevei a chiId vilh ADHD nainlains vaves in lhe
15-18 Hz iange alove a ceilain anpIilude lhieshoId (lela incieasing) vhiIe keeping vaves
in lhe 4-8 Hz iange leIov a ceilain lhieshoId (lhela decieasing). CIienls iequiie 2O lo 6O


276
liaining sessions lo achieve lheii goaIs. Tiaining lakes pIace 1-3 lines foi al Ieasl one houi of
liaining pei veek. Once lhe oiiginaI goaIs of liealnenl have leen nel, lhe cIienl conlinues
lo liain foi an addilionaI 5 lo 1O sessions lo pievenl ieIapse (Denos, 2OO5).
Iiioi lo leginning neuiofeedlack liaining an assessnenl is conducled lo exanine
piesenling piolIens, cIienl hisloiy, conliiluling faclois, cuiienl nedicalions lhe palienl
nay le laking, and olhei ieIevanl infoinalion. Inleivievs, synplon checkIisls, conpulei
lased lesls (i.e. CIT, TOVA, IVA), and ieviev of ieIevanl docunenlalion aie connon
conponenls of lhe assessnenl. A pie- and posl liealnenl oljeclive assessnenl of lhe cIienls
QLLC shouId le peifoined. The QLLC oljecliveIy assess lhe funclioning of lhe liain in
conpaiison vilh noinalive dalalase (Hannond el aI., 2O11). One can use QLLC dalalase
and lopogiaphicaI liain naps lo evaIuale lhe Iocalion and lype of LLC fealuie lo laigel foi
neuiofeedlack liaining.
Aflei ievieving lhe dala galheied duiing lhe assessnenl a liaining piolocoI is deveIoped.
The neuiofeedlack piolocoIs covei lhe foIIoving queslions:
Iovei of vhich fiequency landvidlh laigeled lo le changed`
Which aieas of lhe liain aie lo le liained (eIecliodes Iocalion)`
Which nonlage nusl le used (iefeienliaI oi lipoIai)` Which Iocalions aie chosen foi
aclive eIecliode, iefeience and giound`
Hov lhieshoId IeveIs aie sel foi each cIienl`
The ialionaIe foi neuiofeedlack piolocoIs is lased on soIid ieseaich and cIinicaI piaclice.
IniliaIIy, neuiofeedlack liealnenls foi ADHD aie founded on lhe gioundlieaking ieseaich
conducled ly Sleinan (iolh el aI., 1967, sleinan and Wyivicka, 1967, Wyivicka and
sleinan, 1968, sleinan el aI., 1969 and Lulai and Shouse, 1976, Lulai and Lulai, 1984). A
liief hisloiy couId le inleiesling. Sleinans ieseaich lean conducled a syslenalic
exaninalion of LLC palleins and idenlified lhe sensoiy noloi ihylhn-SMR (12 -15 Hz) ovei
lhe RoIandic coilex. They veie alIe lo liain cals lo inciease pioduclion of lhis ihylhn ly
pioviding food as an innediale ievaid. In Ialei ieseaich lhose cals exhililed a significanl
inpiovenenl in slaliIily vhen exposed lo Hydiazine olseived lo evoke seizuie aclivily in
cals lhal had nol ieceived lhe SMR incieasing. SulsequenlIy, lhey denonslialed lhal
palienls vilh seizuie disoideis couId deveIop inpioved conlioI ovei epiIeplifoin aclivily
ly Ieaining seIf-ieguIalion of lhe SMR (Sleinan, 2OOO).
Sleinans pioceduie vas iepIicaled ly Lulai vho used lhe sane liaining lo ieduce lhe
synplons exhililed ly 'hypeikinelic chiIdien. IniliaIIy, Lulai and Shouse (1976) iepoiled
sone inpiovenenls in a hypeiaclive chiId vho had Ieained lo ieduce lhela and inciease
pioduclion of SMR. SulsequenlIy, Lulai and Lulai (1984) iepoiled lhal chiIdien diagnosed
vilh an allenlion deficil disoidei denonslialed inpioved allenlion and lehavioiaI conlioI
aflei leing liained lo inciease pioduclion of LLC aclivily in a fasl fiequency iange (lela)
vhiIe Ieaining lo suppiess sIov vave aclivily (lhela).
These lvo piinaiy liaining appioaches piovide lhe foundalion foi each of lhe piolocoIs lhal
have leen exanined in lhe conlioIIed gioup sludies of neuifeedlack foi ADHD. In a ieviev
sludy, Monaslia (2OO5) has sunnaiized lhiee neuiofeedlack piolocoIs lhal have leen
invesligaled in conlioIIed gioup sludies. These ieseaich-lased piolocoIs aie lhe foIIoving
(Monaslia, 2OO5):


277
IiolocoI 1- SMR enhancenenl/lhela suppiession: in lhis piolocoI, palienls (ADHD vho
piesenl vilh piinaiy synplons of hypeiaclivily and inpuIsivily) insliucled lo inciease
lheii SMR (12-15 Hz) ovei one of lvo siles (C3 oi C4) vhiIe sinuIlaneousIy suppiessing
lhe pioduclion of lhela (4-7 oi 4-8 Hz) aclivily. LLC iecoidings aie ollained fion one
aclive sile, iefeienced lo Iinked eaiIoles. Audiloiy and visuaI feedlack is piovided lased
on palienl success in conlioIIing povei of lhela leIov and SMR alove pieliealnenl
lhieshoIds.
IiolocoI 2- Thela suppiession/lela1 enhancenenl: In lhis piolocoI, palienls aie ieinfoiced
foi incieasing pioduclion of lela1 aclivily (16-2O Hz) vhiIe suppiessing lhela aclivily (4-8
Hz). Recoidings aie ollained al Cz vilh Iinked eai iefeiences, al ICz-ICz vilh singIe eai
iefeience, oi al Cz-Iz vilh eai iefeience. A vaiialion of lhis piolocoI aIso has leen iepoiled
in lhe liealnenl of ADHD, piedoninaleIy inallenlive lype (Iuchs el aI., 2OO3). In lhis
liaining piolocoI, lhela suppiession and lela enhancenenl aie ieinfoiced al C3.
IiolocoI 3- SMR enhancenenl/lela2 suppiession: in lhis piolocoI, chiIdien vilh ADHD,
piedoninaleIy hypeiaclive/inpuIsive lype, aie liained lo inciease SMR (12-15 Hz) vhiIe
suppiessing lela2 aclivily (22-3O Hz) (Iuchs el aI., 2OO3) Recoidings aie ollained al C4 vilh
Iinked eai iefeience. In ADHD, conlined lype, lhis piolocoI is used duiing haIf of each
session. Duiing lhe olhei poilion of each liaining session, SMR enhancenenl/lhela
suppiession al C3 is used. SeIeclion of a neuiofeedlack piolocoI shouId le lased on IeveI of
expeiience and liaining, acciedilalion, lhe fiaclion of lhe lheiapisls piaclice devoled lo
neuiofeedlack, iepoils fion cIienls and oljeclive assessnenls, and lhe lheiapisls specific
expeiience in liealing AD/HD (foi noie infoinalion see Monaslia, 2OO5, Denos, 2OO5,
Hannond el aI., 2O11).
Since lhe voik of Lulai and Shous (1976), nuneious sludies have used neuiofeedlack
appioaches foi liealing ADHD and iepoiled successfuI dininulion of inallenlivily and
hypeiaclivily, and inpiovenenl in acadenic peifoinance and concIuded lhal despile sone
Iinilalions, neuiofeedlack nay le voilhy of fuilhei consideialion as a vialIe liealnenl
appioach foi ADHD (Shouse and Lulai , 1979, Lulai and Lulai, 1984, Lulai el aI., 1995,
Rossilei and La Vaque, 1995, Linden el aI., 1996, Thonpson and Thonpson, 1998, Kaisei
and Olhnei, 2OOO, Cainody el aI., 2OO1, Monaslia, 2OO2, Iuchs el aI., 2OO3, Heyvood and
eaIe, 2OO3, Cho el aI., 2OO4, Heiniich el aI., 2OO4, Rossilei el aI., 2OO4, Xiong el aI., 2OO5,
Kiopolov el aI., 2OO5, eauiegaid and Levesque, 2OO6, Levesque el aI., 2OO6, SliehI el aI.,
2OO6, CevensIelen el aI., 2O1O, Nazaii el aI., 2O11, foi ieviev see Rossilei, 2OO4, , Veinon el
aI., 2OO4, Monaslia, 2OO5, ulnik, 2OO5, IiieI, 2OO7, TopIak el aI., 2OO8, }ohn and Iiichep,
2OO9, Colen and Lvans, 2O11). In an exceIIenl nela-anaIylic sludy, Ains el aI (2OO9)
invesligaled iesuIls of 15 conlioIIed sludies. They concIuded lhal neuiofeedlack liealnenl
foi ADHD can le consideied "efficacious and specific" vilh a high effecl size foi inallenlion
and inpuIsivily and a nediun foi hypeiaclivily (Ains el aI., 2OO9).
CevensIelen el aI (2OO9) conducled a iandonized conlioIIed liiaI enconpassing 1O2
chiIdien vilh ADHD. In lhis liiaI lehavioiaI and neuiophysioIogicaI effecls of
neuiofeedlack, veie anaIyzed in conpaiison lo a conpuleiised allenlion skiIIs liaining (as
a seni-aclive conlioI gioup). They have shovn neuiofeedlack lo le supeiioi lo conlioI
gioup (CevensIelen el aI., 2OO9)" They iepoiled foIIov-up lehavioiaI dala assessed 6


