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In 1994, I sketched the broad outlines of a proto-theory of EF at this level and applied it specifically to attention deficit hyperactivity disorder

(ADHD), a relatively chronic developmental disorder of inattention, impulsivity, and hyperactivity known to be associated with various deficits in EF (Frazier et al., 2004; Hervey et al.; 2004; Willcutt et al., 2006). This "hybrid" theory was not so much a theory of ADHD but a theory about the nature of EF. That model of EF was then used to show how a particular disorder, in this case ADHD, could be characterized by its adverse impact on normal EF development. That theory was subsequently further developed (Barkley, 1997a) and eventually published as a book (1997b).

movement not required to complete a task, such as wriggling their feet and legs, tapping things, rocking while seated, or shifting their posture or position while performing relatively boring tasks. Younger children with the disorder may show excessive running, climbing, and other gross motor activity. While this tends to decline with age, even teenagers with ADHD are more restless and fidgety than their peers. In adults with the disorder, this restlessness

Fact Sheet: Attention Deficit Hyperactivity Disorder (ADHD) Topics Attention-deficit hyperactivity disorder (ADHD) is the current term for a specific developmental disorder seen in both children and adults that is comprised of deficits in behavioral inhibition, sustained attention and resistance to distraction, and the regulation of ones activity level to the demands of a situation (hyperactivity or restlessness). This disorder has had numerous different labels over the past century, including hyperactive child syndrome, hyperkinetic reaction of childhood, minimal brain dysfunction, and attention deficit disorder (with or without hyperactivity). MAJOR CHARACTERISTICS The predominant features of this disorder include: 1. Impaired response inhibition, impulse control, or the capacity to delay gratification. This is often noted in the individuals inability to stop and think before acting; to wait ones turn while playing games, conversing with others, or having to wait in line; to interrupt their responding quickly when it becomes evident that their actions are no longer effective; to resist distractions while concentrating or working; to work for larger, longer-term rewards rather than opting for smaller, more immediate ones; and inhibiting the dominant or immediate reaction to an event, as the situation may demand. 2. Excessive task-irrelevant activity or activity that is poorly regulated to the demands of a situation. Individuals with ADHD in many cases are noted to be excessively fidgety, restless, and on the go. They display excessive from one uncompleted activity to another without completing these activities. Loss of concentration during tedious, boring, or protracted tasks is commonplace, as is an inability to return to their task on which they were working should they be unexpectedly interrupted. Thus, they are easily distracted during periods when concentration is important to the task at hand. They may also have problems with completing routine assignments without direct supervision, being unable to stay on task during independent work. These are the three most common areas of difficulty associated with ADHD. However, research is suggesting that those with ADHD, particularly the subtypes associated with impulsive behavior (see below), may also have difficulties in the following areas of psychological functioning as well: 1. Remembering to do things, or working memory. Working memory refers to the capacity to hold information in mind that will be used to guide ones actions, either now, or at a later time. It is essential for remembering to do things in may be more subjective than outwardly observable, although with some adults they remain outwardly restless as well and report a new to always be busy or doing something and being unable to sit still. 3. Poor sustained attention or persistence of effort to tasks. This problem often arises when the individual is assigned boring, tedious, protracted, or repetitive activities that lack intrinsic appeal to the person. They often fail to show the same level of persistence, stick-to-it-tiveness, motivation, and will-power of others their age when uninteresting yet important tasks must be performed. They often report becoming easily bored with such tasks and consequently shift

the near future. Those with ADHD often have difficulties with working memory and so are described as forgetful around doing things, unable to keep important information in mind that they will need to guide their actions later, and disorganized in their thinking and other activities as they often lose track of the goal of their activities. They may often be described as acting without hindsight or forethought, and being less able to anticipate and prepare for future events as well as others, all of which seem to be dependent on working memory. Recently, research suggests that those with ADHD cannot sense or use time as adequately as others in their daily activities, such that they are often late for appointments and deadlines, ill-prepared for upcoming activities, and less able to pursue long-term goals and plans as well as others. Problems with time management and organizing themselves for upcoming events are commonplace in older children and adults with the disorder. 2. Delayed development of internal language (the minds voice) and rule-following. Research has lately been suggesting that children with ADHD are significantly delayed in the development of internal language, the private voice inside ones mind that we employ to converse with ourselves, contemplate events, and direct or command our own behavior. This private speech is absolutely essential to the normal development of contemplation, reflection, and self-regulation. Its delay in those with ADHD contributes to significant problems with their ability to follow through on rules and instructions, to read and follow directions carefully, to follow through on their own plans, rules, and dolists, and even to act with legal or moral principles in mind. When combined with their difficulties with working memory, this problem with self-talk or private speech often results in significant interference with reading comprehension, especially of complex, uninteresting, or extended reading assignments. 3. Difficulties with regulation of emotions, motivation, and arousal. Children and adults with ADHD often have problems inhibiting their emotional reactions to events as well as do others of their age. It is not that the emotions they experience are inappropriate, but that those with ADHD are more likely to publicly manifest the emotions they

experience than would someone else. They seem less able to internalize their feelings, to keep them to themselves, and even to moderate them when they do so as others might do. Consequently, they are likely to appear to others as less emotionally mature, more reactive with their feelings, and more hot-headed, quicktempered, and easily frustrated by events. Coupled with this problem with emotion regulation is the difficulty they have in generating intrinsic motivation for tasks that have no immediate payoff or appeal to them. This capacity to create private motivation, drive, or determination often makes them appear to lack will-power or self-discipline as they cannot stay with things that do not provide immediate reward, stimulation, or interest to them. Their motivation remains dependent on the immediate environment for how hard and how long they will work, whereas others develop a capacity for intrinsically motivating themselves in the absence of immediate rewards or other consequences. Also related to these difficulties with regulating emotion and motivation is that of regulating their general level of arousal to meet situational demands. Those with ADHD find it difficult to activate or arouse themselves to initiate work that must be done, often complain of being unable to stay alert or even awake in boring situations, and frequently seem to be daydreamy or in a fog when they should be more alert, focused, and actively engaged in a task. 4. Diminished problem-solving ability, ingenuity, and flexibility in pursuing long-term goals. Often times, when we are engaged in goal-directed activities, problems are encountered that are obstacles to the goals attainment. At these times, individuals must be capable of quickly generating a variety of options to themselves, considering their respective outcomes, and selecting among them those which seem most likely to surmount the obstacle so they can continue toward their goal. Persons with ADHD find such hurdles to their goals to be more difficult to surmount; often giving up their goals in the face of obstacles and not taking the time to think through other options that could help

