Impulsivity among adolescents with ADHD and bronchial asthma
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《美国医学杂志》
1 Department of Pediatrics,Unit, Edith Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University, Israel
2 Department of Epidemiology,Unit, Edith Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University, Israel
Abstract
Objective: To determine the level of impulsivity of adolescents diagnosed as suffering from ADHD, Bronchial Asthma and Healthy adolescents (without any chronic disease). Methods: All participants (n=97) had completed the Barrett (Bis 10) questionnaire. Results: The adolescents suffering from Attention-deficit hyperactivity disorder (ADHD) scored the highest points 51.6; the control group without any chronic disease was second with 25.2 and the asthmatic adolescents were third with 23.4 points for their impulsivity. Conclusion: It should be made clear to the people that the child comes in contact with his impulsive behavior is uncontrollable, and there is no justification for being angry with him nor any punishment. Patience and education is the answer. These adolescent should be under professional care in order to help him define more acceptable ways and means of deportment according to the norms and standards of his society.
Keywords: Impulsivity; ADHD; Bronchial asthma; Chronic reaction
Impulsivity is a neuro-behavioral disturbance that affects the child's relationship with his environment. One of the most difficult problems which occupied teachers, educational advisors and psychologists is the recurrent chronic impulsive reaction of the child and adolescent. It could mean to react quickly without precognition, without restraint and without thinking of the consequences. They lack mechanism of inhibition control.[1]
This type of child does not react logically to the subject of reward and punishment. He does not take into consideration others' wants and needs. In the severe stages, there would be intermittent severe emotional outbursts in the child,[2] there is no way to control these episodes after they begin. People in the proximity of the child tend to mistakenly interpret his behavior as aggression. The child will react to their remarks with frustration, increasing the conflicts with others and damaging his social relationships and position. Finally, not understanding the real cause of such impulsivity most members of the society will sever themselves from associating with this type of individual.
The incidence of ADHD in different countries varies according to interpretation of criteria: impulsivity is included and mandatory in two sub-groups: hyperactivity-impulsivity and combined type. Among US children the prevalence rate ranged from 4% to 12%.[3] Barbaresi et al have found a prevalence of 7.5% among 19 year-old-young people in USA.[4] In Israel, the prevalence of ADHD among pupils learning in an academic high school is 15.2%.[5] In India, Prahbhjot et al pointed out a prevalence of 10-20% in comparison with 1-2% mentioned in more conservative studies.[6] They mentioned that impulsivity is one cardinal symptom out of three included in definition. Srivastava et al marked 1% of ADHD prevalence in the total general population in India, whereas 3-3.5% of children may be diagnosed to suffer from ADHD.[7] Mukhopadhyay et al found a prevalence of 15.5% of ADHD in pediatric clinics in India; they recommend pediatricians to be aware of the profile of this disorder that will serve them for early detection and intervention.[8]
The prognosis of adolescent impulsivity is reserved and depends upon the intensity and severity of the impulsive behavior during preceding years. Fairbanks et al pointed out that adolescents impulsivity is age limited.[9] Fawcett pointed out that adolescent's impulsivity which is bound to comorbidity such as anxiety, panic attacks, agitation and depression increases the suicidal risk tendencies;[10] but if they are diagnosed and treated early with effective medications and watchful support the suicidal risk decreases with time.
The purpose of the study is to compare the level of impulsivity among adolescents of three groups: ADHD patients, asthmatics and a control group of adolescents without any chronic disease.
