رابطه بی توجهی، بیش فعالی و اختلالات فکری و روانی در میان نوجوانان

This study is an extension of Colledge and Blair’s (2001) investigation on the inter-relationship between core features of attention deficit/hyperactivity disorder and conduct disorder. The current study extended the earlier work using methodological refinements in sample selection, psychiatric diagnostic assessment, and instruments used to measure inattention, hyperactivity, and psychopathy. The primary outcome was that the impulsiveness-conduct problem component of psychopathy was specifically associated with inattention and hyperactivity components of attention deficit/hyperactivity disorder. Impulsivity may be an underlying mechanism common to both disorders and may represent a selective target for treatment.

Attention deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) are common disorders in child psychiatry, and there has been considerable effort to determine the unique and common features of these disorders. The most common neurodevelopmental disorder in children is ADHD (Rowland, Lesesne, & Abramowitz, 2002), which is characterized by processes of inattention and hyperactivity–impulsivity that are “maladaptive and inconsistent with developmental level” (DSM-IV-TR, American Psychiatric Association, 2000; p. 92). Inattention includes symptoms like careless mistakes, difficulty organizing, or avoidance of sustained mental effort, while the hyperactivity–impulsivity component of ADHD involves symptoms like fidgeting, excessive talking, and difficulty waiting (DSM-IV-TR, American Psychiatric Association, 2000). Among those with ADHD the rates of comorbidity with CD have been reported to be as high as 50% ( Dulcan & Benson, 1997). This comorbidity is especially pronounced among youth with the hyperactivity–impulsivity type of ADHD ( Willcutt, Pennington, Chhabildas, Friedman, & Alexander, 1999). Further, the comorbidity of ADHD and CD imparts poor prognosis in terms of severity and persistence of psychiatric symptoms ( Abikoff & Klein, 1992) and the development of substance abuse and criminal behaviors ( Hinshaw, 1994, Pliszka, 2003 and Satterfield and Schell, 1997). CD involves a “persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated” (DSM-IV-TR, American Psychiatric Association, 2000; p. 98). Psychopathy is a core feature of CD and includes traits of callous-unemotionality, impulsive-conduct problems, and narcissism ( Frick & Ellis, 1999). Children with high levels of psychopathy are likely to be diagnosed with CD ( Frick, Bodin, & Barry, 2000) and show high rates of physical fighting ( Frick, Cornell, Barry, Bodin, & Dane, 2003). While the core features of ADHD and CD are conceptually distinct, their frequent co-occurrence raises the question of the specific nature of the relationship between inattention, hyperactivity, and psychopathy. Previous research has focused on the role of inattention and hyperactivity–impulsivity in ADHD and CD, both alone and in combination (e.g., Hinshaw, 1987, Leung and Connolly, 1996 and Oosterlaan et al., 1998), although this research has yielded mixed findings as to the relative roles of each construct. For example, some studies have suggested that youths with comorbid CD/ADHD perform more like those with ADHD (Oosterlaan et al., 1998), while other studies have indicated that the comorbid groups perform more like those with CD (Leung & Connolly, 1996). Based on these divergent outcomes, the nature of the relationship between ADHD and CD remains unclear. In an effort to better understand the relationship between the core features of each disorder, Colledge and Blair (2001) compared teacher-ratings of inattention and hyperactivity–impulsivity (using DuPaul’s ADHD Rating Scale; DuPaul, 1991), as well as psychopathy (using the Psychopathy Screening Device; Frick et al., 2000) of 71 boys attending “special schools for children with emotional and behavioral difficulties” (p. 1178). Analyses showed significant inter-correlation between each of the components of ADHD and CD. These analyses were followed-up by examining the inter-relationship between each of the individual scales, while partialing out the effect of the other constituent scale scores and mental age (e.g., partial-correlation between inattention and impulsive-conduct problems controlling for callous unemotionality and mental age). Based on this series of partial-correlations, Colledge and Blair concluded that the inter-relationship between ADHD and CD was primarily due to the association between the hyperactivity–impulsivity component of ADHD and the impulsiveness-conduct problems component of CD. Their results were interpreted as consistent with the suggestion that there are multiple pathways to the development of antisocial behaviors (Blair and Frith, 2000, Frick, 1995, Frick, 2006 and Frick et al., 2003) and that one of these routes involves a syndrome of impulsivity that is a risk factor for both ADHD and CD (Colledge and Blair, 2001 and Moeller et al., 2001). The current study was designed to extend this line of investigation using several methodological refinements of the earlier Colledge and Blair (2001) study. First, their sample selection was to some degree exclusive; composed of boys receiving psychiatric services and recruited from an institutional-type setting. This limits generalizability or at least warrants extension to a more gender-balanced and community-based sample. Second, no diagnostic interview was conducted to determine psychiatric condition of the sample. Third, their study relied exclusively on teacher ratings of ADHD and CD features, with moderate inter-rater reliability (.51–.62; Colledge & Blair, 2001, p. 1179). In addition to teachers, adolescent self-ratings are valid for assessment of ADHD and CD symptoms (Achenbach, 1995 and Conners, 2001). Finally, there are more recent measures of inattention, hyperactivity and psychopathy that may improve the capacity to assess relationships between features of ADHD and CD. Previously, Colledge and Blair used the DuPaul (1991) ADHD Rating Scale which contains only 14-items. The 87-item Conners-Wells’ Adolescent Self-Report Scale (Conners, 2001), which has been described as among the best normed and validated for the assessment of ADHD symptoms (Dulcan & Benson, 1997), may be better suited to characterize ADHD symptoms. Similarly, the Psychopathy Screening Device (Frick et al., 2000), which initially included scales for the assessment of impulsive-conduct problems and callous unemotionality in the previous study, has been updated (i.e., Antisocial Process Screening Device; Frick & Hare, 2001) to include narcissism as a third component of psychopathy. The current study was designed to compare the relationship of CD and ADHD symptoms. Here we extend the earlier work of Colledge and Blair (2001) by examining self-report ratings of inattention, hyperactivity, and psychopathy in a sample of boys and girls recruited from the community. All were diagnosed with CD/ADHD or CD-only (using a semi-structured interview) and were not currently undergoing treatment. Ratings were obtained for ADHD symptoms of inattention and hyperactivity (Conners-Wells’ Adolescent Self-Report Scale; Conners, 2001), as well as psychopathy (Antisocial Process Screening Device; Frick & Hare, 2001). It was hypothesized that there will be a strong relationship between the hyperactivity–impulsivity component of ADHD and impulsiveness-conduct problems of the psychopathy measures, reflecting impulsivity as a common underlying characteristic of CD and ADHD.