them succeed toward their goal. Thus they may appear as less flexible in approaching problem situations, more likely to respond automatically or on impulse, and so are less creative at overcoming the road-blocks to their goals than others are likely to be. These problems may even be evident in the speech and writing of those with the disorder, as they are less able to quickly assemble their ideas into a more organized, coherent explanation of their thoughts. And so they are less able to rapidly assemble their actions or ideas into a chain of responses that effectively accomplishes the goal given them, be it verbal or behavioral in nature. 5. Greater than normal variability in their task or work performance. It is typical of those with ADHD, especially those subtypes associated with impulsive behavior, to show substantial variability across time in the performance of their work. These wide swings may be found in the quality, quantity, and even speed of their work, failing to maintain a relatively even pattern of productivity and accuracy in their work from moment to moment and day to day. Such variability is often puzzling to others who witness it as it is clear that at some times, the person with ADHD can complete their work quickly and correctly while at others times, their tasks are performed poorly, inaccurately, and quite erratically. Indeed, some researchers see this pattern of high variability in work-related activities to be as much a hallmark of the disorder as is the poor inhibition and inattention described above. OTHER CHARACTERISTICS Several other development characteristics are associated with the disorder: 1. Early onset of the major characteristics. The symptoms of ADHD appear to arise, on average, between 3 and 6 years of age. This is particularly so for those subtypes of ADHD associated with hyperactive and impulsive behavior. Others may not develop their symptoms until somewhat later in childhood. But certainly the vast majority of those with the disorder have had some symptoms since before the age of 13 years. Those who have the Predominantly Inattentive Type of ADHD that is not associated with impulsiveness appear to develop their attention problems

somewhat later than do the other subtypes, often in middle or later childhood. And so the disorder is believed to be one of childhood onset, regardless of the subtype, suggesting that should these symptoms develop for the first time in adulthood, other mental disorders rather than ADHD should be suspected. 2. Situational variation of symptoms. The major symptoms of ADHD are likely to change markedly as a consequence of the nature of the situation the person happens to be in. Research suggests that those with ADHD behave better in one-to-one situations, when doing tasks that they enjoy or find interesting, when there is some immediate payoff for behaving well, when they are supervised, in their work done earlier in the day rather than later, and, for children, when they are with their fathers compared to their mothers. Conversely, those with ADHD may manifest more of their symptoms in group settings, when they must perform boring work, when they must work independently of supervision, when their work must be done later in the day, and when they are with their mothers. Sometimes or in some cases, these situational factors may have little effect on the persons level of ADHD symptoms but they have been noted often enough in research to make such situational changes in their symptoms important to appreciate. 3. Relatively chronic course. ADHD symptoms are often quite developmental stable. Although the absolute level of symptoms does decline with age, this is true of the inattentiveness, impulsiveness, and activity levels of normal individuals as well. And so those with ADHD may be improving in their behavior but not always catching up with their peer group in this regard. This seems to leave them chronically behind others of their age in their capacity to inhibit behavior, sustain attention, control distractibility, and regulate their activity level. Research suggests that among those children clinically diagnosed with the disorder in childhood, 50-80 percent will continue to meet the criteria for the diagnosis in adolescence, and 10-65 percent may continue to do so in adulthood. Whether or not they have the

full syndrome in adulthood, at least 50-70 percent may continue to manifest some symptoms that are causing them some impairment in their adult life. ADULT OUTCOME It has been estimated that anywhere from 15 to 50 percent of those with ADHD ultimately outgrow the disorder. However, these figures come from follow-up studies in which the current and more rigorous diagnostic criteria for the disorder were not used. When more appropriate and modern criteria are employed, probably only 20-35 percent of children with the disorder no longer have any symptoms resulting in impairment in their adult life. Over the course of their lives, a significant minority of those with ADHD experience a greater risk for developing oppositional and defiant behavior (50%+), conduct problems and antisocial difficulties (25-45%), learning disabilities (2540%), low selfesteem, and depression (25%). Approximately 5-10 percent of those with ADHD may develop more serious mental disorders, such as manic-depression or bipolar disorder. Between 10 and 20 percent may develop antisocial personality disorder by adulthood, most of whom will also have problems with substance abuse. Overall, approximately 10-25 percent develop difficulties with over-use, dependence upon, or even abuse of legal (i.e., alcohol, tobacco) or illegal substances (i.e., marijuana, cocaine, illicit use of prescription drugs, etc.), with this risk being greatest among those who had conduct disorder or delinquency as adolescents. Despite these risks, note should certainly be taken that upwards of half or more of those having ADHD do not develop these associated difficulties or disorders. However, the majority of those with ADHD certainly experienced problems with school performance, with as many as 30-50 percent having been retained in their school grade at least once, and 25-36 percent never completing high school. As adults, those with ADHD are likely to be under-educated relative to their intellectual ability and family educational background. They are also likely to be experience difficulties with work adjustment, and may be under-employed in

their occupations relative to their intelligence, and educational and family backgrounds. They tend to change their jobs more often than others do, sometimes out of boredom or because of interpersonal problems in the workplace. They also tend to have a greater turnover of friendships and dating relationships and seem more prone to marital discord and even divorce. Difficulties with speeding while driving are relatively commonplace, as are more traffic citations for this behavior, and, in some cases, more motor vehicle accidents than others are likely to experience in their driving careers. Thus, they are more likely to have had their drivers license suspended or revoked. SUBTYPES Since 1980, it has become possible to place those with ADHD into several subtypes, depending upon the combinations of symptoms they experience. Those who have difficulties primarily with impulsive and hyperactive behavior and not with attention or concentration are now referred to as having the Predominantly HyperactiveImpulsive Type. Individuals with the opposite pattern, significant inattentiveness without being impulsive or hyperactive are called the Predominantly Inattentive Type. However, most individuals with the disorder will manifest both of these clinical features and so are referred to as the Combined Type of ADHD. Research on those with the Combined Type suggests that they are likely to develop their hyperactive and/or impulsive symptoms first and usually during the preschool years. At this age, then, they may be diagnosed as having the Predominantly HyperactiveImpulsive Type. However, in most of these cases, they will eventually progress to developing the difficulties with attention span, persistence, and distractibility within a few years of entering school such that they will now be diagnosed as having the Combined Type. There is considerably less research on the Predominantly Inattentive Type of ADHD, or what used to be referred to as attention deficit disorder without hyperactivity. What research does exist suggests some qualitative differences between the attention problems these individuals experience and those with the other types of ADHD in which hyperactive or impulsive behavior is present. The Predominantly Inattentive Type of ADHD appears to be associated

with more daydreaming, passiveness, sluggishness, difficulties with focused or selective attention (filtering important from unimportant information), slow processing of information, mental fogginess and confusion, social quietness or apprehensiveness, hypo-activity, and inconsistent retrieval of information from memory. It is also considerably less likely to be associated with impulsiveness (by definition) as well as oppositional/defiant behavior, conduct problems, or delinquency. Should further research continue to demonstrate such differences, there would be good reason to view this subtype as actually a separate and distinct disorder from that of ADHD. PREVALENCE ADHD occurs in approximately 3-7 percent of the childhood population and approximately 2-5 percent of the adult population. Among children the gender ratio is approximately 3:1 with boys more likely to have the disorder than girls. Among adults, the gender ration falls to 2:1 or lower. The disorder has been found to exist in virtually every country in which it has been investigated, including North America, South America, Great Britain, Scandinavia, Europe, Japan, China, Turkey and the middle East. The disorder may not be referred to as ADHD in these countries and may not be treated in the same fashion as in North America but there is little doubt that the disorder is virtually universal among human populations. The disorder is more likely to be found in families in which others have the disorder or where depression is more common. It is also more likely to occur in those with conduct problems and delinquency, tic disorders or Tourettes Syndrome, learning disabilities, or those with a history of prenatal alcohol or tobacco-smoke exposure, premature delivery or significantly low birth weight, or significant trauma to the frontal regions of the brain. ETIOLOGIES ADHD has very strong biological contributions to its occurrence. While precise causes have not yet been identified, there is little question that heredity/genetics makes the largest contribution to the expression of the disorder in the

