Brief ReportsAttention-deficit hyperactivity disorder and the stress response
Introduction
Attention-deficit hyperactivity disorder (ADHD) is a developmental disorder characterized by three main symptoms: inattention, impulsiveness, and hyperactivity (American Psychiatric Association 1994). Recently, a number of theorists have argued that poor response inhibition is the central feature of this disorder Barkley 1997a, Quay 1997, Schachar et al 1993 and have marshaled substantial evidence in favor of this view (see Barkley 1997b). Quay (1988) has adapted Gray’s neuropsychological theory of anxiety disorders (Gray 1987) to argue that this deficit in response inhibition occurs as a result of underfunctioning in the behavior inhibition system (BIS), one of three interactive systems in Gray’s model. Cloninger (1988) also has proposed a similar inhibitory system (harm avoidance) in his theory of personality dimensions. Like Gray, Cloninger argues that this system is monoaminergically mediated and is activated by signals of punishment and frustrative nonreward. This activation results not only in response inhibition but also in cortisol release and other stress responses. If the central deficit in ADHD is one of poor response inhibition, then children with ADHD should show evidence of underactivity in the BIS. This may be measured indirectly by their responding under conditions of punishment and reward (see McBurnett 1992, Milich et al 1994), but also by various indicators of their stress responses, which are thought to be mediated by neuronal and endocrine factors of the hypothalamic–pituitary–adrenal (HPA) axis (King 1996). Therefore, the present studies were designed to look at the functioning of the HPA axis in response to mental stress in aggressive ADHD subjects participating in a longitudinal study of various psychosocial treatments (Barkley et al 1996). The hypothesis to be tested is whether ADHD subjects who maintained their diagnosis over the first year of this study would have a blunted physiological response to a stressor as manifested through blunted cortisol levels after psychological testing in comparison to those ADHD subjects who no longer retained the disorder 1 year later.
Section snippets
Subjects
The subjects consisted of children aged 4–6 years who had been identified at their kindergarten registration as demonstrating high levels (> 93rd percentile) of both aggressive and hyperactive–impulsive–inattentive behavior by parent ratings (see Barkley et al 1996 for further details of subject identification). Therefore all subjects demonstrated either oppositional defiant disorder (ODD) or the more severe conduct disorder (CD). The pool of subjects was identified each year for a period of 3
Results
Figure 1 summarizes the blunted changes in cortisol levels in the ADHD children who retained their diagnosis of the first year of the project compared to those subjects who no longer met DSM-IV criteria for ADHD after this year. There were no differences between boys and girls or comorbidity with ODD or CD in the sample. Baseline and stimulated levels of cortisol were significantly lower in ADHD youngsters who had retained their diagnosis than those who had not (p ≤ .05 and p ≤ .01,
Discussion
This study contributes to a growing body of evidence showing that the HPA axis may be dysfunctional in some subjects with ADHD. In particular, subjects who appeared to have persistence of their ADHD over a 1-year period of time displayed a reduced level of stress response at pretesting and posttesting relative to ADHD children whose disorder did not persist over this 1-year period. Such findings also support the contentions of theorists that children with ADHD may have an underactive BIS (Quay
Acknowledgements
Funding for this project was provided by NIMH grant # MH45714 to Dr. Barkley.
The authors would like to thank Meredith Mattison and Bhas Ray for their assistance with sample collection.
The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the Institute.
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