Abstract: Objectives: The aim of the study was to determine the prevalence of attention deficit hyperactivity Disorder (ADHD) and associated risk factors among children were attended the general pediatric outpatient clinic of Menoufia University Hospital. Background: Attention deficit hyperactivity disorder is the most commonly seen developmental disorders, with significant impacts on the child's social, psychological, and scholastic functioning. Methods: The study was conducted on 600 children (5 - 12 years ) were attended the general pediatric outpatient clinic of Menoufia University Hospital . All studied patients were subjected to adequate history taking, full clinical examination, a questionnaire regarding socioeconomic, family and maternal variables and a parent-completed, ADHD Rating Scale of attention deficit hyperactivity symptoms was used. Results: The study revealed that the prevalence of probable ADHD in our study was 19.7%. and was higher in males than in females with a ratio 2.7:1. The most common type of probable ADHD was the combined type and the least frequent type was the inattentive type. There were many factors that were sought to be associated with increase possibility of developing ADHD. Conclusion: The present study shows a high prevalence of probable ADHD in children. our study also revealed that probable ADHD was associated with many risk factors, prevalence was high in the male sex, living in urban areas, low socioeconomic families, large family size, living with a single parent, family history of ADHD, preterm children, low birth weight and bottle fed children.
Attention deficit hyperactivity disorder (ADHD) with a set of hyperactivity symptoms, impulsive behaviors and attention deficit leads to concentration problems (1). The disorder consists of three types including hyperactivity-impulsivity, attention and concentration deficit and mixed type (2). The prevalence rate of the disorder in students and is estimated to occur in 3-7% of school aged children (1) and in Tehran have been reported 3-6% (3). The disorder is always associated with a wide range of negative consequences for children (4, 5) and high costs to the family and communities (6), therefore this disorder is considered as one of collective health problems (7). Nowadays, medication is the most common treatment method in children with ADHD. But, due to the wide range of heterogeneity in children with ADHD, medication is not effective in all clients. Furthermore, even some drugs such as methylphenidate which has been
Background: Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder characterized by symptoms of inattention and impulsivity and/or hyperactivity and a range of cognitive dysfunctions. Pharmacological treatment may be beneficial; however, many affected individuals continue to have difficulties with cognitive functions despite medical treatment, and up to 30 % do not respond to pharmacological treatment. Inadequate medical compliance and the long-term effects of treatment make it necessary to explore nonpharmacological and supplementary treatments for ADHD. Treatment of cognitive dysfunctions may prove particularly important because of the impact of these dysfunctions on the ability to cope with everyday life. Lately, several trials have shown promising results for cognitive computer training, often referred to as cognitive training, which focuses on particular parts of cognition, mostly on the working memory or attention but with poor generalization of training on other cognitive functions and functional outcome. Children with ADHD have a variety of cognitive dysfunctions, and it is important that cognitive training target multiple cognitive functions. Methods/Design: This multicenter randomized clinical superiority trial aims to investigate the effect of “ ACTIVATE ™ , ” a computer program designed to improve a range of cognitive skills and ADHD symptoms. A total of 122 children with ADHD, aged 6 to 13 years, will be randomized to an intervention or a control group. The intervention group will be asked to use ACTIVATE ™ at home 40 minutes per day, 6 days per week for 8 weeks. Both intervention and control group will receive treatment as usual. Outcome measures will assess cognitive functions, symptoms, and behavioral and functional measures before and after the 8 weeks of training and in a 12- and 24-week follow-up.