population. The heritability of ADHD averages approximately 80 percent, meaning that genetic factors account for 80 percent of the differences among individuals in this set of behavioral traits. For comparison, consider that this figure rivals that for the role of genetics in human height. Several genes associated with the disorder have been identified and undoubtedly more will be so given that ADHD represents a set of complex behavioral traits and so a single gene is unlikely to account for the disorder. In instances where heredity does not seem to be a factor, difficulties during pregnancy, prenatal exposure to alcohol and tobacco smoke, prematurity of delivery and significantly low birth weight, excessively high body lead levels, as well as post-natal injury to the prefrontal regions of the brain have all been found to contribute to the risk for the disorder in varying degrees. Research has not supported popularly held views that ADHD arises from excessive sugar intake, food additives, excessive viewing of television, or poor child management by parents. Some drugs used to treat seizure disorders in children may increase symptoms of ADHD in those children as side effects of these drugs but these effects are reversible. TREATMENT No treatments have been found to cure this disorder, but many treatments exist which can effectively assist with its management. Chief among these treatments is the education of the family and school staff about the nature of the disorder and its management, in the case of children with the disorder, and the education and counseling of the adult with ADHD and their family members. But among the treatments that results in the greatest degree of improvement in the symptoms of the disorder, research overwhelmingly supports the use of the stimulant medications for this disorder (e.g., methylphenidate or Ritalin, d-amphetamine or Dexedrine, Adderall, and, in rare cases, pemoline or Cylert). Evidence also shows that the tricyclic antidepressants, in particular desipramine, may also be effective in managing symptoms of the disorder as well as co-existing symptoms of mood disorder or anxiety. However, these

antidepressants do not appear to be as effective as the stimulants. Research evidence is rather mixed on whether or not clonidine is of specific benefit for management of these symptoms apart from its well-known sedation effects. A small percentage of individuals with ADHD may require combinations of these medications, or others, for the management of their disorder, often because of the co-existence of other mental disorders with their ADHD. Psychological treatments, such as behavior modification in the classroom and parent training in child behavior management methods, have been shown to produce short-term benefits in these settings. However, the improvements which they render are often limited to those settings in which treatment is occurring and do not generalize to other settings that are not included in the management program. Moreover, recent studies suggest, as with the medications discussed above, that the gains obtained during treatment may not last once treatment has been terminated. Thus, it appears that treatments for ADHD must often be combined and must be maintained over long periods of time so as to sustain the initial treatment effects. In this regard, ADHD should be viewed like and other chronic medical condition that requires ongoing treatment for its effective management but whose treatments do not rid the individual of the disorder. Some children with ADHD may benefit from social skills training provided it is incorporated into their school program. Children with ADHD are now eligible for special educational services in the public schools under both the Individuals with Disabilities in Education Act (IDEA) and Section 504 of the Civil Rights Act. Adults with ADHD are also eligible for accommodations in their workplace or educational settings under the Americans with Disabilities Act provided that the severity of their ADHD is such that it produces impairments in one or more major areas of life functioning and that they disclose their disorder to their employer or educational institution. Adults with the disorder may also require counseling about their condition, vocational assessment and counseling to

find the most suitable work environment, time management and organizational assistance, and other suggestions for coping with their disorder. The medications noted above that are useful for children with ADHD have recently proven to be as effective in the management of ADHD in adults. Treatments with little or no evidence for their effectiveness include dietary management, such as removal of sugar from the diet, high doses of vitamins, minerals, trace elements, or other popular health food remedies, long-term psychotherapy or psychoanalysis, biofeedback, play therapy, chiropractic treatment, or sensoryintegration training, despite the widespread popularity of some of these treatment approaches. The treatment of ADHD requires a comprehensive behavioral, psychological, educational, and sometimes medical evaluation followed by education of the individual or their family members as to the nature of the disorder and the methods proven to assist with its management. Treatment is likely to be multidisciplinary, requiring the assistance of the mental health, educational, and medical professions at various points in its course. Treatment must be provided over long time periods to assist those with ADHD in the ongoing management of their disorder. In so doing, many with the disorder can lead satisfactory, reasonably adjusted, and productive lives. Adapted from R. A. Barkley & K. R. Murphy (2006) Attention deficit hyperactivity disorder: A clinical workbook (3rd ed.). New York: Guilford Publications. Copyright 2006 by Guilford Publications. Reprinted with permission.


Probably the three most important components to a comprehensive evaluation of the client with Attention-Deficit/Hyperactivity Disorder (ADHD) are the clinical interview, the medical examination, and the completion and scoring of behavior rating scales. When it is feasible, clinicians may wish to supplement these components of the evaluation with objective assessments of the ADHD symptoms, such as psychological tests of attention or direct behavioral observations. These tests are not essential to reaching a diagnosis, however, or to treatment planning, but they may yield further information about the presence and severity of cognitive impairments that could be associated with some cases of ADHD. In those cases,

abnormal scores may be meaningful in indicating the presence of a disorder (not necessarily ADHD) while normal scores should go uninterpreted given the high false negative rate of many ADHD tests. Screening for intellectual ability and academic achievement skills is also important in determining the presence of comorbid developmental delay or learning disabilities. In this course, I describe the details of conducting clinical interviews with parents, teachers, and children/adolescents when it is the child or adolescent who is presenting for evaluation of ADHD. I also briefly discuss the essential features of the medical examination of ADHD children and issues that examination needs to address. This discussion is followed by an overview of some of the most useful behavior rating scales to incorporate in the clinical evaluation. A brief review of the role of psychological tests and direct observations in the evaluation is then presented. Readers wishing to have many of the clinical tools referenced here can find them in a convenient format with limited permission granted by the publisher for photocopying in the clinical manual accompanying my textbook on ADHD (see Barkley & Murphy, 2006). The information contained herein is drawn chiefly from my earlier chapters on assessment authored with the assistance of Gwenyth Edwards, Ph.D., and Michael Gordon, Ph.D. in my handbook for diagnosis and treatment (Barkley, 2006).

Depression) in children. Oppositional behavior is almost universal in juvenile-onset Bipolar Disorder (Giles, DelBello, Stanford, & Strakowski, 2007; Wozniak et al., 1995). Such a disorder is likely to require the use of several psychiatric medications in conjunction with a parent training program and occasionally even inpatient hospitalization.

A further objective of the evaluation is to identify the pattern of the childs psychological strengths and weaknesses and to consider how these strengths and weaknesses may affect treatment planning. This identification may also include gaining some impression as to the parents own abilities to carry out the treatment program as well as the familys social and economic circumstances and the treatment resources that may (or may not) be available within their community and cultural group. Some determination also must be made as to the childs eligibility for special educational services within his or her school district if eligible disorders, such as developmental delay, learning disabilities, or speech and language problems, are present.

Assessment Issues

As the foregoing discussion illustrates, the evaluation of a child for the presence of diagnosable ADHD is but one of many purposes of the clinical evaluation. A brief discussion now follows regarding the different methods of assessment that may be used in the evaluation of ADHD children.