Materials and Methods
Three groups of adolescents were examined in the present study. The first group had children (aged 14-16 years) studying in the 9th-10th grade, suffering from Attention deficit disorder (ADD), Attention-deficit hyperactivity disorder (ADHD) and learning disabilities (LD) and attending a special education school for adolescents with attention deficit and learning disabilities. The second group comprised of asthmatic adolescents (aged 14-16 years as in the first group) studying in an academic high school, suffering from recurrent wheezing and/or dyspneic attacks and diagnosed as asthmatics by pulmonary specialists. The third group was of children without any chronic disease studying in the 9th grade of the same academic high school (in the neighborhood of the first school). The methods of selection of patients in the first group (ADD, ADHD, LD) were based upon diagnostic reports (according to DSM-4 criteria) made by professionals outside school and confirmed by their teachers and educational advisors. In the second group the selection of asthmatics was based upon diagnostic reports made by pediatricians and respiratory specialists outside school, and in most cases had passed spirometrical tests. All children were chosen arbitrarily from medical record files in the above-mentioned classes at school. The data of all participants (three groups) in the study are shown in table1.
All adolescents had completed the Barrett Impulsivity Scale (Bis-10) questionnaire.[11] Five pupils did not participate in the study as they had language difficulties, being new immigrants. The questionnaire included 48 items with four possibilities of answers: (1) never, (2) sometimes (3) frequently and (4) in general. The following subjects are included in the questionnaire: non-planning activity, cognitive impulsiveness, motor impulsivity, non-consistence, social optimism, lack of motor inhibition, aggressive behavior, autonomy and intended activity. High scores reflected increased impulsivity. The statistical analysis was done in the biostatistical unit at the Wolfson Medical Center and included the use of frequencies, means, chi-square and ANOVA.
Results
There were 30 children in the ADHD group. Their mean age was 15.8 + 0.6. Their ADHD diagnosis was done by specialist in the community and was confirmed by teachers at school. They had learning difficulties at school and they had lower marks in comparison with their classmates. They scored highly for their impulsivity (double in comparison with classmates without any chronic disease). The asthmatic group included 34 children. They had been diagnosed as suffering from chronic persistant asthma and the diagnosis was done by physicians who were specialists in respiratory diseases. Their impulsivity score was half of the ADHD children and similar to the healthy children (without any chronic disease) table2.
Discussion
The results of the present study show that the level of impulsivity (score) of the ADHD adolescents was double than that of normal children. The level of impulsivity of the asthmatic group was lower or similar to the control group.
The impulsivity of ADHD adolescents is influenced by comorbidity such as oppositional defiant (ODD), mood disorders and aggressive reaction. Methyphenidate (Ritalin), which is given to ADHD/LD adolescents, can cause nervousness, sleep disturbances, daytime weariness and headache as side effects;[12] all these factors can increase the level of impulsivity. Pliszka pointed out that coexisting anxiety among ADHD children might attenuate their impulsivity.[13] The Firestone study supports the results of the present study[14]; the author mentioned that the ADHD group had difficulty in self-control, and as a result, were more frustrated. Feingold diet which links impulsive behavior to sugars, salicylate, artificial colors, food additives and artificial flavorings was not confirmed.[15]
In addition, asthmatic children can suffer from a range of comorbidity such as emotional lability, depression and have functional difficulties,[16] lower adaptability, stubbornness[17] and anger.[18] Biederman et al pointed out that ADHD and asthma are different entities and pathologies.[19] The impulsive behavior among asthmatics may be influenced by the level of hypoxia initiated during adyspneic attack or by the medication of arsenal which has psychological and behavioral effects.[20] For example, the beta 2 agonists (salbutamol, terbutaline) can cause restlessness;[21] theophylline can disturb the child's sleep, as well as cause headache and emotional lability.[22] Stein et al confirmed the occurrence of these side effects, but only after the first few time of using the medication.[23] On the other hand, Rappoport, Gil, Weldon et al[24],[25],[26]did not find any changes in the children's behavior after giving them theophylline, nor did it increase their level of impulsivity. Bender et al[16] pointed out the negative psychological side effects of corticosteroids, causing emotional and mood lability.