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2. Evolution: As ADHD is more common than 1 percent of the population, researchers have proposed that due to the high prevalence of ADHD that natural selection has favoured ADHD possibly because the individual traits may be beneficial on their own, and only become dysfunctional when these traits combine to form ADHD. The high prevalence of ADHD may in part be because women in general are more attracted to males who are risk takers, thereby promoting ADHD in the gene pool. Further evidence showing hyperactivity may be evolutionarily beneficial was put forth in 2006 in a study that found it may carry specific benefits for certain forms of society. In these societies, those with ADHD are hypothesized to have been more proficient in tasks involving risk, competition, and/or unpredictable behavior (i.e. exploring new areas, finding new food sources, etc.), where these societies may have benefited from confining impulsive or unpredictable behavior to a small subgroup. In these situations, ADHD would have been beneficial to society as a whole even while severely detrimental to the individual. More recent research suggests that because ADHD is more common in mothers who are anxious or stressed that ADHD is a mechanism of priming the child with the necessary traits for a stressful or dangerous environment, such as increased impulsivity and explorative behaviour etc. A genetic variant associated with ADHD (DRD4 48bp VNTR 7R allele) has been found to be at higher frequency in more nomadic populations and those with more of a history of migration. Consistent with this, another group of researchers observed that the health status of nomadic Ariaal men was
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to the ADHD group and this could be due to a severity issue. They represent a mixed bag o f severely psychiatrically impaired individuals, referred for having problems in attention and impulse control, that results in a loss on the core features one takes to find in the ADHD disorder. Thus, although diagnostically they are clearly not a mild ADHD group as they neither have the childhood history nor meet adult criteria, they may self-report to have problems similar to ADHD adults. For example, they differed from the ADHD group on self-reported items that could be substantiated by alternative sources, i.e. childhood variables that were supported by either parent report and/or childhood reports. Furthermore, the clinic control group had been referred to the clinic for problems with attention and impulsiveness and expected to receive a diagnosis of ADHD (Van der Linden et al, in submission). Therefore they did not represent an ideal comparison group for researching the psychosocial impact of ADHD in adulthood using a self-reported measure. Future research should use abetter control comparison, such as a personality disordered group, in order to examine the psychosocial outcome of adult ADHD
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It has been suggested that fluctuating top-down control, as indexed by increased RT variability, may be a partial explanation for impaired sustained attention (Bellgrove, Hawi, Kirley et al., 2005; Castellanos et al., 2005; Stuss et al., 2003). Working from the hypothesis that neuropsychological heterogeneity within ADHD samples may conceal clinically important deficits, we adopted a heterogeneity reduction technique recently advocated by Nigg and colleagues (Nigg et al., 2005). Impairment on the SART was defined as a commission error score that was 1.5SD above the mean commission error rate for control participants. This cut-off is consistent with criteria used to define
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These findings are generally consistent with those of Sykes et al. (1973) and indicate that there is a marked differences in performance between ADHD and normal groups on measures of sustained attention. While there is a significant developmental influence on children's CPT performance decrement (with younger children producing greater deficits), the effect of age on the time-by-group interaction was not assessed. Research addressing this issue would provide further information on the
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In recent years, meditation has become increasingly popular as treatment for psychological conditions. There is emerging evidence from randomized trials to support popular beliefs concerning the beneficial effects of yoga in the treatment of neuropsychiatric disorders such as depression or sleep disorder. The long periods of concentration required by yoga are thought to potentially help reduce attention deficits. In addition, yoga may produce a state of calmness and contentment which is lacking in patients with ADHD. combinations of the following:
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rural area was probably an index of low socio-economic status. Indeed, in a Turkish study , enuresis was re- ported to be associated with low maternal education and with low monthly income, indices of poor socio-economic status. Ethnicity was significantly associated with enuresis/ encopresis in this study. As previously discussed under probable epilepsy, the association between enuresis/enco- presis and ethnicity may be underlined by the same reasons namely, as a pointer to an underlying genetic underpinning for enuresis/encopresis , secondly, as a marker for socio-economic disadvantage. The association between en- uresis/encopresis and ‘less HIV viral load suppression’ ob- served in this study may be due to the direct neurotoxic effect of HIV or/ and to the increased psychological distress associated with a worse HIV clinical state. Lastly, enuresis/ encopresis were the only neurological disorders significantly associated with both externalising and internalising psychi- atric disorders. Previous research has reported that 20–40% of all children with enuresis have additional comorbid psy- chiatric disorders which include the externalising disorders of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) and the internalising disorder of depression . In a large community study, children with encopresis were reported to have increased rates of the externalising disorders of ADHD and ODD and the internalising disorders of separation anxiety, specific phobia and generalised anxiety disorders .