Clinicians should bear in mind several goals when evaluating children for ADHD. A major goal of such an assessment is the determination of the presence or absence of ADHD as well as the differential diagnosis of ADHD from other childhood psychiatric disorders. This differential diagnosis requires extensive clinical knowledge of these other psychiatric disorders, and readers are referred to the DSM-IV (American Psychiatric Association, 2000) for diagnostic criteria and to my earlier text on child psychopathology for a review of the major childhood disorders (see Mash & Barkley, 2003). In any child evaluation, it may be necessary to draw on measures that are normed for the individuals ethnic background, if such instruments are available, to preclude the over diagnosis of minority children when diagnostic criteria developed on white American children are extrapolated to other ethnic groups. For further discussion on gender, socioeconomic status, and cross cultural issues related to diagnosis and prevalence of ADHD, please see the first course in this series titled ADHD: Nature, Course, Outcomes, and Comorbidity.

Information Obtained at the Time of Referral

A second purpose of the evaluation is to begin delineating the types of interventions needed to address the psychiatric disorders and psychological, academic, and social impairments identified in the course of assessment. As noted later, these may include individual counseling, parent training in behavior management, family therapy, classroom behavior modification, psychiatric medications, and formal special educational services, to name just a few.

Another important purpose of the evaluation is to determine conditions that often coexist with ADHD and the manner in which these conditions may affect prognosis or treatment decision making. For instance, the presence of high levels of physically assaultive behavior by a child with ADHD may indicate that a parent training program is contraindicated, at least for the time being, because such training in limit setting and behavior modification could temporarily increase child violence toward parents when limits on noncompliance with parental commands are established. Or, consider the presence of high levels of anxiety specifically and internalizing symptoms more generally in children with ADHD. Research shows such symptoms may be a predictor of poorer responses to stimulant medication. Similarly, the presence of high levels of irritable mood, severely hostile and defiant behavior, and periodic episodes of serious physical aggression and destructive behavior may be early markers for later Bipolar Disorder (Manic

Surprisingly enough, the initial phase of a diagnostic interview might not be conducted by the clinician but by a support staff member. The initial phone intake provides invaluable information when conducted by a well-trained individual; otherwise, it is a lost opportunity. When a parent calls to request an evaluation, it is useful to collect the following information: What is the reason for the parents request? Is it an open-ended question, such as Whats wrong with my child?, or a specific one, Does my child have ADHD? Who referred the family? Is the family self-referred because members recently read a newspaper article or saw a television program which raised their concerns? Is the family referred by the childs school because of school-related rather than parental concerns? Is the family referred by a pediatrician or another health or mental health professional who questions ADHD but wants diagnostic confirmation? Has the child been previously evaluated or tested by someone else? Is the family looking for a second opinion, or for a reevaluation of ADHD that was diagnosed when the child was younger? Does the child have any other diagnosed conditions, such as mood disorders, substance abuse, or other developmental delays? Has the child been tested and diagnosed by the school system to have learning disabilities or cognitive delays? Is the child already on medication? Are the parents seeking an evaluation of their childs response to medication rather than a diagnostic evaluation? If the child is on stimulant medication, would the parents consent to withhold the medication on the day of the evaluation? The content of the diagnostic interview is influenced by all these factors, and important information can be collected and reviewed ahead of time when the reason for the referral is clear.

Thus, once the child is referred for services, the clinician must glean some important details from the telephone interview. This information also allows the clinician to set in motion some initial procedures. In particular, it is important at this point to do the following: (1) obtain any releases of information to permit reports of previous professional evaluations to be sought, (2) contact the

childs treating physician for further information on health status and medication treatment if any, (3) obtain the results of the most recent evaluation from the childs school or have the parent initiate one immediately if school performance concerns are part of the referral complaints, (4) mail out the packet of parent and teacher behavior rating forms to be completed and returned before the initial appointment, being sure to include the written release of information permission form with the school forms, and (5) obtain any information from social service agencies that may be involved in providing services to this child.

parents. This packet could contain the teacher version of the CBCL or BASC, the School Situations Questionnaire (SSQ), and the same rating scale for assessing ADHD symptoms (see Barkley & Murphy, 2006, for the latter two scales and their norms). The Social Skills Rating System (Gresham & Elliott, 1990) might also be included if the clinician desires information about the childs social problems in school as well as his or her academic competence. The clinician can quickly see, for example, if the teacher feels the child is functioning at grade level in various subject areas, how the child has performed on group-administered achievement or aptitude tests, or subjective impressions of the childs general mood and behavioral functioning. If possible, it is quite useful to contact the childs teachers for a brief telephone interview prior to meeting with the family. Otherwise, a meeting can take place following the familys appointment.

Information Obtained in Advance of the Interview

Clinicians may want to send out a packet of questionnaires to parents and teachers following the parents call to their clinic but in advance of the scheduled appointment. In fact, the parents of children referred to our clinic are not given an appointment date until these packets of information are completed and returned to the clinic. This system ensures that the packets are completed reasonably promptly and that the information is available for review by the clinician prior to meeting with the family, making the evaluation process far more efficient in its collection of important information. In these days of increasing cost consciousness concerning mental health evaluations, particularly in managed care environments, efficiency of the evaluation is paramount and time spent directly with the family is often limited and at a premium. Besides a form cover letter from the professional asking the parents to complete the packet of information, and it also contains the General Instruction Sheet, a Child and Family Information Form, and a Developmental and Medical History Form, all of which can be obtained for limited photocopying purposes in my clinical manual (Barkley & Murphy, 2006). This packet also includes a reasonably comprehensive child behavior rating scale that covers the major dimensions of child psychopathology, such as the Child Behavior Checklist (CBCL; Achenbach, 2001) or the Behavior Assessment System for Children (BASC-2; Reynolds & Kamphaus, 2005). Also in this packet should be a copy of a rating scale that specifically assesses ADHD symptoms. Such a form can also be found in the clinical manual by Barkley and Murphy (2006). That scale permits the clinician to obtain information ahead of the appointment concerning the presence of symptoms of Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), as well as ADHD symptoms and their severity. ODD and CD are quite common among children referred for ADHD, and it is useful to know of their presence in advance of the appointment. Clinicians who wish to assess adaptive behavior via the use of a questionnaire might consider including the Normative Adaptive Behavior Checklist (NABC; Adams, 1984) in this packet. Finally, the Home Situations Questionnaire (HSQ) is included so that the clinician can gain a quick appreciation for the pervasiveness and severity of the childs disruptive behavior across a variety of home and public situations (see Barkley & Murphy, 2006, for this form and its norms). Such information is of clinical interest not only for indications of pervasiveness and severity of behavior problems but also for focusing discussions around these situations during the evaluation and subsequent parent training program. These rating scales are discussed later.

Once the parent and teacher packets are returned, the family should be contacted by telephone and given their appointment date. It is our custom also to send out a letter confirming this appointment date with directions for driving to the clinic. With this letter, the clinician might send a short instruction sheet entitled How to Prepare for Your Childs Evaluation. It is provided in my clinical manual (Barkley & Murphy, 2006). This instruction sheet gives the parents some information about what to expect on the day of the evaluation and what information to organize prior to this appointment. It also may set them at ease if having a mental health evaluation is disconcerting or anxiety inducing for them.

On the day of the appointment, the following still remains to be done: (1) parental and child interview, (2) completion of self-report rating scales by the parents, and (3) any psychological testing that may be indicated by the nature of the referral (intelligence and achievement testing, etc.).