The findings of the present study are important factors in daily life of the ADHD children or adolescents as they cannot control their impulsive behavior. There is no appropriate place, neither punishment that would help; for instance, when these children interrupt other's conversations, furthermore, allowances and negotiation have to be made about their difficulties to postpone "immediate satisfaction". Environmental stressors may increase their impulsivity, but it should be remembered that their impulsivity is non-voluntary and uncontrollable even more. Dinn et al[27] emphasized that ADHD children and adolescents are indifferent to punishments, and as a result, cannot change their reactive behavior nor decrease the level of their impulsive behavior. Even though "educative" punishments may be used to deal with their impulsive behavior. However, an impulsive violence against anyone should not be allowed to be done. Educators can develop with them a personal contact in order to cope with and decrease their impulsive behavior.
As expected, children suffering from ADHD received the maximal score for their pathological impulsivity (in comparison with asthmatic and healthy adolescents).The practical implication is that impulsiveness of ADHD children and adolescents is a difficult non-voluntary behavior. Impulsiveness breaks down the reciprocal communication between the child and the members of the family, teachers, classmates and friends. As a result of ignorance, these children are often punished at school by their teachers and/or educational advisors for their impulsive behavior. In severe cases of impulsiveness, psychiatrists should recommend the use of medications until the child or adolescent learns to attenuate and control his/her impulsive behavior. It is important to inform parents, family members, teachers and even friends that the child suffers from a neuro-behavioral disability, and that it does not express lack of education. There is no place for punishing these children or adolescents for their impulsive behavior, but they should understand their responsibility to prevent any antisocial behavior.
References
1. Avila C, Cuenca I, Felix V, Parcet MA, Miranda A. Measuring impulsivity in school-age boys and examinig its relationship with ADHD and ODD rating. J Abnorm Child Psychol 2004; 32: 295-304.
2. Hollander E. Impulsivity. J Psychopharmacol 2000; 14(2 Suppl 1): S39-S44.
3. Brown RT, FreemanWS, Perrin JM, Stein MT, Amler RW, Feldman HM, Pierce K, Wolreich ML(Amer. Acad. of Pediatrics). Prevalence and assessment of ADHD in Primary Care Setting. Pediatrics 2001; 107: 1-11.
4. Barbaresi W, Katusic S, Colligan R, Weaver A, Pankratz V, Marzek, Jacobson S. How common is ADHD Toward resolution of the controversy: result from a population-based cohort study. Acta Pediatr Suppl 2004; 93: 55-59.
5. Brook U, Boaz M. ADHD/LD among high school pupils in Holon (Israel). In press. Patient Education and Counselling (PEC), 2004.
6. Prahbhjot M, Pratibha S. Spectrum of ADHD in children Among Referral to Psychology Services. Indian Pediatr 2000; 37: 1256-12560.
7. Srivastava RK, Shinde S. ADHD: An emerging market in India. Express Pharma Pulse 2004; 1021: 1-4.
8. Mukhopadhyay M, Misra S, Mitra T, Niyogi P. ADHD. The Indian J Pediatr 2003; 70: 789-792.
9. Fairbanks LA, Jorgensen MJ, Huff A, Blau K, Hung YY, Mann JJ. Adolescent impulsivity predicts adult dominance attainment vervet monkeys. Am J Primatol 2004; 64: 1-17.
10. Fawcett J. Treating impulsivity and anxiety in the suicidal patient. Ann NY Acad Sci 2001; 932: 94-102.
11. Patton JH, Stanford MS, Barratt ES. Factor structure of the Barratt impulsiveness scale. J Clin Psychol 1995; 51: 768-774.
12. Greenhill LL, Findling RL, Swanson JM. ADHD Study Group. A double-blind, placebo-controlled study of modified-release methylphenidate in children with ADHD. Pediatr 2002;109:E93.
13. Pliszka SR. Patterns of psychiatric comorbidity with ADHD. Child Adolesc Psychiatr Clin N Am 2002; 9: 525-540.
14. Firestone P. An analysis of the hyperactive syndrome: a comparison of hyperactive behavior problem, asthmatic and normal children. J Abnorm Child Psychology 1979; 7: 261-273.
15. Feingold BE. Feingold diet. Aust Fam Physician 1980; 9: 60-61.
16. Bender BG, Lerner JA, Ikle D, Comer C, Szefler S. Psychological change associated with theophylline treatment of asthmatic children: a six month study. Ped Pulmonol 1991; 11: 233-242.