278
nonlhs aflei conpIelion of lhe liaining (eilhei neuiofeedlack liaining oi allenlion skiIIs
liaining). Inpiovenenls in lhe neuiofeedlack gioup al foIIov-up veie supeiioi lo lhose of
lhe conlioI gioup and conpaialIe lo lhe effecls al lhe end of lhe liaining. They concIuded
lhal "lhough liealnenl effecls appeai lo le Iiniled, lhe iesuIls confiin lhe nolion lhal
neuiofeedlack is a cIinicaIIy efficacious noduIe in lhe liealnenl of chiIdien vilh ADHD"
(CevensIelen el aI., 2O1O).
In a cIinicaI oulcone sludy, Nazaii el aI (2O11) invesligaled vhelhei neuiofeedlack conpaied
lo nelhyIphenidale achieves an equaIIy effeclive oulcone. Iailicipanls veie 39 chiIdien: 13
chiIdien vilh ADHD veie liained lo enhance lhe anpIilude of lhe lela1 aclivily and deciease
lhe anpIilude of lhe lhela aclivily, 13 of vhich veie liealed vilh nelhyIphenidale aIone, and
13 heaIlhy chiIdien did nol ieceive inleivenlion. SeveiaI lehavioiaI, neuiopsychoIogicaI and
expeiinenlaI lesls veie adninisleied lefoie and aflei inleivenlion. WhiIe lehavioiaI
neasuies veie inpioved ly lolh lypes of nelhod, nelhyIphenidale vas significanlIy noie
effeclive lhan neuiofeedlack. Response inhililion (assessed ly Slioop) vas inpioved onIy ly
neuiofeedlack. olh neuiofeedlack and nelhyIphenidale veie associaled vilh inpiovenenls
on lhe vaiialiIily and accuiacy neasuies of conpuleiized allenlion lesls. InleIIecluaI aliIily
(neasuied ly fuII veision of WISC-III) incieased aIso ly lolh nelhods. AIlhough aveiaged
effecl size foi nelhyIphenidale seens lo le giealei lhan foi neuiofeedlack, lhe diffeience vas
nol significanl. In conjunclion vilh olhei sludies lhey concIuded lhal neuiofeedlack can
significanlIy inpiove seveiaI lehavioiaI and cognilive funclions in chiIdien vilh ADHD and
il nighl le an aIleinalive liealnenl foi ADHD, pailicuIaiIy foi lhose lheii paienls favoi a non-
phainacoIogicaI liealnenl (Nazaii el aI., 2O11).
Neuiofeedlack is conliaindicaled vilh suljecls undei age six yeais, oi suljecls vilh nenlaI
ielaidalion, deveIopnenlaI deIay oi olhei significanl nedicaI, neuioIogicaI, oi psychialiic
disease. Suljecls fion faniIies vilh significanl naiilaI discoid lhal couId inleifeie vilh
pailicipalion in lhe liealnenl piocess (IiieI, 2OO7).
Side effecl can sonelines occui duiing neuiofeedlack and piaclilioneis shouId le avaie lhal
occasionaIIy negalive effecls nay occui (Hannond & Kiik, 2OO8, Hannond el aI., 2OO1, Lulai
& Shouse, 1976, Toddei el aI., 2O1O) if liaining is nol leing supeivised ly a knovIedgealIe and
ceilified piofessionaI. Adveise effecls lhal have leen iepoiled ly sone cIinicians incIude
incieased anxiely and agilalion, headaches, faligue, sIeep disluilance, angei and iiiilaliIily,
ciying and enolionaI IaliIily, enuiesis, an inciease in depiession, inciease in sonalic
synplons (incIuding lics and lvilches), seizuies, and lenpoiaiy disoiienlalion. These iepoils
aie unconlioIIed case iepoils fion vhich one cannol knov lhe degiee lo vhich olhei
confounding evenls in lhe palienls Iives nay have conliiluled lo lhese negalive synplons
(Hannond & Kiik, 2OO8). Hovevei, neuiofeedlack piovidei as a heaIlh-ieIaled piofession
shouId pionole lhe veIfaie of lheii cIienls. Theiefoie, lhey shouId peifoin appiopiiale and
oljeclive assessnenls piioi lo, duiing and aflei pioviding neuiofeedlack lo assess ieguIaiIy
lhe effecliveness of lhe seivices piovided, and lhey inquiie fiequenlIy aloul any side effecls oi
adveise ieaclions. When il is olseived lhal side effecls oi negalive effecls aie occuiiing,
piovideis docunenl lhe delaiIs, discuss lhen vilh lhe cIienl, and lake appiopiiale aclion lo
ienediale negalive effecls as quickIy as possilIe. Such aclion nay incIude nodifying
neuiofeedlack piolocoIs, veiifying lhe anounl oi fiequency of liealnenl, uliIizing adjunclive


279
liealnenls, and seeking consuIlalion (Hannond el aI., 2O11). Il shouId le nenlioned lhal
palienls vilh a hisloiy of epiIepsy shouId onIy ieceive neuiofeedlack fion piaclilioneis vho
aie veII veised in neuiofeedlack foi seizuie disoideis.
Sone peopIe inleiesled in aIleinalive heaIlh ieacl lo lhe neuiofeedlack vilh hesilalion.
Neuiofeedlack has leen consideied as a ieIaliveIy unsludied liealnenl, and lhe sludies lhal
have leen conducled have iepoiledIy leen piolIenalic, due lo nelhodoIogicaI piolIens
such as confounded liealnenls, inconsislenl use of dependenl neasuies, snaII sanpIe size,
and a Iack of cIinicaIIy neaningfuI dependenl neasuies (KIine, iann, & Loney, 2OO2,
Waschlusch & HiII, 2OO3, Loo and aikIey, 2OO5, HoIlnann and SladIei, 2OO6). In lhis Iine,
lheie aie sone fundanenlaI queslions:
Does neuiofeedlack iesuIl in lhe inlended LLC changes`
Is lheie ieaIIy an effecl lhal Ieads lo significanl nodificalions in cognilion and lehavioi`
CouId lhese changes le ieIialIy Iinked lo neuiofeedlack liaining`
Hov does il conpaie lo lhe cuiienl slandaid of liealnenl`
Aie lhese changes ielained ovei line`
Hov does neuiofeedlack voik`
Ioi vaIidaling puipose, sone conlioIIed sludies on heaIlhy suljecls (i.e. Lgnei and
CiuzeIiei, 2OO1, Lgnei el aI., 2OO2, Veinon el aI., 2OO3, Lgnei and CiuzeIiei, 2OO4) assessed
specific cognilive, neuiopsychoIogicaI and eIecliocoilicaI effecls fion liaining of specific
fiequency lands. They concIuded lhal lhe noduIalion of specific fiequency lands Ied lo
significanl and piolocoI-specific effecls. Il seens lhal despile lhese vaIidalion voiks nuch
ienains lo le done lo piovide a scienlific lasis foi neuiofeedlack.
Il has leen aigued lhal a polenliaI expIanalion of lhe effecls of neuiofeedlack couId le
cognilive-lehavioiaI liaining effecl as veII as cIienl-lheiapisl ieIalionship effecl since
chiIdien aie engaging in a liaining foi oflen 3O-5O sessions. Such conceins couId le
addiessed ly doulIe-lIind conlioIIed sludies. Consideiing lhe elhicaI piolIen of incIuding
unliealed palienl oi palienl undeigoing pIacelo and lhe difficuIly of conducling a doulIe-
lIind pIacelo conlioIIed sludy in neuiofeedlack, sone gioups (DiechsIei el aI., 2OO7,
CevensIelen el aI., 2OO9) have sliII addiessed lhese conceins ly conpaiing neuiofeedlack
gioup vilh a seni-aclive conlioI gioup (can le consideied a ciedilIe shan conlioI). In lhese
sludies neuiofeedlack in conpaiison lo lhis seni-aclive conlioI gioup sliII had nediun lo
Iaige LS foi inallenlion and inpuIsivily, and snaII lo nediun LS foi hypeiaclivily (Ains el
aI., 2OO9).
La Vaque and Rossilei (2OO1) poinled oul lhal, ialhei lhan conpaiing a nev liealnenl (e.g.,
neuiofeedlack) lo a no-liealnenl pIacelo, il shouId le conpaied lo a piolocoI of 'knovn
efficacy lo deleinine vhelhei such an inleivenlion vouId iesuIl in an equivaIenl effecl.
This lype of design is oflen iefeiied lo equivaIenl sludy (Veinon el aI., 2OO4). Regaiding lhe
veII eslalIished efficacy of nelhyIphenidale, seveiaI sludies have conpaied lhe effecls of
neuiofeedlack and nelhyIphenidale. ResuIls ieveaIed lhal aIlhough aveiaged effecl size foi
nelhyIphenidale vas giealei lhan foi neuiofeedlack, lolh veie in nediun iange and lhe
diffeience vas nol significanl (i.e. Nazaii el aI., 2O11). None of lhe sludies conpaiing
neuiofeedlack vilh slinuIanl nedicalion used iandon assignnenl. AIlhough seIf-seIeclion