Parent Interview

The parent (often maternal) interview, although often criticized for its unreliability and subjectivity, is an indispensable part of the evaluation of children and adolescents presenting with concerns about ADHD. No adult is likely to have the wealth of knowledge about, history of interactions with, or sheer time spent with a child than the parents.

It is useful to collect and review previous records before the interview. They might include any one or combination of the following: report cards, standardized testing results, medical records (including neurology, audiology, optometry, speech, and occupational therapy), individual educational plans, psychoeducational testing, psychological testing, and psychotherapy summaries.

Whether wholly accurate or not, parent reports provide the most ecologically valid and important source of information concerning the childs difficulties. It is the parents complaints that often lead to the referral of the child, will affect the parents perceptions of and reactions to the child, and will influence the parents adherence to the treatment recommendations to be made. Moreover, the reliability and accuracy of the parental interview have much to do with the manner in which it is conducted and the specificity of the questions offered by the examiner. An interview that uses highly specific questions about symptoms of psychopathology that have been empirically demonstrated to have a high degree of association with particular disorders greatly enhances diagnostic reliability.

A similar packet of information is sent to the teachers of this child, with parental written permission obtained beforehand, of course. This packet does not contain the Medical and Developmental History Form or any adaptive behavior survey that may have been included for

The interview, particularly a semistructured interview, allows the clinician in a sense to become another instrument in the assessment process. Although scorable data are obtained, the small details and nuances of parent and child report resonates with clinician-acquired knowledge (from

previous interviews, research, readings, workshops, etc.) in such a way as to flesh out and support final diagnostic conclusions. In other words, the interview provides the phenomenological data that rating scales cannot capture. The interview must also, however, focus on the specific complaints about the childs psychological adjustment and any functional parameters (eliciting events and their consequences) associated with those problems if psychosocial and educational treatment planning is to be based on the evaluation.

problems, such as what they did or failed to do with the child earlier in development that has led to this problem (i.e., placing the child in infant daycare, an earlier divorce, the childs diet in earlier years, etc.). The interactional interview discussed later can serve to shift the parents attention to more immediate antecedents and consequences surrounding child behaviors, thereby preparing the parents for the initial stages of parent training in child management skills. The interview is designed to formulate a diagnosis and to develop treatment recommendations. Although diagnosis is not always considered necessary for treatment planning (a statement of the childs developmental and behavioral deficits is often adequate), the diagnosis of ADHD, however, does provide some utility in terms of predicting developmental course and prognosis for the child, determining eligibility for some special educational placements, and predicting potential response to a trial on stimulant medication. Many child behavior problems are believed to remit over short periods in as many as 75% of the cases. However, ADHD is a relatively chronic condition warranting much more cautious conclusions about eventual prognosis and preparation of the family for coping with these later problems. A parental interview may serve as sheer catharsis, especially if this is the first professional evaluation of the child or when previous evaluations have proven highly conflicting in their results and recommendations. Ample time should be permitted to allow parents to ventilate this distress, hostility, or frustration. It may be helpful to note at this point that many parents of ADHD children have reported similarly distressing, confusing, or outright hostile previous encounters with professionals and educators about their child, as well as well-intentioned but overly enmeshed or misinformed relatives. Compassion and empathy for the plight of the parents at this point can often result in a substantial degree of rapport with and gratitude toward the examiner and a greater motivation to follow subsequent treatment recommendations. At the very least, parents are likely to feel that they have finally found someone who truly understands the nature of their childs problems and the distress they have experienced in trying to assist the child and has recommendations to do something about them. The suggestions that follow for interviewing parents of ADHD children are not intended as rigid guidelines, only as areas that clinicians should consider. Each interview clearly differs according to individual child and family circumstances. Generally, those areas of importance to an evaluation include demographic information, child-related information, school-related information, and details about the parents, other family members, and community resources that may be available to the family.


The parental interview often serves several purposes.

It establishes a necessary rapport among the parents, the child, and the examiner that will prove invaluable in enlisting parental cooperation with later aspects of assessment and treatment. The interview is an obvious source of highly descriptive information about the child and family, revealing the parents particular views of the childs apparent problems and narrowing the focus of later stages and components of the evaluation. It can readily reveal the degree of distress the childs problems are presenting to the family, especially the parent being interviewed, and well as the overall psychological integrity of the parent. Hypotheses as to the presence of parental personality or psychiatric problems (depression, hostility, marital discord, etc.) may be revealed that will require further evaluation in subsequent components of the evaluation and consideration in formulating treatment recommendations. Examiners must be cautious not to over interpret any informal observations of the childs behavior during this clinic visit. The office behavior of ADHD children is often far better than that observed at home (Sleator & Ullman, 1981). Such observations merely raise hypotheses about potential parentchild interaction problems that can be explored in more detail with parents toward the end of this interview as well as during later direct behavioral observations of parent and child during play and task performance together. At the end of this portion of the interview, the examiner should inquire how representative the childs immediate behavior is compared to that seen at home when the parent speaks with other adults in the childs presence. I do not typically have the child in the same room when I conduct the parental interview. Other clinicians, however, may choose to do so. The presence of the child during the parental interview, however, raises thorny issues for the evaluation to which the examiner must be sensitive. Some parents are less forthcoming about their concerns and the details of the childs specific problems when the child is present, not wishing to sensitize or embarrass the child unnecessarily or to create another reason for arguments at home about the nature of the childs problems. Others are heedless of the potential problems posed for their child by this procedure, making it even more imperative that the examiner reviews these issues with them before beginning the evaluation. Still other parents may use the childs presence to further publicly humiliate the child about his or her deficiencies or the distress the child has created for the family by behaving the way he or she does. Suffice it to say here that before starting the interview, the examiner must discuss and review with each unique family whether the advantages of having the child present are outweighed by these potential negative effects. The initial parent interview can help to focus the parents perceptions of the childs problems on more important and more specific controlling events within the family. Parents often tend to emphasize historical or developmental causes of a global nature in discussing their childrens

Demographic Information

If not obtained in advance, the routine demographic data concerning the child and family (e.g., ages of child and family members; childs date of birth; parents names, addresses, employers, and occupations; and the childs school, teachers, and physician) should be obtained at the outset of the appointment. I also use this initial introductory period to review with the family any legal constraints on the confidentiality of information obtained during the interview, such as the clinicians legal duty (as required by state law) to report to state authorities instances of suspected child abuse, threats the child (or parents) may make to cause physical harm to other specific individuals (the duty to inform), and threats the child (or parents) may make to harm themselves (e.g., suicide threats).

Major Parental Concerns

The interview then proceeds to the major referral concerns of the parents, and of the professional referring the child when appropriate. A parental interview form designed by Barkley and colleagues is available in my clinical manual (Barkley & Murphy, 2006). It can be very helpful in collecting the information discussed later. This form not only contains major sections for the important information discussed here but also contains the diagnostic criteria used for ADHD as well as the other childhood disorders most likely to be seen in conjunction with ADHD (ODD, CD, anxiety and mood disorders, Bipolar Disorder). Such a form allows clinicians to collect the essential information likely to be of greatest value to them in evaluating children using a convenient and standardized format across their client populations.

family for these presenting problems. When the history suggests potentially treatable medical or neurological conditions (allergies, seizures, Tourettes Disorder, etc.), a referral to a physician is essential. Without evidence of such problems, however, referral to a physician for examination usually fails to reveal any further useful treatment information. But when the use of psychiatric medications is contemplated, a referral to a physician is clearly indicated.