17. Kim SP, Ferrara A, Chess S. Temperament of asthmatic children. J Pediatr 1980; 97: 483-486.
18. Viney LL, Westbrook MT. Pattern of psychological reaction to asthma in children. J Abnorm Child Psychol 1985; 13: 477-484.
19. Biederman J, Milberger S, Faraone SV, Guite J, Warburton R. Association between childhood asthma and ADHD: issues of psychiatric comorbidity and familiality. J Am Acad Child Adolesc Psychiatry 1994; 33: 842-848.
20. Pretorius E. Asthma medication may influence the psychological function of children. Med Hypotheses 2004; 63: 409-413.
21. White BA, Sander N. Asthma from the perspective of the patient. J Allergy Clin Immunol 1999; 109(2 Pt 2): 547-552.
22. Rachelefsky GS, Wo T, Adelson J, Mickey MR, Spector SL et al. Behavior abnormalities and poor school performance due to oral theophylline use. Pediatr 1986; 78: 1133-1138.
23. Stein MA, Lerner CA. Behavioral and cognitive effect of theophylline: a dose-response study. Ann Allerg 1993; 70: 135-140.
24. Rappaport L, Coffman H, Guare R, Fenton T, DeGraw C, Tworog F. Effects of theophylline on behavior and learning in children with asthma. Am J Dis Child 1989; 143: 368-372.
25. Gil CA, Silveira ML, Soares FJ, Sole S, Naspitz C. Study of the effects of treatment with theophylline on the cognitive process and behaviour of children with bronchial asthma. Allergol Immunopathol 1993; 21: 204-206.
26. Weldon DP, McGeady SJ. Theophylline effects on cognition, behavior and learning. Arch Pediatr Adolesc Med 1995; 149: 90-93.
27. Dinn WM, Robbins NC, Harris CL. Adult ADHD: neuropsychological correlated and clinical presentation. Brain Cogn 2001; 46: 114-121.(Brook Uzi, Boaz Mona)
2 Department of Epidemiology,Unit, Edith Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University, Israel
Abstract
Objective: To determine the level of impulsivity of adolescents diagnosed as suffering from ADHD, Bronchial Asthma and Healthy adolescents (without any chronic disease). Methods: All participants (n=97) had completed the Barrett (Bis 10) questionnaire. Results: The adolescents suffering from Attention-deficit hyperactivity disorder (ADHD) scored the highest points 51.6; the control group without any chronic disease was second with 25.2 and the asthmatic adolescents were third with 23.4 points for their impulsivity. Conclusion: It should be made clear to the people that the child comes in contact with his impulsive behavior is uncontrollable, and there is no justification for being angry with him nor any punishment. Patience and education is the answer. These adolescent should be under professional care in order to help him define more acceptable ways and means of deportment according to the norms and standards of his society.
Keywords: Impulsivity; ADHD; Bronchial asthma; Chronic reaction
Impulsivity is a neuro-behavioral disturbance that affects the child's relationship with his environment. One of the most difficult problems which occupied teachers, educational advisors and psychologists is the recurrent chronic impulsive reaction of the child and adolescent. It could mean to react quickly without precognition, without restraint and without thinking of the consequences. They lack mechanism of inhibition control.[1]
This type of child does not react logically to the subject of reward and punishment. He does not take into consideration others' wants and needs. In the severe stages, there would be intermittent severe emotional outbursts in the child,[2] there is no way to control these episodes after they begin. People in the proximity of the child tend to mistakenly interpret his behavior as aggression. The child will react to their remarks with frustration, increasing the conflicts with others and damaging his social relationships and position. Finally, not understanding the real cause of such impulsivity most members of the society will sever themselves from associating with this type of individual.