280
lhe liealnenl nay lias lhese findings, seIf seIeclion polenliaIIy naxinizes lhe effecls of
expeclancy in lolh gioups. Hovevei, noie sludies using iandonizalion and Iaigei sanpIe
sizes aie needed lo invesligale fuilhei hov neuiofeedlack conpaies lo slinuIanl
nedicalion in lhe liealnenl of ADHD.
SeveiaI foIIov-up sludies (Monaslia el aI., 2OO2, SliehI el aI., 2OO6, Cani el aI., 2OO8,
CevensIelen el aI., 2O1O) shoved lhal inpiovenenls in lehavioi and allenlion luined oul lo
le slalIe. Tesl iesuIls foi allenlion and sone of lhe paienls ialings once noie inpioved
significanlIy. ased on lhese ieseaiches, il can le concIuded lhal lhe cIinicaI effecls of
neuiofeedlack aie slalIe and nighl even inpiove fuilhei vilh line. This, in conliasl lo
slinuIanl nedicalion vheie il is knovn lhal vhen lhe nedicalion is slopped oflen lhe
iniliaI conpIainls viII cone lack again and iecenl evidence shoving lhal lenpoiaiy
liealnenl vilh slinuIanl nedicalion is nol IikeIy lo inpiove Iong-lein oulcones (MoIina el
aI., 2OO9).
Yel anolhei donain in need of fuilhei invesligalion invoIves lhe lheoielicaI lasis and lhe
undeiIying nechanisns of neuiofeedlack inpacl. Today, lo undeisland "hov does
neuiofeedlack voik`" is one of lhe nosl inleiesling and chaIIenging lasks. Il is nol
suipiising lhal lhe fieId of neuioscience alliacls a Iol of ieseaicheis liy lo ansvei lhis
queslion.
Despile sone Iinilalions, neuiofeedlack nay le voilhy of fuilhei consideialion as a vialIe
liealnenl appioach foi ADHD (See Veinon, 2OO5, IiieI, 2OO7, TopIak el aI., 2OO8, Yucha and
Monlgoneiy, 2OO8, Ains el aI., 2OO9). On lhe lasis of cuiienlIy avaiIalIe ieseaich iesuIls, lhe
success of lhis lheiapeulic nelhod is indicaled ly videspiead uliIizalion, and iepoils of
caiefuIIy designed sludies suggesl lhe uliIily of lhis nelhod (}ohn and Iiichep, 2OO9). LLC
liofeedlack lheiapy foi AD/HD iesuIls in significanl inpiovenenl in cognilive funclioning
foi 75-85 peicenl of palienls. Il is possilIe lhal faslei and lellei oulcones nighl le achieved
ly conlining olhei aIleinalive lheiapies vilh LLC liofeedlack (IiieI, 2OO7). Neuiofeedlack
neels lhe Aneiican Acadeny of ChiId and AdoIescenl Isychialiy ciileiia foi cIinicaI
guideIine foi liealnenl of ADHD. As nenlioned lefoie, nela-anaIysis iesuIls of Ains and
his coIIeagues (2OO9) denonslialed lhal neuiofeedlack liealnenl foi ADHD can le
consideied "efficacious and specific".
Iiank H. Duffy, M.D., Iiofessoi and Iedialiic NeuioIogisl al Haivaid MedicaI SchooI,
slaled in an ediloiiaI in lhe }anuaiy 2OOO issue of lhe }ouinaI CIinicaI
LIeclioencephaIogiaphy lhal lhe schoIaiIy Iileialuie suggesls lhal neuiofeedlack shouId
pIay a najoi lheiapeulic ioIe in nany difficuIl aieas:
^2" 8) +7#"#+"1 #, .") 8%6#<.(#+" 3.6 6%8+"'(&.(%6 '4<3 . D#6% '7%<(&48 +, %,,#<.<) #( D+456 /%
4"#$%&'.55) .<<%7(%6 ."6 D#6%5) 4'%6_ B7F $CF ^2( #' . ,#%56 (+ /% (.E%" '%&#+4'5) /) .55F_ B7F $##CF
UnliI 2OO5, neuiofeedlack vas iepoiledIy used ly noie lhan 15OO piaclilioneis (ulnik,
2OO5) and lhe Iasl yeais have seen a iapid giovlh of lhe fieId of neuiofeedlack in lhe US
and al Ieasl 27 counliies (udzynski el aI., 2OO9). Theie aie noie lhan 1OO heaIlh-ieIaled
piofessions in Iian lhal using neuiofeedlack in lheii iouline cIinicaI piaclice. AII of lhen
have leen liained ly lhe iofeedlack Ioundalion of Luiope-IL (vvv.lfe.oig) insliuclois
in lhe Iaaiand SpeciaIized Cenlei foi Hunan Lnhancenenl-ISCHL (vvv.paaiand.oig).


281
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15
The Effect of Psycho-EducationaI Therapy
on EIectroencephaIographic
Biofeedback Scores in
Attention Deficit Hyperactivity Disorder
Iiene Nikaina
1
, Aspa IaspaIi
2
,
Ceoigia KIeidaiia
2
and Anligone IapavasiIiou
1

1
Dcpar|ncn| cf Ncurc|cgq, Pcndc|i Cni|drcn's Hcspi|a|, A|ncns
2
D|K|PSY, A|ncns
Grcccc
1. Introduction
Allenlion deficil/Hypeiaclivily (ADHD) disoidei, a neuiopsychialiic disoidei chaiacleiized
ly inallenlion, hypeiaclivily and inpuIsivily, has leen pieciseIy desciiled ly lhe Aneiican
Isychialiic Associalion (AIA, DSM-IV, 2OOO). Accoiding lo lhe diagnoslic ciileiia lhese nain
synplons nusl appeai lefoie lhe age of 7 yeais, le piesenl foi al Ieasl 6 nonlhs, le evidenl
in al Ieasl lvo sellings, and lhe inpaiinenl nusl conliilule lo sociaI, acadenic, oi
occupalionaI dysfunclion. An incieasing nunlei of palienls, noslIy chiIdien, aie diagnosed
vilh ADHD. Recenl sludies focusing on lhe epidenioIogy of lhe disoidei, iepoiled vaiialIe
pievaIence of ADHD in chiIdhood lhal ieached in sone sludies lhe peicenlage of 14
(ailaiesi el aI, 2OO4, IioehIich el aI, 2OO7, IIiszka, 2OO7, Meiinkagas el aI, 2O1O, CDC, 2O1O).
Il is eslinaled lhal 3O-7O of chiIdien vilh ADHD conlinue lo expeiience ADHD synplons
inlo aduIlhood (VoIInei, 1998, Wendei, 1997, Mannuzza el aI, 1991, LIia el aI, 1999).
The lheiapeulic appioach of ADHD incIudes seveiaI liealnenl nodaIilies (phainacolheiapy,
lehavioiaI, psychoIogicaI and educalionaI inleivenlions). The choice of liealnenl depends
nainIy on lhe palienl's chaiacleiislics such as age al diagnosis, lhe piesence of co-noilid
condilions and lhe lheiapeulic goaIs. ehavioiaI inleivenlions aIone have nol leen effeclive in
aneIioialing lhe coie synplons of ADHD lo a significanl exlenl (The MuIlinodaI
Tiealnenl sludy of ChiIdien vilh ADHD |MTAj, 1999, iovn el aI, 2OO5). Theii nain
conliilulion is lhe inpiovenenl of lhe lehavioiaI piolIens lhal fiequenlIy acconpany
ADHD (KoIko el aI, 1999, IeIhan el aI, 1998). Ihainacolheiapy is one of lhe nosl
efficacious liealnenl appioaches lolh in chiIdien and adoIescenls. SlinuIanls have leen foi
nany yeais lhe fiisl-Iine liealnenl foi ADHD vilh a iesponse iale of appioxinaleIy 7O oi
noie vhen palienls aie sliiclIy conpIying vilh lhe liealnenl (MTA, 1999, MiIIei el aI, 1998,
Schachlei el aI, 2OO1). Alonoxeline seens lo le aloul equaIIy effeclive lo slinuIanls, even
lhough in a iecenl nela-anaIysis il vas iepoiled lhal slinuIanls (especiaIIy lhe Iong-Iasling
ones) denonslialed giealei efficacy lhan alonoxeline duiing lhe shoil duialion of