General descriptions of concerns by parents must be followed with specific questions by the examiner to elucidate the details of the problems and any apparent precipitants. Such an interview probes for the specific nature, frequency, age of onset, and chronicity of the problematic behaviors. It can also obtain information, as needed, on the situational and temporal variation in the behaviors and their consequences. If the problems are chronic, which they often are, determining what prompted the referral at this time reveals much about parental perceptions of the childrens problems, current family circumstances related to the problems severity, and parental motivation for treatment.

Information about the childs family is essential for two reasons. First, while ADHD is not caused by family stress or dysfunction, such adverse family factors can contribute to oppositional behavior or frank ODD. Therefore, the family history can help to clarify whether the childs attentional or behavioral problems are developmental or actually a reaction to or product of stressful events that have taken place. Second, a history of certain psychiatric disorders in the extended family might influence diagnostic impressions or treatment recommendations. For example, because ADHD is hereditary, a strong family history of ADHD in biological relatives lends weight to the ADHD diagnosis, especially when other diagnostic factors are questionable. A family history of Bipolar Disorder in a child with severe behavioral problems might suggest that the child may be at higher risk for the disorder (8-fold increase in risk) and particular medication choices that otherwise might not be considered.

Review of Major Developmental Domains

Following this part of the interview, the examiner should review with the parents potential problems that might exist in the developmental domains of motor, language, intellectual, academic, emotional, and social functioning. Such information greatly aids in the differential diagnosis of the childs problems. To achieve this differential diagnosis requires that the examiner have an adequate knowledge of the diagnostic features of other childhood disorders, some of which may present as ADHD. For instance, many children with Atypical Pervasive Developmental Disorders, Aspergers Disorder, or early Bipolar Disorder may be viewed by their parents as ADHD as the parents are more likely to have heard about the latter disorder than the former ones and will recognize some of the qualities in their children. Questioning about inappropriate thinking, affect, social relations, and motor peculiarities may reveal a more seriously and pervasively disturbed child. If such symptoms seem to be present, the clinician might consider employing the Childrens Atypical Development Scale (see Barkley, 1990) or the Child Bipolar Parent Questionnaire (Papolos, Hennen, Cockerham, Thode Jr., & Youngstrom , 2006) to obtain a more thorough review of these symptoms. Inquiry also must be made as to the presence or history of tics or Tourettes Disorder in the child or the immediate biological family members. When noted, these disorders would result in a recommendation for the cautious use of stimulant drugs in the treatment of ADHD or, perhaps, lower doses of such medicine than typical to preclude the exacerbation of the childs tic disorder.

The interviewer can organize this section by first asking about the childs siblings (whether there is anything significant about sibling relationships, whether siblings have any health or developmental problems). Then, questions about the parents may include how long they have been married, the overall stability of their marriage, whether each parent is in good physical health, whether either parent has ever been given a psychiatric diagnosis, and whether either parent has had a learning disability. The clinician should always be cautious of inquiring too much into the parents personal concerns. The purpose is to rule out family stress as a cause for the childs difficulties and to determine what treatment recommendations may be appropriate.

In asking about extended family history, the interviewer should include maternal and paternal relatives (see clinical workbook by Barkley & Murphy, 2006).

Although it may seem tedious, it is extremely useful to go through the childs school history year by year, starting with preschool. The examiner should ask parents open-ended questions: What did his teachers have to say about him?, How did he do academically?, or How did he get along socially? The examiner should avoid pointed, leading questions (e.g., Did the teacher think he had ADHD?). Examiners should allow parents to tell them their childs story and listen for the red flags (e.g., the teacher thought he was immature, he had trouble with work completion, his organizational skills were terrible, he could not keep his hands to himself, or he would not do homework).

School, Family, and Treatment Histories Gathering a reliable school history gives the clinician two crucial pieces of the diagnostic puzzle. First, is there evidence of symptoms or characteristics of ADHD in school previous to adolescence? Second, is there evidence of impairment in the childs academic functioning as a result of these characteristics?

The examiner should also obtain information on the school and family histories. The family history must include a discussion of potential psychiatric difficulties in the parents and siblings, marital difficulties, and any family problems centered around chronic medical conditions, employment problems, or other potential stress events within the family. Of course, the examiner will want to obtain some information about prior treatments received by the child and his or her

Examiners should ask parents what strategies teachers may have attempted to help the child in class. They should also inquire about tutoring services, school counselors, study skills classes, or peer helpers. The examiner should find out when and why teachers referred the child for psychoeducational testing. If the child is not doing well in school, the examiner should ask whether school personnel have ever offered an explanation. As always, the examiner should listen for clues about possible problems with behavioral regulation, impulse control, or sustained attention. If the child has a diagnosed learning disability, are there problems in school that cannot be explained by that learning disability?

The cutoff scores on both symptom lists (6 of 9) were primarily based on children ages 416 years in the DSM-IV field trial (Lahey et al., 1994), making the extrapolation of these thresholds to age ranges outside those in the field trial of uncertain validity. ADHD behaviors tend to decline in frequency within the population over development, again suggesting that a somewhat higher threshold may be needed for preschool children (ages 24). The children used in the DSM-IV field trial were predominantly males. Studies reliably demonstrate that parents and teachers report lower levels of those behaviors associated with ADHD in girls than in boys (Achenbach & Edelbrock, 1983, 1986; DuPaul, 1991). It is possible, then, that the cutoff points on the DSM-IV symptom lists, based as they are mainly on males, are unfairly high for females. Some latitude should be granted to females who are close to but may fall short of the diagnostic criteria by a single symptom. The specific age of onset of 7 years is not particularly critical for identifying ADHD children (Barkley & Biederman, 1997; Barkley, Murphy, & Fischer, 2008). The field trial for the DSM-IV found that ADHD children with various ages of onset were essentially similar in the nature and severity of impairments as long as their symptoms developed prior to ages 1012 years (Applegate et al., 1997). Thus, so stipulating an onset of symptoms as occurring before age 12 in childhood is probably sufficient for purposes of clinical diagnosis, as is now being proposed by the DSM5 committee developing revised guidelines for the diagnosis of ADHD (expected in 2013). The criterion that the duration of symptoms be at least 6 months was not specifically studied in the field trial and was held over from earlier DSMs primarily out of tradition. Some research on preschool children suggests that a large number of 2- to 3-year-olds may manifest the symptoms of ADHD as part of that developmental period and that they may remain present for periods of 36 months or longer (Campbell, 1990; Palfrey, Levine, Walker, & Sullivan, 1985). Children whose symptoms persisted for at least 1 year or more, however, were likely to remain deviant in their behavior pattern into the elementary school years (Campbell & Ewing, 1990; Palfrey et al., 1985). Adjusting the duration criterion to 12 months would seem to make good clinical sense. The criterion that symptoms must be evident in at least two of three settings (home, school, work) essentially requires that children have sufficient symptoms of ADHD by both parent and teacher report before they can qualify for the diagnosis. This requirement bumps up against a methodological problem inherent in comparing parent and teacher reports. On average, the relationship of behavior ratings from these two sources tends to be fairly modest, averaging about 0.30 (Achenbach, McConaughy, & Howell, 1987). However, if parent and teacher ratings are unlikely to agree across the various behavioral domains being rated, the number of children qualifying for the diagnosis of ADHD is unnecessarily limited, due mainly to measurement artifact. Fortunately, some evidence demonstrates that children who meet DSM criteria (in this case, DSM-III-R; American Psychiatric Association, 1987) by parent reports have a high probability of meeting the criteria by teacher reports (Biederman, Keenan, & Faraone, 1990). Even so, stipulating that parents and teachers must agree on the diagnostic criteria before a diagnosis can be rendered is probably unwise and unnecessarily restrictive. For now, to grant the diagnosis, clinicians are advised to seek evidence that symptoms of the disorder existed at some time in the past or present of the child in several settings rather than insisting on the agreement of the parents with a current teacher. The foregoing issues should be kept in mind when applying the DSM criteria to particular clinical cases. It helps to appreciate the fact that the DSM represents guidelines for diagnosis, not rules of law or dogmatic prescriptions. Some clinical judgment is always going to be needed in the application of such guidelines to individual cases in clinical practice. For instance, if a child meets all criteria for ADHD including both parent and teacher agreement on symptoms except that the age of onset for the symptoms and impairment is 9 years, should the diagnosis be withheld? Given the previous discussion concerning the lack of specificity for an age of onset of 7 years and ADHD, the wise clinician would grant the diagnosis anyway. Likewise, if an 8-yearold girl meets five of the nine ADHD Inattention or HyperactiveImpulsive symptoms and all other conditions are met for ADHD, the diagnosis should likely be granted given the previous