International guidelines for the diagnosis and management of adult ADHD are available (Canadian Attention Deficit Hyperactivity Disorder Resource Alliance, European Network Adult ADHD, National Institute of Health and Clinical Excellence, and British Association of Psychophar- macology). Treatment plan recommendations vary in their detail across the international bodies; however, a multi-modal approach to treatment, consisting primarily of pharmacologi- cal intervention and/or behavioral therapy, is recommended. Several medications are approved for adult ADHD in North America, whereas in those European countries in which medication is approved for use in adults, it is limited to those with a previous diagnosis or evidence of childhood or adolescent ADHD. 71
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Children with ADD should be need directed and reminded more according to their peers who can easily perform these tasks in their daily lives. Parents and acquaintances increasingly feel confusion and despair as the child falls behind in learning the management of daily tasks and interactions in life and at school. In order to achieve this, more than a particular talent is needed and child has a tendency to have problems in self-management. Since children's growth rate varies from person to person, it is possible that parents do not understand whether their children grow slowly or it is a matter of neurobehavioral disorder. In the beginning, the child may seem to fail to understand and achieve the expectations of parents compared to peers or there can be an unusual inconsistency in child’s behaviors. Parents are worried about this situation and they may suppose that their children should be more matured in order to perform these tasks compared to their peers. This delay is generally very long in children with ADHD and the absence of the expected development and maturation leads to an increasing concern. Children with ADHD have more injuries due to their hyperactivity and disturbing behaviors (13). Children with ADHD are highly restless and fearless. Majority of peers ask for directions and help for some dangerous situations. However, children with ADHD can be brave to touch hot or sharp things or walk across the street alone. They can resist against the control of adults. Brown (4) classifies prominent features of a child with ADD as follows.
Some attributes guide attention better than others, e.g., colour, orientation, motion, and size (Wolfe & Horowitz, 2004). Therefore, some conjunction searches can be very efficient (0-10 ms/item) – such as an X target amongst Os, whilst others result in slow, inefficient (< 20 ms/item) search times, such as search for an S target among distractors (Wolfe, 1998). The fact that some single feature searches can be inefficient while some conjunction searches can be inefficient, demonstrates that the serial/parallel categories do not hold. Similarly, when there is more information provided such as in the case of triple conjunctions, search becomes more efficient than in the case of two conjunctions (Wolfe, Cave, & Franzel, 1989), – which is consistent with Guided search but not with FIT. Search for triple conjunctions (e.g., colour × size × form) is very efficient, almost parallel and does not depend on display size (Quinlan & Humphreys, 1987; Wolfe et al., 1989). To test the efficiency of search in a triple conjunction task, Wolfe et al. (1989) compared four conditions: two triple conjunction tasks in which the target differed in one dimension from the distractors, one triple conjunction tasks in which the target differed in two dimensions from the distractors, and a simple conjunction task. The results showed that search for triple conjunctions differing in two
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professional functioning, and impose significant economic burdens on the society . ADHD is associated with many diseases, including cognitive impairment, sleep disorders and allergic diseases. Allergic rhinitis (AR) is one of the most common allergic diseases affecting children. Preva- lence of global childhood allergic rhinitis has been re- ported to be as high as 40% . Allergic rhinitis and ADHD affect children of similar ages . Symptoms of allergic rhinitis may lead to daytime inattention, irritability and hyperactivity, which is commonly observed in ADHD children. Although there have been studies showing that AR has a strong relationship with ADHD [8, 9], the mech- anism is still controversial. The prevalence of ADHD and allergic disease has increased worldwide. Both allergy and ADHD rely on gene-environment interaction. At present, there are few studies in this area in China. Our previous research has confirmed that children with AR have higher
Stimulants have shown a high behavioral efﬁ cacy in numer- ous randomized controlled trials conducted since the 1960s, with improvement noted for 65%–75% of patients in all age groups (Pliszka 2006). Stimulants effectively alleviate the symptoms of ADHD, including poor attention span, distract- ibility, impulsive behavior, hyperactivity, and restlessness. Stimulants also improve vigilance, cognition, reaction time, response inhibition, and short-term memory (Connor 2005; Hechtman 2005). Methylphenidate in clinical doses improves spatial working memory, set-shifting, and other prefrontal cortex cognitive functions in healthy individuals and in children with ADHD (Arnsten and Dadly 2005). Stimulant medications are also associated with fewer errors on a driv- ing simulator in teens and adults with ADHD. Barkley and colleagues demonstrated that methylphenidate may have a beneﬁ cial effect on some aspects of driving, for example less steering variability, slower driving speed, greater use of turn signals, and a fewer impulsive responses (Barkley et al 2005).