The incidence of ADHD in different countries varies according to interpretation of criteria: impulsivity is included and mandatory in two sub-groups: hyperactivity-impulsivity and combined type. Among US children the prevalence rate ranged from 4% to 12%.[3] Barbaresi et al have found a prevalence of 7.5% among 19 year-old-young people in USA.[4] In Israel, the prevalence of ADHD among pupils learning in an academic high school is 15.2%.[5] In India, Prahbhjot et al pointed out a prevalence of 10-20% in comparison with 1-2% mentioned in more conservative studies.[6] They mentioned that impulsivity is one cardinal symptom out of three included in definition. Srivastava et al marked 1% of ADHD prevalence in the total general population in India, whereas 3-3.5% of children may be diagnosed to suffer from ADHD.[7] Mukhopadhyay et al found a prevalence of 15.5% of ADHD in pediatric clinics in India; they recommend pediatricians to be aware of the profile of this disorder that will serve them for early detection and intervention.[8]
The prognosis of adolescent impulsivity is reserved and depends upon the intensity and severity of the impulsive behavior during preceding years. Fairbanks et al pointed out that adolescents impulsivity is age limited.[9] Fawcett pointed out that adolescent's impulsivity which is bound to comorbidity such as anxiety, panic attacks, agitation and depression increases the suicidal risk tendencies;[10] but if they are diagnosed and treated early with effective medications and watchful support the suicidal risk decreases with time.
The purpose of the study is to compare the level of impulsivity among adolescents of three groups: ADHD patients, asthmatics and a control group of adolescents without any chronic disease.
Materials and Methods
Three groups of adolescents were examined in the present study. The first group had children (aged 14-16 years) studying in the 9th-10th grade, suffering from Attention deficit disorder (ADD), Attention-deficit hyperactivity disorder (ADHD) and learning disabilities (LD) and attending a special education school for adolescents with attention deficit and learning disabilities. The second group comprised of asthmatic adolescents (aged 14-16 years as in the first group) studying in an academic high school, suffering from recurrent wheezing and/or dyspneic attacks and diagnosed as asthmatics by pulmonary specialists. The third group was of children without any chronic disease studying in the 9th grade of the same academic high school (in the neighborhood of the first school). The methods of selection of patients in the first group (ADD, ADHD, LD) were based upon diagnostic reports (according to DSM-4 criteria) made by professionals outside school and confirmed by their teachers and educational advisors. In the second group the selection of asthmatics was based upon diagnostic reports made by pediatricians and respiratory specialists outside school, and in most cases had passed spirometrical tests. All children were chosen arbitrarily from medical record files in the above-mentioned classes at school. The data of all participants (three groups) in the study are shown in table1.
All adolescents had completed the Barrett Impulsivity Scale (Bis-10) questionnaire.[11] Five pupils did not participate in the study as they had language difficulties, being new immigrants. The questionnaire included 48 items with four possibilities of answers: (1) never, (2) sometimes (3) frequently and (4) in general. The following subjects are included in the questionnaire: non-planning activity, cognitive impulsiveness, motor impulsivity, non-consistence, social optimism, lack of motor inhibition, aggressive behavior, autonomy and intended activity. High scores reflected increased impulsivity. The statistical analysis was done in the biostatistical unit at the Wolfson Medical Center and included the use of frequencies, means, chi-square and ANOVA.
Results
There were 30 children in the ADHD group. Their mean age was 15.8 + 0.6. Their ADHD diagnosis was done by specialist in the community and was confirmed by teachers at school. They had learning difficulties at school and they had lower marks in comparison with their classmates. They scored highly for their impulsivity (double in comparison with classmates without any chronic disease). The asthmatic group included 34 children. They had been diagnosed as suffering from chronic persistant asthma and the diagnosis was done by physicians who were specialists in respiratory diseases. Their impulsivity score was half of the ADHD children and similar to the healthy children (without any chronic disease) table2.
Discussion
The results of the present study show that the level of impulsivity (score) of the ADHD adolescents was double than that of normal children. The level of impulsivity of the asthmatic group was lower or similar to the control group.