Review of Childhood Psychiatric Disorders

As part of the general interview of the parent, the examiner must cover the symptoms of the major child psychiatric disorders likely to be seen in ADHD children. A review of the major childhood disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000) in some semi-structured or structured way is imperative if any semblance of a reliable and differential approach to diagnosis and the documentation of comorbid disorders is to occur (see interview in Barkley & Murphy, 2006). The examiner must exercise care in the evaluation of minority children to avoid over diagnosing psychiatric disorders simply by virtue of ignoring differing cultural standards for child behavior. Should the parent indicate that a symptom is present, one means of precluding over identification of psychopathology in minority children is to ask the following question: Do you consider this to be a problem for your child compared to other children of the same ethnic or minority group? Only if the parent answers yes is the symptom to be considered present for purposes of psychiatric diagnosis.

Before proceeding, an explanation is in order as to why ODD and CD are queried first. Many parents arrive at the diagnostic evaluation overwhelmed by emotional stress, frustrations with home behaviors, or endless criticisms about the child from the school; thus they may be inclined to say yes to anything. Starting with ODD and CD questions allows these parents to get some of this frustration out of their system. Thus, when they are asked questions about ADHD, the answers are potentially more reliable and accurate.

In addition, unfortunately some parents actually shop for the ADHD diagnosis. They may have an agenda that involves obtaining a diagnosis for their child that is not entirely objective. Beginning the clinical interview with the reason for referral and then the ODD questions may assist the clinician in gaining important clinical impressions about the parents agenda. This is also why it can be extremely useful for clinicians to completely eliminate the word attention from their vocabulary during the interview. When the clinician asks specific questions about ADHD symptoms, the questions should be phrased in such a way that they are concrete and descriptive.

As suggested in the first of these three CE courses on ADHD, adjustments may need to be made to the DSM-IV criteria for ADHD:

comments about gender bias within these criteria. Some flexibility (and common sense), then, must be incorporated into the clinical application of any DSM criteria. However, several studies found negative results. Two follow-up studies using DSM-III criteria for the disorder and retrospective data collection on smoking during pregnancy did not detect an association with ADHD (Hill, Lowers, Locke-Wellman, & Shen, 2000; McGee & Stanton, 1994). Two cohort studies using DSM-III-R criteria for ADHD also did not find a positive association (Wakschlag et al., 1997; Weissman, Warner, Wickramaratne, & Kandel, 1999). In a prospective population-based study, smoking during pregnancy was associated with conduct disorder, but there was no association with ADHD (Maughan et al., 2001). Also, recently Knopik and colleagues (2005) assessing 1,936 pairs of twin siblings did not show the above-mentioned association. It has been suggested in the literature that the inattentive type is the most common subtype of ADHD in non-referred samples, accounting for about half of the cases (Woo & Key, 2005). However, there were no reports in the literature addressing specifically the association between prenatal exposure to nicotine and ADHD - predominantly inattentive type (ADHD-I). Thus, in a recent publication, we described a case-control study where a non-referred Brazilian sample of 100 children and adolescents with ADHD-I and 100 non-ADHD controls (6 to 18 years of age) was evaluated to investigate an association of this ADHD subtype and smoking during pregnancy (Schmitz et al., 2006). cases and controls, matched by gender and age, were screened using teacher reports in the SNAP-IV scale and the diagnosis of ADHD-I and its comorbidities were performed in our outpatient clinic through structured diagnostic interviews. To assure that we are dealing with a relatively pure ADHD - inattentive type, we only included cases fulfilling DSM-IV criteria for ADHD- inattentive type but presenting at most three symptoms of hyperactivity/impulsiviry. We were able to identify in conditional logistic regression (adjusted for alcohol during pregnancy, ODD, maternal ADHD, and birth weight) that the odds of having ADHD-I was 3.44 times higher for children whose mothers smoked 10 cigarettes a day during pregnancy compared to children whose mothers did not smoke during pregnancy. Also, dimensional analyses documented significant results. The controversy in the literature on this association might be related to problems in controlling well-known potential confounders (maternal age, comorbidities, perinatal factors, maternal ADHD). In our study, we took into account all of these confounders in analyses, reinforcing the role of smoking during pregnancy in ADHD-I. To the best of our knowledge, ours are the first results indicating the association between smoking during pregnancy and ADHD in a nonreferred sample including specifically subjects with ADHD-I. Nicotine is the main psychoactive substance of tobacco and possibly compromises the development of neurotransmitter systems by different ways. First, its vasoconstrictor effect increases maternal blood pressure and heart rate, resulting in a reduction of uterine blood flow and also in a lower level of oxygen in the fetus brain (Disney, Elkins, McGue, & Iacono, 1999). It is well known that prenatal hypoxia produces alterations in neurotransmitter development in rats (Lynskey & Fergusson, 1995). Also, nicotine interferes in cell replication, one of the most critical stages of fetal development that ends when cell differentiation begins (Flory et al., 2003). According to the hypothesis of Slotkin, Cho, and Whitmore (1987), fetal exposure to nicotine results in a premature switch from replication to differentiation of the target cells of cholinergic stimulation, causing very damaging consequences to the future synaptic connections. There is evidence of a predominantly pre-synaptic site for nicotine receptors in the central nervous system, which is consistent with a modulatory role in neurotransmitter release. Some studies indicate that the nicotine receptors enhance pre-synaptic release of dopamine, noradrenaline, and serotonin. Therefore, prenatal exposure to nicotine probably has direct effects in these systems as well. The disruptions in the development of catecholaminergic systems may explain the increased incidence of ADHD in individuals exposed to nicotine during the prenatal period, given the role of catecholamines in this disorder (Tercyak, Lerman, & Audrain, 2002).