288
liealnenl evaIualion (> 2 veeks) (Wang el aI, 2OO7, Iaiaone & CIall, 2O1O). In nosl of lhe
palienls il is leneficiaI lo conline nedicalions vilh psychoIogicaI and educalionaI
inleivenlions especiaIIy vhen lheie is a suloplinaI iesponse lo phainacolheiapy, a co-
noilid disoidei and sliessois in lhe faniIy. A syslenalic ieviev of 11 iandonized
conlioIIed liiaIs, incIuding 428 chiIdien 5-18 yeais oId, denonslialed lhal conlinalion
lheiapy vilh nelhyIphenidale and lehavioiaI/psychoIogicaI liealnenls significanlIy
inpioved ADHD lehaviois, synplons, and neasuies of acadenic achievenenl conpaied
lo lehavioi/psychoIogicaI liealnenls aIone (Loid & IaisIey, 2OOO). CuideIines on lhe
nanagenenl of ADHD in chiIdien incIude aII afoienenlioned oplions, aIone oi in
conlinalion (Aneiican Acadeny of Iedialiics, 2OO1, CoIgnan el aI, 1998, DuIcan, 1997).
The nexl inpoilanl issue on ADHD nanagenenl is lhe duialion of lhe posilive effecls of
lhese inleivenlions. Ioi exanpIe, lhe Iong lein efficacy of nedicalions has nol leen
denonslialed. The MuIlinodaI Tiealnenl Sludy of ChiIdien vilh lhe conlined lype of
ADHD (MTA sludy), vhich conpaied phainacolheiapy- shoil acling nelhyIphenidale -
veisus lehavioiaI lheiapy oi lheii conlinalion oi lhe slandaid caie piovided ly
connunily piovideis, iepoiled in 2OO4 lhal liealnenl vilh slinuIanls foi 24 nonlhs had a
ieduced effecl, as conpaied lo lhe effecliveness al 14-nonlhs pulIished ly lhe sane gioup
(MTA, 2OO4). Al 3 yeais of foIIov-up of lhe sane palienls, lhe advanlage of nedicalions in
conpaiison lo aII olhei liealnenl oplions disappeaied aIlhough in aII liealnenl gioups an
inpiovenenl on ADHD synplons vas olseived conpaied lo laseIine (}ensen el aI, 2OO7).
The possilIe expIanalions of lhe Ioss of lhe phainacolheiapy advanlage ovei aII olhei
liealnenls veie an age-ieIaled decIine in ADHD synplons, changes in lhe inlensily of
nedicaI nanagenenl, and aIleinaling peiiods of liealnenl/no-liealnenl aflei lhe 14 nonlh
sludy peiiod. In 2OO2, Monaslia el aI denonslialed lhal palienls liealed vilh shoil acling
slinuIanls (RilaIin) Iosl lhe lenefils deiived fion lhe diugs one yeai aflei cessalion of lhe
diug (Monaslia el aI, 2OO2). SiniIai iesuIls had aIso leen piesenled on lhe Iong lein
effecliveness of alonoxeline, 9 nonlhs aflei diug disconlinualion (MicheIson el aI, 2OO4). AII
lhese olseivalions aIong vilh lhe facl lhal 25-4O of chiIdien vilh ADHD do nol iespond
lo nedicalions and olhei conseivalive liealnenls nakes lhe ieseaich on aIleinalive
lheiapeulic appioaches an inleiesling fieId (MTA, 1999, IeIhan el aI, 1998, MiIIei el aI, 1998,
Svanson el aI, 1993, aikIey, 1998).
Neuiofeedlack, a foin of liofeedlack Iinked lo liain aclivily, vas fiisl desciiled as an
oplion foi ADHD liealnenl in lhe nid-197O's, ly Lulai and Shouse (Lulai & Shouse, 1976).
The hypolhesis lehind lhe use of lhis nelhod is lhal il nay enalIe lhe usei lo nodify
liainvave aclivily in oidei lo inpiove allenlion, ieduce inpuIsivily and conlioI
hypeiaclive lehavioi. This nodificalion is lased on seIf-ieguIalion of neuionaI osciIIalions
iecoided ly LLC. The goaI is lo enhance sone lypes of LLC aclivily oi ieduce sone olheis
in one oi noie fiequency lands ly visuaI oi audiloiy feedlack, foi exanpIe in ADHD, lhe
ain is lo enhance lela aclivily and lo inhilil lhela aclivily. Theie aie lvo najoi calegoiies of
neuiofeedlack liaining piolocoIs: one lhal uses fiequency lands of lhe liain aclivily and a
second vhich invoIves liaining of sIov coilicaI polenliaIs (SCIs), vilh lhe fiisl leing fai
noie sludied lhan lhe Iallei (Veinon el aI, 2OO4). Conceining lhe fiisl liaining slialegy, lhiee
paianeleis aie usuaIIy used in chiIdien vilh ADHD: lhela fiequency (4-8 Hz), lela
fiequency (15-2O Hz) and sensoiinoloi ihylhn (SMR) (12-15 Hz). The laigel of lhe palienl
undei liaining is lo deciease lhe povei of lhela aclivily and/oi lo inciease povei of lela
The Effect of Psycho-Educational Therapy
on Electroencephalographic Biofeedback Scores in Attention Deficit Hyperactivity Disorder

289
aclivily and SMR aclivily, in oidei lo inpiove allenlion skiIIs. Reseaich piolocoIs usuaIIy
conline lvo oi even noie paianeleis. SCIs veie fiisl desciiled ly Heiniich el aI in 2OO4
(Heiniich el aI, 2OO4). They aie evenl-ieIaled shifls of coilicaI aclivily Iasling fion seveiaI
hundied niIIiseconds lo seveiaI seconds (iilaunei el aI, 199O). The liaining of lhe SCIs
invoIves an effoil lo inciease posilivily oi negalivily ovei sensoiinoloi coilex, in oidei lo
enalIe lhe suljecl lo conlioI coilicaI ieguIalion and lo aIIocale iesouices efficienlIy,
funclions lhal aie supposed lo le inpaiied in ADHD (Seigeanl, 2OOO, 2OO5).
SeveiaI sludies have denonslialed lhal neuiofeedlack has a favoialIe effecl on ADHD
synplonaloIogy and cognilive funclion, as conpaied lo lolh pIacelo and
psychoslinuIanls, iegaidIess of lhe piolocoI used (Monaslia el aI, 2OO2, Ains el aI, 2OO9,
CevensIelen el aI, 2OO9a, DiechsIei el aI, 2OO7, Heiniich el aI, 2OO7, Levesque el aI, 2OO6,
Rossilei, 2OO4, Iuchs el aI, 2OO3). Iuilheinoie, in 2O1O, CevensIelen H el aI pulIished a 6
nonlhs foIIov-up sludy pioviding evidence foi Iong-lein lenefils of neuiofeedlack
liaining in chiIdien vilh ADHD (CevensIelen el aI, 2O1O).
In spile of lhese pionising iesuIls consideialIe conlioveisy conlinues lo suiiound
neuiofeedlack as a lheiapeulic oplion foi ADHD palienls. The skeplicisn lovaids lhis lype
of liaining is lased noslIy on nelhodoIogicaI shoilconings of lhe pulIished ieseaich. SnaII
sanpIe size, non-iandonized gioup assignnenl, and conlioI condilions lhal do nol conlioI
foi confounding faclois since lhey Iack a doulIe-lIind selup aie lhe najoi design piolIens,
lhal aie nol easy lo oveicone (Heiniich el aI, 2OO7). Il is queslionalIe vhelhei lehavioiaI
inpiovenenls aflei neuiofeedlack liaining can le ieIaled lo lhe inpioved coilicaI
ieguIalion oi ialhei lo non-specific liealnenl effecls such as invesled line and allenlion,
lheiapisl- palienl inleiaclion, expeclancies, changes in lhe paienlaI allilude, enhanced
avaieness of lhe piolIen oi naluialion-ieIaled faclois. Since syslenalic ieinfoicenenl and
a posilive ieIalionship lo a lheiapisl aie inlegiaI pails of lhe neuiofeedlack liaining and of
any olhei lehavioiaI inleivenlion especiaIIy vilh chiIdien, seIeclive effecls of lhe
neuiofeedlack aie difficuIl lo isoIale (DiechsIei el aI, 2OO7). The lesl vay lo iesoIve lhis is
lhe coiiecl choice of a conlioI gioup. Hovevei, lhe inpIenenlalion of a conlioI condilion
foi neuiofeedlack liaining is aIso difficuIl. Ioi ieseaich puiposes, lhe lesl conlioI condilion
vouId le a pIacelo neuiofeedlack condilion in vhich piovided feedlack is siniIai lo
neuiofeedlack, lul nol ieIaled lo lhe chiIds ovn liain aclivily. The nain advanlage of lhis
lype of conlioI condilion vouId le lhal il couId aIIov pailicipaling chiIdien, paienls and
liaineis lo le lIinded foi gioup aIIocalion, lhus confounding faclois vouId le nininized.
Hovevei, inpIenenling a pIacelo conlioI condilion in a iandonized conlioIIed liiaI nay
Iead lo elhicaI conceins, noslIy lecause lhis design aIso invoIves vilhhoIding evidence-
lased liealnenl (LaVaque & Rossilei, 2OO1, SliehI el aI, 2OO6). Moieovei, il has leen aigued
lhal pIacelo neuiofeedlack liaining nay nol le feasilIe since posilive oi negalive
lheiapeulic effecls viII le peiceived ly lhe palienl oi lhe lheiapisl (Kolchouley el aI, 2OO1).
AddilionaIIy, in a pIacelo-conlioIIed sludy il is inpoilanl lo noniloi adveise evenls duiing
lhe liaining peiiod in oidei lo lesl lhe safely of lhe pIacelo condilion, lhal couId polenliaIIy
iepiesenl a piolIen in lhis lype of selling (iilaunei el aI, 1992). Ioi lhese ieasons, lhe use of
a pIacelo-conlioI sludy design is ialhei Iiniled. To oui knovIedge, onIy one doulIe-lIind
pIacelo-conlioIIed liiaI has aIieady leen pulIished (Lansleigen el aI 2O11). Olhei lypes of
conlioI gioups lhal have leen uliIized aie a vailing Iisl conlioI gioup (Heiniich el aI, 2OO4,
Levesque el aI, 2OO6), chiIdien undeigoing gioup lheiapy (DiechsIei el aI, 2OO7), and a gioup