The impulsivity of ADHD adolescents is influenced by comorbidity such as oppositional defiant (ODD), mood disorders and aggressive reaction. Methyphenidate (Ritalin), which is given to ADHD/LD adolescents, can cause nervousness, sleep disturbances, daytime weariness and headache as side effects;[12] all these factors can increase the level of impulsivity. Pliszka pointed out that coexisting anxiety among ADHD children might attenuate their impulsivity.[13] The Firestone study supports the results of the present study[14]; the author mentioned that the ADHD group had difficulty in self-control, and as a result, were more frustrated. Feingold diet which links impulsive behavior to sugars, salicylate, artificial colors, food additives and artificial flavorings was not confirmed.[15]
In addition, asthmatic children can suffer from a range of comorbidity such as emotional lability, depression and have functional difficulties,[16] lower adaptability, stubbornness[17] and anger.[18] Biederman et al pointed out that ADHD and asthma are different entities and pathologies.[19] The impulsive behavior among asthmatics may be influenced by the level of hypoxia initiated during adyspneic attack or by the medication of arsenal which has psychological and behavioral effects.[20] For example, the beta 2 agonists (salbutamol, terbutaline) can cause restlessness;[21] theophylline can disturb the child's sleep, as well as cause headache and emotional lability.[22] Stein et al confirmed the occurrence of these side effects, but only after the first few time of using the medication.[23] On the other hand, Rappoport, Gil, Weldon et al[24],[25],[26]did not find any changes in the children's behavior after giving them theophylline, nor did it increase their level of impulsivity. Bender et al[16] pointed out the negative psychological side effects of corticosteroids, causing emotional and mood lability.
The findings of the present study are important factors in daily life of the ADHD children or adolescents as they cannot control their impulsive behavior. There is no appropriate place, neither punishment that would help; for instance, when these children interrupt other's conversations, furthermore, allowances and negotiation have to be made about their difficulties to postpone "immediate satisfaction". Environmental stressors may increase their impulsivity, but it should be remembered that their impulsivity is non-voluntary and uncontrollable even more. Dinn et al[27] emphasized that ADHD children and adolescents are indifferent to punishments, and as a result, cannot change their reactive behavior nor decrease the level of their impulsive behavior. Even though "educative" punishments may be used to deal with their impulsive behavior. However, an impulsive violence against anyone should not be allowed to be done. Educators can develop with them a personal contact in order to cope with and decrease their impulsive behavior.
As expected, children suffering from ADHD received the maximal score for their pathological impulsivity (in comparison with asthmatic and healthy adolescents).The practical implication is that impulsiveness of ADHD children and adolescents is a difficult non-voluntary behavior. Impulsiveness breaks down the reciprocal communication between the child and the members of the family, teachers, classmates and friends. As a result of ignorance, these children are often punished at school by their teachers and/or educational advisors for their impulsive behavior. In severe cases of impulsiveness, psychiatrists should recommend the use of medications until the child or adolescent learns to attenuate and control his/her impulsive behavior. It is important to inform parents, family members, teachers and even friends that the child suffers from a neuro-behavioral disability, and that it does not express lack of education. There is no place for punishing these children or adolescents for their impulsive behavior, but they should understand their responsibility to prevent any antisocial behavior.
References
1. Avila C, Cuenca I, Felix V, Parcet MA, Miranda A. Measuring impulsivity in school-age boys and examinig its relationship with ADHD and ODD rating. J Abnorm Child Psychol 2004; 32: 295-304.
2. Hollander E. Impulsivity. J Psychopharmacol 2000; 14(2 Suppl 1): S39-S44.
3. Brown RT, FreemanWS, Perrin JM, Stein MT, Amler RW, Feldman HM, Pierce K, Wolreich ML(Amer. Acad. of Pediatrics). Prevalence and assessment of ADHD in Primary Care Setting. Pediatrics 2001; 107: 1-11.
4. Barbaresi W, Katusic S, Colligan R, Weaver A, Pankratz V, Marzek, Jacobson S. How common is ADHD Toward resolution of the controversy: result from a population-based cohort study. Acta Pediatr Suppl 2004; 93: 55-59.
