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QEEG ADHD

Clinical Neurophysiology Volume 114, Issue 2 , February 2003, Pages 171-183

doi:10.1016/S1388-2457(02)00362-0 | How to Cite or Link Using DOI Copyright 2002 Elsevier Science I reland Ltd. All rights reserved. Cited By in Scopus (118)

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Invited review

A review of electrophysiology in attention-deficit/hyperactivity disorder: I. Qualitative and

quantitative electroencephalography

Robert J. Barry , , Adam R. Clarke and Stuart J. Johnstone

Department of Psychology and Brain & Behaviour Research Institute, University ofWollongong, Northfields Avenue, Wollongong, NSW 2522, Australia

Accepted 24 September 2002. ;

Available online 19 December 2002.

Abstract

Objective : This article reviews the electroencephalography (EEG) literature in relation to attention-deficit/hyperactivity disorder (AD/HD).

Methods : The review briefly outlines the history of the disorder, focusing on the changing diagnosticsystems which both reflect and constrain research into AD/HD. Both qualitative and quantitative EEGstudies are examined, and their results are discussed in relation to various models of AD/HD.

Implications of these data for future research and development in AD/HD are considered.

Results : In terms of resting EEG, elevated relative theta power, and reduced relative alpha and beta,together with elevated theta/alpha and theta/beta ratios, are most reliably associated with AD/HD.Theta/alpha and theta/beta ratios also discriminate diagnostic subgroups of AD/HD. Recent studies ofEEG heterogeneity in this disorder indicate the existence of different profiles of cortical anomalieswhich may cut across diagnostic types.

Conclusions : The research to date has identified a substantial number of EEG correlates of AD/HDwhich hold promise for improving our understanding of the brain dysfunction(s) underlying thedisorder. Further work in this field may benefit from a broader conceptual approach, integrating EEGand other measures of brain function.

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8/9/2019 QEEG_ADHDreview

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Author Keywords: Attention-deficit/hyperactivity disorder; Electrophysiology;Electroencephalography; Review

Article Outline

1. Introduction

2. The syndrome of attention-deficit/hyperactivity disorder

2.1. Historical changes in definition

2.2. International perspectives

2.3. Prevalence of AD/HD

3. Electroencephalographic studies in AD/HD

3.1. Qualitative EEG studies

3.2. Quantitative EEG studies

3.2.1. Waveform amplitude

3.2.2. Power studies

3.2.3. Ratio coefficients

3.2.4. Coherence studies

3.2.5. DSM type differences

3.2.6. Summary of EEG findings

3.2.7. EEG in diagnosis

4. EEG-based models of AD/HD

4.1. The Maturational Lag model of AD/HD

4.2. Developmental Deviation Model of AD/HD

4.2.1. Hypoarousal model of AD/HD

4.3. Limitations of the Maturational Lag and Developmental Deviation models of AD/HD

4.4. EEG-defined subtypes of AD/HD

5. Future directions

5.1. Types and subtypes

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8/9/2019 QEEG_ADHDreview

3/28

5.2. Comorbidity

5.3. Specificity

5.4. EEG in diagnosis

References

1. Introduction

This paper reviews the field of electroencephalography (EEG) in attention-deficit/hyperactivity disorder (AD/HD). Here, and in the companion paper reviewing the fieldof event-related potentials (ERPs) in AD/HD (Barry et al., 2003 ), we examine currentknowledge of the electrophysiology of AD/HD. We first provide a brief overview of thesyndrome, and outline the shifting perspectives which have both reflected and informedresearch in the field, up to and including the present international differences in diagnosticsystems. These shifting perspectives impose a particular burden when considering data in thisfield, as differences in diagnostic criteria, and the consequent grouping of children intocategories with different symptom clusters, can be expected to contribute substantially todifferent research outcomes, making the sifting of meaningful data difficult. In this regard, wereport data using the diagnostic categories of the particular piece of research under discussion,

but attempt to separate out the systematic effects relatable to symptom clusters in the moderndiagnostic categories. It should be noted that even simple aspects of the disorder, such as its

prevalence rate, are further impacted upon by issues of different types of AD/HD, as well ascomorbidity, age and gender differences, and these variables serve to further cloud ourunderstanding of the electrophysiology of AD/HD.

2. The syndrome of attention-deficit/hyperactivity disorder

AD/HD refers to a variable cluster of hyperactivity, impulsivity, and inattention symptoms,the occurrence of which substantially affects normal cognitive and behavioural functioning ofthe individual. Children and adolescents with AD/HD are at risk for later delinquency

problems (e.g. Satterfield and Weiss ), and some symptoms may persist through the lifespan.Over the last 30 years, substantial changes have occurred in the conceptualization of AD/HD,and unfortunately, these changes impede understanding of the electrophysiological studies ofthe disorder.