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This study is not without limitations. The NSCH is a random digital dialing telephone survey based on the responses of parent/guardians. So the responses could be affected by recall bias or the given information could be fallacious (such as misreporting of height/weight). In particular, the diagnosis of ADHD was solely dependent on the response given by a parent to a single question [“Has a doctor or health professional ever told you that S.C. has attention deficit disorder or attention deficit hyperactive disorder, that is, ADD or ADHD?”]; this may have resulted in diagnostic misclassification. In other words, as this is not a clinical study, it is unclear how many children who met the ADHD criteria were undiag- nosed and/or untreated. Further, the survey question on SMOKE [Does anyone living in the household use cigar- ettes, cigar, and pipe tobacco?] does not specify whether the child or someone else in the household including parent/guardian was a smoker; results may alter if the smoker in the household was the child him/herself. Also, some bias is expected due to the cross-sectional nature of the study. For example, the survey fails to capture whether the ADHD, DEP, and ANX diagnosis were con- current or at different time points in the lifetime of the child. Due to these and the observational nature of the study design, the association found in our study cannot be interpreted as causation for ADHD. For example, the association observed between ADHD and the factors SPORTS and CLUBS could be due to the fact that ADHD diagnosed children are just not welcomed on a sport/club teams because of their behavioral problems rather than lack of sporting/physical activity being a risk factor for ADHD. That is, some of the associated factors could be consequences of having ADHD.
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sign of the above-mentioned study, additional controlled trials are indicated before advocating fish, with its atten- dant mercury exposure, or fatty acids as a general sub- stitute for medication. The introduction of a relatively safe and well-tolerated dietary treatment could, if proven successful, serve as a complementary or substi- tute treatment and offset the increase in concern regard- ing adverse effects of drug therapies. Initial trials of adjunctive therapy with fatty acids in our attention- deficit disorder clinic have been disappointing.
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Operant conditioning of the electroencephalographic rhythm (EEG biofeedback) is argued to be an effective method for treating children with ADHD. This study was designed to evaluate whether this method, compared to methylphenidate, achieves an equally effective outcome. Participants were 39 children aged between 7 - 12 years. Thirteen children with attention-deficit/hyperactivity disorder (ADHD) were trained to enhance the amplitude of the beta1 activity (15 - 18 Hz) and decrease the amplitude of the theta activity (4 - 8 Hz), and 13 of which were treated with methylphenidate alone. Thirteen healthy children did not receive intervention. Several behavioral, neuropsychological and experimental tests were administered before and after intervention. While behavioral measures were improved by both types of method, methylphenidate was significantly more effective than EEG biofeedback. Response inhibition was improved only by EEG biofeedback. Both EEG biofeedback and methylphenidate were associated with improvements on the variability and accuracy measures of computerized tests. Intellectual ability increased also by both methods. Although averaged effect size for methylphenidate seems to be greater than for EEG biofeedback, the difference was not significant. In conjunction with other studies, these findings demonstrate that EEG biofeedback can significantly improve several be- havioral and cognitive functions in children with ADHD, and it might be an alternative treatment for non-responders or incomplete responders to medication as well as for those their parents favor a non-pharmacological treatment.
Limitations of the present study include the sample size and composition. Previous studies have shown group dif- ferences in MBDQ errors as well as violations and lapses  suggesting that our study may have been under- powered to find an effect on errors. However, the effect is likely to be small in that case, and certainly less important than violations and lapses. In the current study there were also relatively few female participants, which may have af- fected the results as studies of healthy adults have shown that females report more errors than males . Although more prevalent in males than females in childhood, there is an approximately equal gender ratio in community sam- ples of adults with ADHD . Future driving research should ensure that this equality is reflected in participant samples. Finally, in the present study, the oculomotor measures did not yield significant effects. This could re- flect insufficient power to detect an effect, although one other study also reported no differences in oculomotor ac- tivity during driving in ADHD and controls . Future research should employ other measures of attention and arousal regulation, such as heart rate variability, and should also determine whether contextual factors, such as the novelty of the driving simulator environment, normal- ise arousal in lab-based studies of driving in ADHD. In re- lation to this, the role of distractors such as mobile phones has received very little attention in previous re- search with one study showing equivalent levels of distrac- tion among adolescents with and without ADHD . Further work is needed to extend this to other distractors, such as car stereos and satellite navigation systems and to explore the cognitive factors that contribute to distraction during driving.