5. Brook U, Boaz M. ADHD/LD among high school pupils in Holon (Israel). In press. Patient Education and Counselling (PEC), 2004.
6. Prahbhjot M, Pratibha S. Spectrum of ADHD in children Among Referral to Psychology Services. Indian Pediatr 2000; 37: 1256-12560.
7. Srivastava RK, Shinde S. ADHD: An emerging market in India. Express Pharma Pulse 2004; 1021: 1-4.
8. Mukhopadhyay M, Misra S, Mitra T, Niyogi P. ADHD. The Indian J Pediatr 2003; 70: 789-792.
9. Fairbanks LA, Jorgensen MJ, Huff A, Blau K, Hung YY, Mann JJ. Adolescent impulsivity predicts adult dominance attainment vervet monkeys. Am J Primatol 2004; 64: 1-17.
10. Fawcett J. Treating impulsivity and anxiety in the suicidal patient. Ann NY Acad Sci 2001; 932: 94-102.
11. Patton JH, Stanford MS, Barratt ES. Factor structure of the Barratt impulsiveness scale. J Clin Psychol 1995; 51: 768-774.
12. Greenhill LL, Findling RL, Swanson JM. ADHD Study Group. A double-blind, placebo-controlled study of modified-release methylphenidate in children with ADHD. Pediatr 2002;109:E93.
13. Pliszka SR. Patterns of psychiatric comorbidity with ADHD. Child Adolesc Psychiatr Clin N Am 2002; 9: 525-540.
14. Firestone P. An analysis of the hyperactive syndrome: a comparison of hyperactive behavior problem, asthmatic and normal children. J Abnorm Child Psychology 1979; 7: 261-273.
15. Feingold BE. Feingold diet. Aust Fam Physician 1980; 9: 60-61.
16. Bender BG, Lerner JA, Ikle D, Comer C, Szefler S. Psychological change associated with theophylline treatment of asthmatic children: a six month study. Ped Pulmonol 1991; 11: 233-242.
17. Kim SP, Ferrara A, Chess S. Temperament of asthmatic children. J Pediatr 1980; 97: 483-486.
18. Viney LL, Westbrook MT. Pattern of psychological reaction to asthma in children. J Abnorm Child Psychol 1985; 13: 477-484.
19. Biederman J, Milberger S, Faraone SV, Guite J, Warburton R. Association between childhood asthma and ADHD: issues of psychiatric comorbidity and familiality. J Am Acad Child Adolesc Psychiatry 1994; 33: 842-848.
20. Pretorius E. Asthma medication may influence the psychological function of children. Med Hypotheses 2004; 63: 409-413.
21. White BA, Sander N. Asthma from the perspective of the patient. J Allergy Clin Immunol 1999; 109(2 Pt 2): 547-552.
22. Rachelefsky GS, Wo T, Adelson J, Mickey MR, Spector SL et al. Behavior abnormalities and poor school performance due to oral theophylline use. Pediatr 1986; 78: 1133-1138.
23. Stein MA, Lerner CA. Behavioral and cognitive effect of theophylline: a dose-response study. Ann Allerg 1993; 70: 135-140.
24. Rappaport L, Coffman H, Guare R, Fenton T, DeGraw C, Tworog F. Effects of theophylline on behavior and learning in children with asthma. Am J Dis Child 1989; 143: 368-372.
25. Gil CA, Silveira ML, Soares FJ, Sole S, Naspitz C. Study of the effects of treatment with theophylline on the cognitive process and behaviour of children with bronchial asthma. Allergol Immunopathol 1993; 21: 204-206.
26. Weldon DP, McGeady SJ. Theophylline effects on cognition, behavior and learning. Arch Pediatr Adolesc Med 1995; 149: 90-93.
27. Dinn WM, Robbins NC, Harris CL. Adult ADHD: neuropsychological correlated and clinical presentation. Brain Cogn 2001; 46: 114-121.(Brook Uzi, Boaz Mona)