2.1. Historical changes in definition

Early accounts described defects in moral control, mischievousness and destructive behaviour(Hoffman and Still ), regarded as resulting from traumatic brain injury (e.g. Goldstein andMeyer ), influenza-related encephalitis (e.g. Hohman and Kennedy ), or various childhoodcentral nervous system (CNS) infections (e.g. Bender, 1942 ). Strauss and Lehtinen (1947) termed it the minimal brain dysfunction (MBD) syndrome. This was followed byhyperkinetic impulse disorder, with symptoms of hyperactivity, short attention span,variability, impulsiveness, irritability, explosive anger fits, and poor school work ( Laufer andDenhoff, 1957 ). Clements and Peters (1962) re-introduced the MBD terminology, broadlydefined to include specific learning deficits, perceptual-motor deficits, general coordinationdeficits, hyperkinesis, impulsivity, emotional lability, short attention span and/ordistractibility, and equivocal neurological signs.

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8/9/2019 QEEG_ADHDreview

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The disorder was first listed in the second edition of the Diagnostic and Statistical Manual ofMental Disorders (DSM-II; APA, 1968 ) as hyperkinetic reaction of childhood, emphasizinginattention, impulsivity and motor activity. DSM-III ( APA, 1980 ) renamed it AttentionDeficit Disorder (ADD), shifting emphasis from m otor activity to attention, with two types:with hyperactivity (ADDh) and without hyperactivity (ADDwo). In the DSM-III-R ( APA,

1987 ), it was renamed Attention Deficit Hyperactivity Disorder (ADHD), and consideredunidimensional in nature, with a single diagnostic checklist. A second category,Undifferentiated Attention Deficit Disorder (U -ADD), featured marked inattention withoutspecific diagnostic criteria. Subsequent studies suggested that the disorder wasmultidimensional ( Bauermeister ; Lahey and Morgan ), characterized by inattention andhyperactivity/impulsivity. In the DSM-IV ( APA, 1994 ), the criteria changed again to reflectthese findings, with 3 main types: Predominantly Inattentive (AD/HDin); PredominantlyHyperactive-Impulsive (AD/HDhyp); and Combined Type (AD/HDcom).

2.2. International perspectives

Hyperkinetic Disorder (HKD) in the 10th revision of the International Classification ofDiseases (ICD-10; WHO, 1993 ) lists similar criteria for a childhood disorder characterized byinattention, impulsivity and hyperactivity. However, ICD-10 requires symptoms from each ofthe 3 behavioural categories. Both systems use the same 18 behavioural items, but the twosystems group the items differently, and have different diagnostic thresholds. Children withan ICD-10 HKD diagnosis are most likely AD/HDcom, but a child may meet minimumcriteria for HKD yet fail the hyperactivity/impulsivity criteria in DSM-IV, resulting in adiagnosis of AD/HDin.

2.3. Prevalence of AD/HD

AD/HD is one of the most common disorders treated by child and adolescent psychiatrists inAmerica, comprising as much as 50% of child psychiatry clinic populations (Cantwell, 1996 ).The DSM-IV ( APA, 1994 ) estimated prevalence at approximately 3 5% of school-agechildren, and studies based on these criteria have found prevalence to range from 3 to 6% (Pelham and Lindgren ). AD/HD is more common in males ( James and Taylor, 1990 ), withrelative rates of up to 9:1 in clinical samples, and 4:1 in epidemiological studies ( APA,1994 ), although community-based studies have found ratios as low as 2:1 ( Szatmari andTaylor ). AD/HD is also a highly comorbid disorder, often co-occurring with conduct disorder(CD) and oppositional defiant disorder (ODD) ( Bird et al., 1994 ), anxiety disorders ( August and Anderson ), major depressive disorder or dysthymia ( Anderson ; Alessi and Woolston )

and learning difficulties (LD) ( August and Silver ).

More-recent studies have also found that between 50 and 70% of children with AD/HD willcontinue to suffer from the disorder as adults (Mannuzza and Bellak ). In adults, the disorder istypified by poor concentration, explosive outbursts, impulsivity, restlessness, as well as non-medical drug use, court referrals, incarceration, and personality disorders ( Hechtman ; Hechtman ; Loney and Wender ).

3. Electroencephalographic studies in AD/HD

EEG provides information about the electrical activity of the brain, but due to the intervening

media, the scalp-recorded signal provides a diffuse picture of that underlying activity. Nevertheless, that record can provide valuable information on the brain, with high temporal

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