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Abbreviations: ABC, Aberrant Behavior Checklist; ABC-H, Aberrant Behavior Checklist-Hyperactivity Scale; ADHD, attention-deficit hyperactivity disorder; ADHD-RS-IV, Attention-Deficit/Hyperactivity Disorder Rating Scale-IV; ADHDRS-IV-Parent:Inv, ADHD Rating Scale-IV-Parent-Version:Investigator-Administered and Scored; ADHDRS- IV-Teacher-Version, ADHD Rating Scale-IV-Teacher-Version; ADHD-RS, Attention-Deficit/Hyperactivity Disorder Rating Scale; ASD, autism spectrum disorder; ATX, atomoxetine; cb-CPT, computer-based continuous performance test; CBTT, Corsi Block Tapping Test; CD, conduct disorder; CDRS, Children’s Depression Rating Scale; CDRS-R, Children’s Depression Rating Scale-Revised; CGI, Clinical Global Impression; CGI-ADHD-S, Clinical Global Impression-Attention-Deficit Hyperactivity Disorder- Severity; CGi-S, Clinical Global impression-Severity; CGi-Tic/Neuro-S, CGi Tic/Neurologic Severity Scale; CHQ, Child Health Questionnaire; CPRS-R:S, Conners’ Parent Rating Scale-Revised Short Form; CTRS-R:S, Conners’ Teacher Rating Scale-Revised Short Form; DSM-iv, Diagnostic and Statistical Manual of Mental Disorders, 4th edition; iQ, intelligence quotient; KiNDL-R, Revidierter KiNDer Lebensqualitätsfragebogen; K-SCT, Kiddie-Sluggish Cognitive Tempo; K-TeA, Kaufman Test of educational Achievement; MASC, Multidimensional Anxiety Scale for Children; MDD, major depressive disorder; Mi/CBT, motivational interviewing/cognitive behavioral therapy; MT, infrared motion tracking device; NNTs, numbers needed to treat; ODD, oppositional defiant disorder; PARS, Pediatric Anxiety Rating Scale; PBO, placebo; PDD, pervasive developmental disorder; PGi-ADHD-S, Physician Global impression: ADHD Severity; Pts, patients; RCT, randomized clinical trial; RD, reading disorder; SNAP-iv, Swanson, Nolan, and Pelham Rating Scale-Revised; SSRT, Stop Signal Reaction Time; SUD, substance use disorder; vADPRS, vanderbilt ADHD Diagnostic Parent Rating scale; wMTB-C, working Memory Test Battery for Children; YGTSS, Yale Global Tic Severity Scale; YMRS, Young Mania Rating Scale.
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Attention-deficit/hyperactivity disorder (ADHD) has become a major aspect of the work of child and adolescent psychiatrists and paediatricians in the UK. In Scotland, Child and Adolescent Mental Health Services were required to address an increase in referral rates and changes in evidence-based medicine and guidelines without additional funding. In response to this, clinicians in Dundee have, over the past 15 years, pioneered the use of integrated psy- chiatric, paediatric, nursing, occupational therapy, dietetic and psychological care with the development of a clearly structured, evidence-based assessment and treatment pathway to provide effective therapy for children and adoles- cents with ADHD. The Dundee ADHD Clinical Care Pathway (DACCP) uses standard protocols for assessment, titration and routine monitoring of clinical care and treatment outcomes, with much of the clinical work being nurse led. The DACCP has received international attention and has been used as a template for service development in many countries. This review describes the four key stages of the clinical care pathway (referral and pre-assessment; assess- ment, diagnosis and treatment planning; initiating treatment; and continuing care) and discusses translation of the DACCP into other healthcare systems. Tools for healthcare professionals to use or adapt according to their own clinical settings are also provided.
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