290
undeigoing conpuleiized allenlion liaining (CevensIelen el aI, 2OO9a). Cioup lheiapy and
conpuleiized allenlion liaining nay effecliveIy conlioI foi unspecific effecls such as invesled
line and liealnenl expeclancies. Wailing Iisl, on lhe olhei hand, nay inlioduce lias lecause
of naluialionaI changes, nuIlipIe lesling oi changed paienlaI alliludes (DiechsIei el aI, 2OO7).
IinaIIy, il has aIso leen aigued lhal neuiofeedlack liaining piolocoIs nay have a seIeclion
lias ly design. Civen lhe financiaI inveslnenl and line connilnenl iequiied foi lhe
conpIelion of neuiofeedlack liaining piogian, lhe najoiily of chiIdien vho ieceive such a
liealnenl aie nosl IikeIy fion slalIe, uppei socioecononic househoIds, vho nay have
sinpIy inpioved ovei line lecause of lheii advanlaged posilion (aydaIa & Wiknan, 2OO1).
NeveilheIess, lhe evidence piovided ly lhe nosl iecenl and lellei designed sludies is
consideied lo le sulslanliaI if nol yel concIusive and lhe use of neuiofeedlack liaining foi
ADHD had gained enpiiicaI suppoil. In addilion lo lhe accunuIaling evidence on lhe
effecliveness of neuiofeedlack in palienls vilh ADHD, il is nov suggesled lhal lhis
liealnenl nay le inlegialed in a nuIlinodaI lheiapeulic appioach (CevensIelen el aI,
2OO9a, MTA, 1999). The conlinalion of neuiofeedlack vilh slandaid lheiapies such as
phainacolheiapy, and/oi sociaI skiIIs liaining and paienlaI inleivenlions couId iesuIl in
addilionaI inpiovenenls nol onIy lo lhe piinaiy synplons of lhe disoidei lul lo olhei
ieIaled aieas such as Ieaining, lehavioi and enolionaI slaliIily. The ain of lhis sludy vas lo
expIoie lhe inleiaclions lelveen neuiofeedlack and a piogian of psychoIogicaI and
educalionaI inleivenlions piesciiled foi lhe nanagenenl of ADHD. Oui hypolhesis vas
lhal lhe conlinalion of lhese liealnenls nay induce Iaigei inpiovenenls of lhe exanined
eIecliophysioIogicaI paianeleis sludied lhan neuiofeedlack aIone, suggesling a syneigislic
effecl of lhese lvo liealnenl nodaIilies on liain liaining.
2. Methods
2.1 Patients
ChiIdien conseculiveIy evaIualed in lhe oulpalienl ChiId NeuioIogy cIinic vilh an ADHD
diagnosis accoiding lo DMS IV ciileiia veie consideied as candidales foi lhis sludy. OnIy
chiIdien lhal scoied vilhin lhe noinaI IQ iange (IQ>8O), accoiding lo WISC III, veie
incIuded in lhe sludy. The piesence of co-noilidilies olhei lhan Ieaining disoideis vas an
excIusion ciileiion. Aflei an iniliaI evaIualion ly lhe cIinicaI psychoIogisl, lhe leachei of
speciaI educalion, lhe speech lheiapisl and lhe occupalionaI lheiapisl, 3O chiIdien vho
fuIfiIIed oui incIusion and excIusion ciileiia veie ieciuiled foi lhis sludy. AII of lhen had
Ieaining difficuIlies in ieading and viiling.
2.2 Interventions
Tvo kinds of lheiapeulic inleivenlions veie pioposed vilh lhe inlenlion lo le conlined: a
psycho-educalionaI piogian (2 houis/veek) and a liofeedlack liaining piolocoI (2
houis/veek). The conlined piogian vas nol accepled ly seveiaI faniIies due noslIy lo
financiaI ieasons (lhe liofeedlack vas coveied ly nosl insuiance agencies), oi due lo line
iesliiclions. As a iesuIl ve ended up vilh lvo gioups: lhe fiisl gioup incIuded 15 chiIdien
vho allended lhe liofeedlack piogian onIy (NI gioup) vheieas in lhe second gioup
(n=15) chiIdien veie liealed vilh lolh liofeedlack and psycho-educalionaI liealnenl
(NI+ISL gioup).

291
2.2.1 Neurofeedback
The liofeedlack piolocoI lhal vas used vas lhe !"#$%&'(%)%& &+,)+( -!./0
"#+1#2"("#)3)+")1 $455&"$$'%#. This is lased on lhe concepl lhal inpioved allenlion and
lehavioiaI conlioI is achieved vhen lhe chiId Ieains lo ieduce lhe pioduclion of lhela and
inciease lhe pioduclion of lhe 12-15 Hz sensoiinoloi ihylhn geneialed ovei lhe eIecliodes
C3 oi C4 lhal aie posilioned ovei lhe noloi coilex. LLC iecoidings veie ollained fion one
aclive sile (C3 oi C4), iefeienced lo Iinked eaiIoles. Thela/ela ialio vas neasuied lefoie
lhe liaining inilialion, aflei lhe 2O
lh
session and aflei lhe 4O
lh
session. In each of lhese
inslances, lhe ialio vas ollained in lhiee condilions: Lyes cIosed, eyes opened and duiing
an allenlionaI lask (eyes fixed lask). Mean vaIues veie caIcuIaled ovei lhese lhiee
condilions.
The neuiofeedlack liaining piogian vas designed lo Iasl foi 4O sessions. Lach
neuiofeedlack session Iasled foi aloul 45 ninules. Lach chiId voiked individuaIIy undei
lhe supeivision of a psychoIogisl (ceilified neuiofeedlack liainei). ChiIdien veie sealed
facing a conpulei scieen. Once lhe eIecliodes veie synchionized vilh lhe liaineis
conpulei, lhe chiIdien veie diiecled lo slail pIaying a conpulei gane. In aII lhe
neuiofeedlack ganes, lhe chiIdien veie asked lo nove a laigel, ly using lheii gaze and ly
ienaining concenlialed on lhe laigel. Ioi as Iong as lhe chiIdien ienained vilh lheii gaze
peifeclIy concenlialed on lhe laigel, lhey gained poinls and conpIeled lhe gane ly
fuIfiIIing lhe defined goaI. VisuaI (aninaled figuies) feedlack vas piovided lased on lhe
palienls success in conlioIIing a) lhe anpIilude in niciovoIls of lhela oi sensoiinoloi
ihylhn (SMR) oi l) lhe peicenlage of line lhal lhela ihylhn vas leIov pie-liealnenl
lhieshoId oi SMR vas alove pie-liealnenl lhieshoId. Ialienls veie infoined via audiloiy
(lone) and visuaI feedlack vhen lhey pioduced O.5 seconds of desiied LLC aclivily. y lhe
end of each gane, lhe chiIdien gol a sun of poinls, depending on lheii peifoinance. The
goaI foi each chiId vas lo achieve a scoie lhal is cIosei lo vhal is consideied appiopiiale foi
his/heis age IeveI. Thioughoul a session lhe chiIdien pIayed as nany as 6 ganes. In
lelveen lhe ganes, lhey ieceived innediale feedlack on lheii peifoinance so lhal lhey
couId lhen pioceed lo adjuslnenls of lhe allenlion IeveI. Aflei a lieak of 1 lo 2 ninules, lhey
pioceeded lo lhe nexl one. This piocess vas iepealed lhioughoul lhe vhoIe session. Al lhe
end of each session, chiIdien and paienls veie infoined on lhe lolaI scoie.
2.2.2 Psycho-educationaI
This vas lased on lhe cognilive-lehavioiaI appioach foi chiIdien vilh ADHD and vas
scheduIed foi 2 houis/veek iighl aflei lhe neuiofeedlack session. The inleivenlion
piogian addiessed lolh ieading and viiling difficuIlies and al lhe sane line lhe
speciaIized lheiapisl piovided suppoil lo lhe chiIdien vho due lo lheii Ieaining difficuIlies
sliuggIed al schooI. Iuilheinoie, lolh palienls and paienls ieceived piaclicaI counseIIing
vilh iegaid lo line oiganisalion and scheduIed aclivilies nanagenenl.
2.3 StatisticaI anaIysis
Mean Thela/ela ialio scoies al lhe fiisl session and aflei lhe 2O
lh
and lhe 4O
lh
(Iasl) session,
veie lesled foi noinaIily using Shapiio-WiIk disliilulionaI lesl. NoinaI dala veie
expiessed as nean vaIues slandaid vaiialion (SD), vheieas non noinaI dala as nedian