To assist clinicians with the differential diagnosis of ADHD from other childhood mental disorders, I compiled a list of differential diagnostic tips (see Table 2.1). Under each disorder, I list those features that would distinguish this disorder, in its pure form, from ADHD. However, many ADHD children may have one or more of these disorders as comorbid conditions with their ADHD; thus the issue here is not which single or primary disorder the child has but what other disorders besides ADHD are present and how they affect treatment planning. Smoking During Pregnancy and ADHD-Inattentive Type Schmitz, Marcelo; Rohde, Luis Augusto. The ADHD Report15. 2 (Apr 2007): 12-13,16. The rates of maternal smoking during pregnancy have decreased over the last few decades, but the estimated percentage remains high. In 2002, smoking during pregnancy was reported by 11.4% of all women giving birth in the United States, although in some states this rate was higher than 20%. The possibility that these findings may be underestimates, since prenatal smoking is underreported in birth certificates, is even more concerning (Martin et al., 2003). Structure and functional abnormalities were found in animal studies that assessed the impact of nicotine exposure in the brain. These abnormalities are similar to those found in humans with Attention-Deficit Hyperactivity Disorder (ADHD) (Castellanos et al., 2002). Reduction in the cerebral blood flow and in the brain weight in fetuses exposed to nicotine (Walker et al., 1999), smaller head circumference in the offspring of "smoking mothers" (Kllen, 2000), and structural abnormalities and retardation in the neural maturation (Roy, Seidler, & Slotkin, 2002) in rats exposed to nicotine are some examples. Besides that, animal studies suggest that prenatal exposure to nicotine can cause hyperactivity in the offspring and that these are long-lasting effects (Ajarem & Ahmad, 1998; Eriksson, Ankaber, & Fredriksson, 2000). Postulated mechanisms to explain the impact of nicotine in the brain are related to the modulation of the dopaminergic system and to an increase of the number of nicotinic receptors (Marks, Farnham, Grady, & Collins, 1993; Slotkin, Lappi, & Seidler, 1993). Although the results are positive in animal studies concerning an association of ADHD symptoms and prenatal nicotine exposure, it remains uncertain whether this association is correct for human beings or whether shared biological factors contribute for the development of hyperactivity and nicotine addiction. For instance, adults with ADHD start smoking earlier and have higher rates of nicotine use and also more difficulties in stop-smoking programs compared with non-ADHD controls (Milberger et al., 1997; Pomerleau et al., 1995). So, it is important to consider that maternal smoking during pregnancy may be a proxy variable for the genetic risk for ADHD in the offspring. There is a growing body of evidence on the association between ADHD and prenatal smoking. In an extensive review of the literature, Linnet and colleagues (2003) described 24 studies on the association between smoking during pregnancy and either ADHD diagnosis or symptomatic correlates of the disorder. The most well-designed studies tend to show positive results (Huizink & Mulder, 2006). Linnet and colleagues (2005) recently documented that smokers during pregnancy had a threefold increased risk for having offspring with Hyperkinetic Disorder (HD) compared with non-smokers in a nested case-control study with 170 children with HD and 3675 population-based controls. In addition, Langley, Rice, Van den Bree and Thapar (2005) determined a pooled odds ratio indicating more than a twofold increase in risk for a diagnosis of ADHD in those individuals whose mothers smoked during pregnancy in a recent meta-analytic study of the literature.

The association between smoking during pregnancy and ADHD-I found in our study supports the search for pathophysiological mechanisms that might explain the neurobiological bases of such prevalent specific phenotype. Moreover, our results reinforce findings from previous studies with clinical samples, including all types of ADHD (mainly combined subtype). Therefore, prospective studies are necessary to establish a causal association. After that, since smoking during pregnancy can be prevented, perhaps through counseling pregnant women on the long term cognitive risks for their children, this would be of great importance in terms of public health

The study contained information on prenatal exposure to cigarette smoke and the concentration of lead in blood samples taken from the children. The researchers, who published their findings in the journal Environmental Health Perspectives, linked blood lead concentrations of 2 micrograms per deciliter or greater to an increased risk of ADHD. Children in that group had a four-fold risk of ADHD compared to children with the lowest blood lead levels -- under 0.8 micrograms per deciliter. Federal standards consider blood lead levels of less than 10 micrograms per deciliter safe. The study confirmed the link found in previous studies between prenatal exposure to cigarette smoke and ADHD. The latest study found that children exposed to tobacco smoke prenatally had a 2.5- fold greater risk of ADHD than unexposed children. There was no connection between childhood exposure to tobacco smoke and ADHD. Lanphear said that taken together, prenatal tobacco smoke and childhood lead exposures accounted for 480,000 of about 1.8 million cases of ADHD. Dr. David Feinberg, medical director of the Stewart & Lynda Resnick Neuropsychiatric Hospital at the University of California, Los Angeles, said children exposed to high levels of lead are often hyperactive, so the link between lead and ADHD sounde reasonable. But Feinberg said the estimates sounded too high. The study didn't account for inherited genetic factors, which are one of biggest predictors of ADHD, Feinberg said. Copyright Grand Rapids Press Oct 24, 2006

Schmitz, M., & Luis, A. R. (2007). Smoking during pregnancy and ADHDinattentive type. The ADHD Report, 15(2), 12-13,16. Retrieved from
ADHD linked to prenatal smoke, lead ; Prenatal exposure to environmental toxins in one-third of all cases: [6 Edition] Denise Gellene / The Los Angeles Times. The Grand Rapids Press [Grand Rapids, Mich] 24 Oct 2006: A8. Translate Abstract ADHD is a condition marked by impulsivity, poor concentration and hyperactivity, making it difficult for children in pay attention in school. About 2 million, or one of every 25 school age children in the U.S., have ADHD. The researchers, who published their findings in the journal Environmental Health Perspectives, linked blood lead concentrations of 2 micrograms per deciliter or greater to an increased risk of ADHD. Children in that group had a four-fold risk of ADHD compared to children with the lowest blood lead levels -- under 0.8 micrograms per deciliter. The study confirmed the link found in previous studies between prenatal exposure to cigarette smoke and ADHD. The latest study found that children exposed to tobacco smoke prenatally had a 2.5- fold greater risk of ADHD than unexposed children. Translate Full textTurn on search term navigation One-third of attention deficit hyperactivity disorder cases are linked to prenatal exposures to cigarette smoke or childhood exposures to lead, researchers recently reported The study, lead by researchers at Cincinnati Children's Hospital Medical Center, was the first to estimate the number of ADHD cases attributable to environmental toxins. The report "provides further evidence that we need to find ways to dramatically reduce prenatal tobacco smoke exposures and childhood lead exposures," said lead author Dr. Bruce Lanphear. ADHD is a condition marked by impulsivity, poor concentration and hyperactivity, making it difficult for children in pay attention in school. About 2 million, or one of every 25 school age children in the U.S., have ADHD. Researchers analyzed data gathered on 4,704 children ages 4 to 15 as part of the federal National Health and Nutrition Examination Survey. The survey was conducted from 1999 to 2002.

Denise Gellene / The Los,Angeles Times. (2006, Oct 24). ADHD linked to prenatal smoke, lead ; prenatal exposure to environmental toxins in one-third of all cases. The Grand Rapids Press. Retrieved from

About 8 percent of children in the study had been diagnosed with ADHD, and 4.2 percent were prescribed drugs to treat the condition.