292
vaIues (25
lh
-75
lh
peicenliIe). The conpaiison of nean neuiofeedlack scoies lelveen lhe
lvo liealnenl oplions vas assessed vilh l-lesl vhen noinaIIy disliiluled oi vilh Mann-
Whilney U Tesl vhen non-noinaI. CalegoiicaI vaiialIes veie conpaied vilh Chi squaie
lesl oi Iishei's exacl lesl accoiding lo nunlei of olseivalions pei ceII. I-vaIues foi lhe lesls
appIied in lvo diffeienl occasions (aflei lhe 2O
lh
and aflei lhe 4O
lh
session) veie coiiecled
vilh onfeiioni Coiieclion foi nuIlipIe conpaiison lesl, in oidei lo ieduce Type I eiioi.
IinaIIy, nixed effecls nodeI vas appIied lo lesl lhe IongiludinaI evoIulion of nean
Thela/ela ialio, laking inlo accounl lhe lheiapy gioup in vhich each palienl is assigned. In
lhese nodeIs, palienl and nunlei of sessions veie liealed as iandon vaiialIes.
3. ResuIts
The palienls (N=3O, 15 loys and 15 giiIs) had a nean age of 7 yeais 7 nonlhs ( 1 yeai 2
nonlhs). The lvo gioups (NI and NI+ISL gioup) consisled of 15 palienls each and lhey
veie siniIai in leins of age and sex. AII palienls foIIoved lheii liealnenl consislenlIy and
lheie veie no diopouls.
Al laseIine (fiisl neuiofeedlack session), nean Thela/ela ialios veie nol significanlIy
diffeienl lelveen lhe lvo lheiapy lianches (3.13 O.O2 foi lhe NI+ISL gioup veisus 3.1O
O.2 foi lhe NI gioup, p-vaIue=O.265). Tvo oul of lhe palienls of lhe NI gioup nanaged lo
ollain lhe laigel ialio (< 3) aIieady duiing lheii fiisl neuiofeedlack liaining session.

Thela/ela ialio al
Iiisl session
Thela/ela ialio
aflei 2O
lh
session
Thela/ela ialio aflei 4O
lh

session
NI gioup 3.1O O.O8 3.O3 O.1O 2.95 O.13
NI+ISL
gioup
3.13 O.O6 3.O5 O.O6 2.94 O.O6
TalIe 1. Mean Thela/ela vaIues foi chiIdien lhe lvo liealnenl gioups al disciele
olseivalion lines
TalIe 1 dispIays nean Thela/ela ialios foi chiIdien in lolh liealnenl gioups. AII palienls
piesenled a deciease in Thela/ela ialio vaIues duiing lheii liealnenl. Accoiding lo lhe
nixed effecls nodeI appIied, lhis olseived deciease vas significanl as liealnenl evoIved (p-
vaIue <O.OO1). Hovevei, lhe size effecl of line eIapsed vas quile snaII vilh lhe ialio aflei
lhe 2O
lh
session leing as nuch as O.O78 unils Iovei lhan ils iniliaI vaIue, and aflei lhe 4O
lh

session leing as nuch as O.172 unils Iovei lhan ils iniliaI vaIue. SiniIaiIy, age of palienls
vas a significanl piedicloi of nean Thela/ela vaIues ollained (p-vaIue <O.OO1). Moie
specificaIIy, chiIdien 8 oi noie yeais oId had sIighlIy Iovei nean vaIues lhan lhose youngei
lhan 8 yeais, adjusled foi liealnenl gioup and line of olseivalion (coefficienl = -O.O82, 95
CI = lelveen -O.127 and -O.O38).
On lhe olhei hand, nean vaIues of Thela/ela ialios veie nol significanlIy diffeienl
lelveen lhe lvo liealnenl gioups, al a piecise line poinl (aflei lhe 2O
lh
oi aflei lhe 4O
lh

neuiofeedlack session - p-vaIue=O.841). These iesuIls aie giaphicaIIy denonslialed in Iig 1.
Hovevei, vhen ve conpaied lhe peicenlages of palienls vho succeeded lo ollain lhe

293
laigel ialio lelveen lhe lheiapy gioups, ve veie alIe lo dispIay lhal significanlIy noie
palienls of lhe NI+ISL gioup ieached lhe laigel, as conpaied lo lhe NI gioup onIy aflei
lhe 4O
lh
session (14 veisus 6 palienls iespecliveIy, p-vaIue=O.OO6). The diffeience aflei lhe
2O
lh
session vas nol significanl (4 palienls of lhe NI+ISL gioup veisus 4 palienls of lhe NI
gioup, p-vaIue=O.841) (Iig 2). In lhis anaIysis, ve onilled lhe lvo palienls of lhe NI gioup
vho had a successfuI fiisl session, aIlhough lheii incIusion does nol ieaIIy affecl lhe iesuIls.

Iig. 1. LongiludinaI evoIulion of nean Thela/ela ialio foi palienls of lhe lvo liealnenl
gioups
First session 20th session 40th session
0
2
4
6
8
10
12
14
16
NF NF+PSE
F
r
e
q
u
e
n
c
y

Iig. 2. Iiequency of chiIdien vho had achieved lhe goaI of Thela/ela <3 al lhe fiisl, aflei
lhe 2Olh and aflei lhe 4O
lh
session


294
4. Discussion
The nain iesuIl in lhis sludy vas lhal lhe addilion of psycho-educalionaI liealnenl lo LLC
liofeedlack iesuIled in noinaIizalion of Thela/ela ialio and lhus in ieducing lhe sIoving
of lhe fionlaI liain aclivily. To oui knovIedge, lhis is lhe fiisl sludy lo iepoil changes on
neuiofeedlack sludied paianeleis in ieIalion lo lhe psycho-educalionaI inleivenlion.
Up lo lhe piesenl line, onIy a fev sludies have assessed lhe effecls of phainacolheiapy,
noslIy psychoslinuIanls, on LLC palleins in chiIdien vilh ADHD. Il has leen
denonslialed lhal lhe use of psychoslinuIanls pioduce a deciease in Thela/ela ialio in
chiIdien vilh ADHD, lo lhe poinl of ieaching noinaI vaIues and lhis vas noie pioninenl
in lhe iighl henispheie (CIaike el aI, 2OO1a, CIaike el aI, 2OO7, Dixil el aI, 2OO2, Keidai el aI,
2OO7, Heinens el aI, 2OO5). In lheii sludy in 2OO5, Song DH el aI denonslialed lhal lhe
liealnenl vilh nelhyIphenidale induced an inciease in Thela/ela ialio in lhe iighl fionlaI
and paiielo-occipilaI iegion in 2O loys vilh ADHD, duiing conlinuous peifoinance lesl
(CIT) and nol in iesling slales (Song el aI, 2OO5).
When used as pail of nuIlinodaI liealnenl in ADHD lhe psycho-educalionaI inleivenlion
ains lo naxinize lhe IikeIihood of lhe chiIds acadenic success ly deveIoping aieas of
slienglh, ly adapling lo speciaI needs and ly ienedialing knovIedge and skiII deficils
(WiIIian & Snuchei, 2OO1). Theie is gieal vaiialiIily conceining lhe foin of psycho-
educalionaI inleivenlion in lilIiogiaphy. Il nay incIude infoinalive sessions on ADHD,
lehavioiaI slialegies (paienlaI liaining, chiId seIf-conlioI insliuclion liaining, schooI-lased
lechniques, faniIy counseIing) and/oi educalionaI packages in conlinalion vilh lehavioiaI
lechniques (Monloya el aI, 2O11).
In lhe piesenl sludy, ve veie alIe lo denonsliale lhal lhe psycho-educalionaI piogian
vhich vas added lo lhe liealnenl of ADHD chiIdien couId enhance lhe effecl of lhe
neuiofeedlack piolocoI used. We have shovn lhal lhe peicenlage of palienls vho ieached
LLC aclivily noinaIizalion vas highei in lhe NI+ISL conpaied lo lhe NI gioup. Hovevei,
vhen ve conpaied lhe IongiludinaI evoIulion of Thela/ela ialio lelveen lhe liealnenl
gioups, lhe psycho-educalionaI piogian did nol have an effecl. Taking inlo accounl lhe facl
lhal aII chiIdien Ieained lo ieduce liain sIoving lul nol aII of lhen achieved noinaI
Thela/ela ialios duiing lhe 4O sessions piogianned, il can le posluIaled lhal lhe
inpIenenlalion of a psycho-educalionaI piogian nay acceIeiale lhe neuiofeedlack
liaining piocess. Whelhei lhe effecl of lhe psycho-educalionaI piogian is nodified ly olhei
unspecified faclois needs lo le fuilhei sludied .
One facloi lhal has leen denonslialed lo le an inpoilanl nodeialing facloi of lehavioi al
hone, especiaIIy in chiIdien liealed vilh neuiofeedlack, vas paienlaI suppoil. In lhe sludy
of Monaslia el aI, vhen syslenalic appioaches lovaids paienl nedialed ieinfoicenenl
slialegies veie used vilh palienls liealed vilh lolh neuiofeedlack and slandaid lheiapies,
inpioved lehavioiaI ialings veie denonslialed nol onIy al schooI enviionnenl lul aIso al
hone, even vhen nedicalion vas disconlinued (Monaslia el aI, 2OO2). On lhe conliaiy,
vhen eIecliophysioIogicaI paianeleis veie exanined, as in lhe sludy of DiechsIei el aI,
lheie vas no evidence of a diiecl infIuence of paienl diiecled appioaches on successfuI
coilicaI conlioI, as 5O of lhe chiIdien vho peifoined veII in neuiofeedlack liaining and
66 of lhose vho peifoined lad, leIonged lo lhe high paienlaI suppoil gioup (DiechsIei el

295
aI, 2OO7). In lhe cuiienl sludy, ve did nol exanine paienlaI suppoil as a facloi lhal couId
affecl lhe iesuIls of lhe piesciiled liealnenl.
TalIe 1 iepoils alsoIule vaIues of Thela/ela ialios on lhiee diffeienl occasions: al fiisl
session, aflei lhe 2O
lh
session and aflei lhe 4O
lh
session. To oui knovIedge, onIy fev
neuiofeedlack sludies focus on liain aclivily nodificalion ilseIf and LLC dala aie iaieIy
avaiIalIe. IniliaI vaIues foi Thela/ela ialio al fiisl session veie nol siniIai lo lhose
iepoiled ly Monaslia el aI in 1999 foi a gioup of ADHD chiIdien of lhe sane age (Monaslia
el aI, 1999). In lhis sludy, aulhois used a Thela/ela vaIue lhal vas al Ieasl 1.5 SD highei
lhan lhe vaIue iepoiled foi noinaI age peeis as a culoff poinl foi ADHD diagnosis. In lhe
cuiienl sludy, nean Thela/ela vaIues al fiisl session (piaclicaIIy lefoie liaining) veie
Iovei as conpaied lo lhose iepoiled in lhe afoienenlioned sludy foi chiIdien vilh ADHD
lul alove lhe lhieshoId foi noinaI chiIdien 6-11 yeais oId (vhich vas sel al lhe vaIue of 3).
On lhe olhei hand, lhe Thela/ela ialios iepoiled ly Song el aI in 2O palienls vilh a nean
age of 8.6 yeais (1.4 yeais) veie Iovei lhan lhose piesenled in oui sludy, in aII liain iegions
lhal veie exanined (Song el aI, 2OO5).
One expIanalion foi lhis discoidance in Thela/ela vaIues nay le due lo lhe posilioning of
eIecliodes. In sone sludies focusing on neuiofeedlack nelhodoIogy, il vas olseived lhal
vhen eIecliodes veie fixed fionlaIIy, vheie noie lhela and Iess lela aclivily in palienls
vilh ADHD is found, lhen ailifacls ly eye novenenls nay le a significanl iisk (Mann el aI,
1992, Lulai el aI, 1995, Chalol & Seifonlein, 1996). Ioi lhis ieason il is suggesled lhal
eIecliodes aie pIaced in a noie cenliaI posilion al C3f (= haIfvay lelveen C3 and I3) and
C4f (= haIfvay lelveen C4 and I4) (Monaslia el aI, 1999). In lhe cuiienl sludy eIecliodes
veie posilioned al C3 oi C4 posilions (a lil posleiioiIy in ieIalion lo lhe posilions desciiled
pieviousIy), vheieas in lhe sludy of Song el aI Thela/ela ialios veie iecoided in aII 3O
iegions defined ly lhe InleinalionaI 1O/2O syslen lul nol ovei C3-C4 oi C3f-C4f (Song el aI,
2OO5, Monaslia el aI, 1999). A second expIanalion nay le lhe diffeience in lhe nelhodoIogy
used and noie pieciseIy in lhe caIcuIalion of lhe nean Thela/ela ialio. In lolh lhe
afoienenlioned sludies and in lhe cuiienl sludy, lhe Thela/ela ialio vas neasuied in
diffeienl condilions (peifoinance lasks, iesling slales, eyes open/cIosed) and lheiefoie lhe
pioduced nean vaIues aie nol expecled lo le siniIai.
Iuilheinoie, in lhe piesenl sludy ve did nol nake a disciininalion of lhe ADHD lype. The
conposilion of lhe sludy gioup in oui sludy couId aIso accounl foi lhe olseived diffeiences in
lhe Thela/ela vaIues fion lhe sludy of Monaslia el aI (Monaslia el aI, 2OO2). Accoiding lo
sone aulhois chiIdien vilh ADHD-Conlined Type nay exhilil noie alsoIule and ieIalive
lhela aclivily, and highei Thela/AIpha and Thela/ela ialios vhen conpaied lo lhose vilh
ADHD-Inallenlive lype (CIaike el aI, 1998, CIaike el aI, 2OO1l, CIaike el aI, 2OO3). AIlhough
lhese iesuIls veie nol iepioduced ly olhei aulhois, lhey nay suggesl lhal chiIdien vilh
ADHD- Conlined Type shov lhe cIassic pallein of giealei undeiaiousaI and naluialionaI
deIay noie so lhan lhe chiIdien vilh ADHD- Inallenlive lype. In conliasl, lhe Iallei gioup of
palienls exhililed noie ieIalive aIpha aclivily in lhe posleiioi iegions lhan lhose vilh
ADHD-Conlined Type, vhich is consislenl vilh iepoils of sIovei cognilive piocessing and
incieased iales of daydieaning anong lhese kids (Monaslia el aI, 2OO1, Loo & aikeIy, 2OO5).
As ve have shovn, Thela/ela ialio decieased sulslanliaIIy, fion lhe fiisl lo lhe 4O
lh

session. SiniIai iesuIls veie iepoiled pieviousIy (Monaslia el aI, 2OO2, Thonpson L &
Thonpson M, 1998, Lulai el aI, 1995, Loo & aikIey, 2OO5, CevensIelen el aI, 2OO9l, Leins el


296
aI, 2OO7). In lhe fiisl of lhese sludies, palienls vho undeivenl neuiofeedlack liaining
piesenled a significanl ieduclion on lheii Thela/ela ialio vaIues fion alove 5.O3
(pieliealnenl) lo Iess lhan 3 (posl-liealnenl) (Monaslia el aI, 2OO2). A deciease in
Thela/ela ialio vas aIso olseived in a iandonized sludy pulIished in 2OO9 ly
CevensIelen and coIIeagues (CevensIelen el aI, 2OO9). In lhis sludy, lhe nodificalion of LLC
aclivily denonslialed in 72 chiIdien vilh ADHD vas alliiluled lo a naiked deciease of
lhela aclivily in posleiioi nidIine posilion. The findings of Leins el aI aie aIso in accoidance,
aIlhough lhey used a diffeienl appioach (Leins el aI, 2OO7). They sludied Thela/ela ialios
in aclivalion and in deaclivalion lasks and in feedlack and liansfei condilions, in oidei lo
pioduce siniIai slales vilh lhe SCI liaining piogian. They olseived lhal Thela/ela ialio
changed significanlIy in deaclivalion lasks lul nol in aclivalion lasks and onIy in feedlack
condilions. In aclivalion lasks, a deciease in Thela/ela ialio vas olseived aIieady vilhin
lhe fiisl sessions of lhe liealnenl lul, in lhe end, il did nol ieach significance. Il shouId le
aIso noled lhal in lhe cuiienl sludy jusl as in lhe sludy pulIished in 2OO2 ly Monaslia el aI,
Thela/ela vaIues ly lhe end of neuiofeedlack liaining veie siniIai lo vaIues pioduced ly
non-ADHD age peeis. Hovevei, lhis finding vas nol iepioduced in lhe sludy of Cainody
el aI, in vhich noinaIizalion of sponlaneous LLC aflei fiequency neuiofeedlack liaining
vas nol found (Cainody el aI, 2OO1).
Anolhei inpoilanl aspecl of lhe cuiienl sludy is lhal aII nenleis of lhe sludy sanpIe
pioved lo le capalIe of aIleiing lheii liain vave fiequency. The peicenlage of palienls vho
Ieain hov lo inciease coilicaI aclivily vaiies acioss lhe sludies pulIished. In nosl of lhen,
lhis peicenlage vas quile high. As in lhe piesenl sludy, Lulai el aI iepoiled, in a pail of
lheii ieseaich, lhal aII palienls nanaged lo sIov coilicaI aclivily (Lulai el aI, 1995). In
suppoil of lhese dala, lhe najoiily of palienls in lhe sludy of Lansleigen el aI Ieained lo
inciease SMR and deciease lhela aclivily (Lansleigen el aI, 2O11). NeveilheIess, il has aIso
leen iepoiled lhal sone pailicipanls faiI lo ollain salisfacloiy liaining iesuIls duiing LLC
feedlack oi liansfei (DiechsIei el aI, 2OO7, Lulai el aI, 1995, SliehI el aI, 2OO6, Kiopolov el aI,
2OO5). This iesuIl vas noslIy olseived in liaining SCIs piolocoIs and il vas alliiluled lo
lhe piolocoI ilseIf since lhe SCI liaining, vhich is ialhei slialegic in naluie and pione lo
ailifacls, nay le noie difficuIl foi chiIdien vilh ADHD lhan a neuiofeedlack liaining
lased on fiequency ialios (DiechsIei el aI, 2OO1).
IinaIIy, il vas shovn lhal lhe effecl of psycho-educalionaI piogian on neuiofeedlack
paianeleis is piesenl onIy aflei 4O sessions. In nosl sludies, il seens lhal a lolaI of 4O
sessions is needed in oidei lo achieve inpiovenenls in ADHD synplons and in daiIy
funclioning. In lhe sludy of Monaslia el aI, lhe LLC neuiofeedlack liaining vas slopped
vhen pailicipanls ollained Thela/ela ialio in lhe noinaI iange foi age (vilhin 1.O SD of
age peeis) foi al Ieasl 4O nin and foi 3 conseculive liealnenl sessions (Monaslia el aI, 2OO2).
The aveiage nunlei of sessions needed lo ieach lhis goaI vas 43 (iange: 34-5O). Hovevei,
fevei sessions nay aIso le enough lo pioduce lhe desiialIe effecl. In lhe sludy of
CevensIelen el aI, lhe aIleialion of liain aclivily iequiied onIy 18 sessions (CevensIelen el
aI, 2OO9l). SiniIai veie lhe iesuIls of Leins el aI vho suggesled lhal palienls Ieain lo aIlei
LLC aclivily al a veiy eaiIy slage of lhe liaining lul lhey don'l shov any inpiovenenl
duiing lhe foIIoving sessions (Leins el aI, 2OO7). When il cones lo Iong-lein lenefils fion
neuiofeedlack, Iox el aI suggesled lhal foi a Iong Iasling change on LLC fiequencies, nany
sessions, up lo 6O, nay le iequiied, even lhough il vas denonslialed lhal 3O of palienls
liealed vilh ADHD aie capalIe of changing lheii liain vaves fiequency foi a Iong line

297
aflei as fev as 2O sessions of neuiofeedlack liaining (Iox el aI, 2OO5, Rossilei & LaVaque,
1995). InpoilanlIy, lhe desiied inpiovenenl on lehavioiaI ialing scaIes and lhe Tesl of
VaiialIes of Allenlion (TOVA) vas aIso achieved in 2O sessions (Rossilei & LaVaque, 1995).
The cuiienl sludy has seveiaI Iinilalions. The nain ones aie lhe ieIaliveIy snaII nunlei of
pailicipanls, lhe sludy design and lhe alsence of foIIov-up dala. Ialienls incIuded in lhe
ieseaich aie nol iandonIy assigned lo lhe liealnenl gioups and aIlhough lhey aie siniIai
foi age and sex, lhey aie nol nalched. AddilionaIIy, lhe pioceduie is nol lIinded, vhich in
conlinalion vilh lhe alsence of iandonizalion oi nalching, nay aIIov confounding
faclois (such as paienlaI expeclalion and slyIe) lo inleifeie vilh lhe iesuIls. ConsequenlIy,
oui iesuIls nay nol le easiIy geneiaIized. Iuilheinoie, aIlhough il vas shovn lhal lhe
addilion of a psycho-educalionaI piogian does induce giealei changes on Thela/ela ialios
lovaids noinaIizalion lhan neuiofeedlack aIone, lhis effecl is onIy appaienl innedialeIy
aflei lhe conpIelion of lhe liaining. We did nol exanine if lhal effecl ielained in lhe Iong
lein. If lhal pioved lo le liue, il vouId giealIy suppoil lhe sinuIlaneous use of
neuiofeedlack vilh olhei lehavioiaI inleivenlions, lased on a Iong slanding, and hopefuIIy
peinanenl liain aclivily nodificalion.
Anolhei Iinilalion of lhe cuiienl sludy is lhe Iack of dala conceining changes on palienls
cIinicaI chaiacleiislics. Hovevei, al lhis poinl of oui invesligalion, lhe sludy vas nol
designed lo exanine lhe coiieIalion lelveen changes piesenled in Thela/ela ialios and
lehavioiaI aIleialions oi if lhe addilion of lhe psycho-educalionaI piogian pioduced
giealei inpiovenenls on ADHD synplons, in conpaiison vilh lhe piesuned inpiovenenls
due lo neuiofeedlack liaining aIone. In 1995, Lulai and covoikeis found lhal aII chiIdien
vho undeilook lhe neuiofeedlack liaining shoved inpiovenenls in lehavioi and
allenlion, aIlhough nol slalislicaIIy significanl. These inpiovenenls veie piesenl in lolh
chiIdien vho nanaged oi did nol nanage lo aIlei liain aclivily (Lulai el aI, 1995).
Hovevei, noie iecenl ieseaich denonslialed lhal lhe exlenl of ADHD synplons
inpiovenenl aIong vilh lhe exlenl of neuiophysioIogicaI paianeleis inpiovenenl is
posiliveIy coiieIaled lo lhe degiee lo vhich lhe palienl is alIe lo Ieain lo aIlei his/hei liain
aclivily duiing liaining sessions. This coiieIalion suggesls lhal funclionaI inpiovenenl is
lased on lhe specific aclion of feedlack-guided Ieaining.(Hiishleig, 2OO7, CiuzeIiei &
Lgnei, 2OO5).
5. ConcIusion
To concIude, lhe decision lo conline a psycho-educalionaI inleivenlion vilh neuiofeedlack
in nanagenenl of chiIdien vilh ADHD nay le an advanlageous oplion. The psycho-
educalionaI piogian seens lo acceIeiale lhe aliIily of lhe chiId lo aIlei liain aclivily and lo
ieach lhe noinaI iange of vaIues of eIecliophysioIogicaI paianeleis. Iuilhei ieseaich
shouId le focused on lhe cIaiificalion of vaiialIes invoIved in lhis li-nodaI appioach e.g.
lhe exacl lype of lhe psycho-educalionaI inleivenlion appIied, vilh delaiIed desciiplion of
palienl and paienl deiivalives and lhe lesl neuiofeedlack piolocoI foi each ADHD
sullype, vilh lhe goaI lo achieve lhe naxinun effecl nol onIy on lhe liain aclivily lul aIso
on lhe ADHD synplons. Il vouId aIso le of inpoilance lo exanine Iong lein effecls of lhe
lvo liealnenls, on liain eIecliophysioIoIogy and on cIinicaI paianeleis such as ADHD
synplons, acadenic achievenenl and even quaIily of Iife.


298
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XL (nelhyIphenidale SR) avaiIalIe as 5, 1O, 2O, 3O, and 4Ong capsuIes.

XL (nelhyIphenidale SR) avaiIalIe as 1O, 2O and 3O ng capsuIes.

(Dexanfelanine) avaiIalIe as: 5 ng lalIels.

1O, 18, 25, 4O, 6O & 8O ng

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