The Spanish Journal of Psychology Copyright 2009 by The Spanish Journal of Psychology

2009, Vol. 12, No. 2, 707-714 ISSN 1138-7416

Salivary Cortisol Response to a Psychosocial Stressor on

Children Diagnosed with Attention-Deficit/Hyperactivity
Disorder: Differences Between Diagnostic Subtypes

Enrique F. Maldonado, Mª Victoria Trianes, Antonio Cortés,

Encarnación Moreno, and Milagros Escobar
Universidad de Málaga (Spain)

The purpose of the present study was to compare the reactivity of the HPA-axis in children diagnosed
with different subtypes of ADHD against a healthy control group. This study included a total of 66
children: 33 children with ADHD diagnoses (10 with prevalent inattentive symptoms, 9 with prevalent
hyperactive-impulsive symptoms and 14 with the combined subtype) and 33 healthy controls. The Trier
Stress Social Test for Children (TSST-C) was employed as stressor. This test included two main stressors:
first, completing a story initiated by an interviewer, and second, executing a timed cognitive task.
Saliva samples were then obtained at -1, and +1, +10, +20 and +30 minutes with respect to the stress-
inducing task. While the repeated-measures ANOVA showed a statistically significant time effect, the
expected cortisol stress-response was not observed in any group. A difference was observed in the
response from the hyperactive-impulsive group that was also observed in the AUCG comparisons with
the subgroups. The ADHD group with prevalent hyperactivity-impulsive symptoms showed more
significantly reduced cortisol levels than the control group and other experimental subgroup with prevalent
inattentive symptoms.
Keywords: attention-deficit/hyperactivity disorder (ADHD), cortisol, Trier social stress test for children
(TSST-C), children.

El objetivo del presente estudio fue comparar la reactividad del eje HPA de niños diagnosticados con
distintos subtipos de TDAH en comparación con un grupo de control sano. En el estudio fueron incluidos
66 niños: 33 con TDAH (10 con predominio inatento, 9 con predominio hiperactivo-impulsivo, y 14 con
sintomatología combinada) y 33 controles sanos. Como estresor se utilizó el Test de Estrés Social de
Trier versión infantil (TSST-C). Este test incluye dos estresores: primero, tras una fase de preparación,
los niños deben concluir la narración de un cuento previamente iniciada por uno de los dos entrevistadores;
y en segundo lugar, tienen que realizar una tarea cognitiva bajo presión de tiempo ante los entrevistadores.
Las muestras de saliva fueron obtenidas a -1 y a +1, +10, +20 y +30 minutos después de la inducción
de estrés. El ANOVA de medidas repetidas arrojó un efecto tiempo estadísticamente significativo aunque
no se observó la respuesta de cortisol esperada en ninguno de los grupos. Se observó una diferencia
en la respuesta del grupo de niños con subtipo hiperactivo-impulsivo que también se constató cuando
se comparó su AUCG con la del resto de los grupos. El grupo TDAH con predominio hiperactivo-impulsivo
mostró niveles significativamente más bajos de cortisol que el grupo control y el resto de los grupos
experimentales al enfrentarse al TSST-C.
Palabras clave: trastorno por déficit de atención/hiperactividad, cortisol, test de estrés social de Trier
versión infantil, niños.

This research study has been co-funded by Boeringher Ingelheim Pharmaton Company, Via Mulini, 6934 Lugano-Bioggio, Switzerland.
Correspondence concerning this article should be addressed to Enrique F. Maldonado. Department of Psychobiology. University of
Malaga. Campus Teatinos, C.P. 29071 Malaga (Spain). Phone: +34-952133476. Fax: +34-952132621. E-mail: fcomm@uma.es

707
708 MALDONADO, TRIANES, CORTÉS, MORENO, AND ESCOBAR
Attention Deficit Hyperactivity Disorder (ADHD) is a
developmental disorder that accompanies the individual
along his/her lifespan. It is characterized by poor attention
capacity from a developmental point of view (Barkley, 1998,
2006; Barkley, Murphy, & Bauermeister, 1998). In addition,
it is considered a neurobiological disorder with a strong
genetic component (Biederman & Faraone, 2005; Faraone
et al., 2005). The American Psychiatric Association (2000)
establishes the following diagnostic subtypes in the DSM-
IV-TR: Predominantly inattentive type of ADHD (ADHD-
IN) when it only meets the conditions for attention deficit;
predominantly hyperactive/impulsive type of ADHD
(ADHD-HY) when it meets the conditions for hyperactivity
and impulsivity; and finally the combined type (ADHD-
CO) when it meets all conditions for attention deficit,
impulsivity and hyperactivity. However, when none of the
above diagnostic conditions are met, a non-specific type
of ADHD can also be diagnosed (Coghill, Rohde, &
Banaschewski, 2008). From an epidemiological point of
view, the prevalence of ADHD in children is estimated in
6.48% (Polanczyk, Lima, Horta, Biederman, & Rohde, 2007)
and is higher among boys than girls (boy/girl ratio of 2.45:1).
In one of the very few research studies on the prevalence
of this disorder carried out in Spain, Cardo, Servera, and
Llobera (2007) have reported a total prevalence of 4.6%
and a prevalence of 1.06% for the hyperactive subtype,
1.06% for the inattentive subtype and 2.25% for the
combined subtype.
Although there are plenty of research studies on the
endocrinological correlates of this disorder in the literature
review (Lurie & O´Quinn, 1991), the raised interest by
investigators to regulate precise evaluation of the
Hypothalamic-Pituitary-Adrenal axis (HPA) in children
diagnosed with ADHD has been much more recent and
limited. The HPA axis regulates the basal level and the stress
response of the cortisol hormone – which is the main
glucocorticoid in the human body – and it constitutes one
of the two main subsystems which the physiological system
of human stress is composed of (Chrousos & Gold, 1992).
Among the few research studies that have evaluated basal
cortisol levels in children diagnosed with ADHD, either
no statistically significant differences were shown (Schultz,
Halperin, Newcorn, Sharma, & Gabriel, 1997; Valdizán,
2004) or high basal levels of cortisol were rarely observed
(White & Mulligan, 2005). Further research has shown that
the most severe forms of this disorder are characterised by
a well-distinguished hyporeactivity of the HPA axis to mental
or cognitive stressors (Hong, Shin, Lee, Oh, & Noh, 2003;
King, Barkley, & Barret, 1998; Shin & Lee, 2007). In this
respect, it is worth stressing that the presence of a comorbid
aggressive symptomatology, - including that associated to
diagnoses of conduct disorder and/or oppositional defiant
disorder (Kariyawasam, Zaw, & Handley, 2002; Snoek,
van Goozen, Matthys, Buitelaar, & van Engeland, 2004;
Yang, Shin, Noh, & Stein, 2007) – as well as impulsive
hyperactive symptomatology (Blomqvist et al., 2007; Hong
et al., 2003; Kaneko, Hoshino, Hashimoto, Okano, &
Kumashiro, 1993; Shin & Lee, 2007; Yang et al., 2007)
have constituted two independent factors to be associated
to these alterations in the basal-circadian activity and/or
reduced reactivity of the HPA axis. However, it has recently
been observed that the inattentive subtype with severe
symptomatology – six or more inattentive symptoms – can
also present hyporeactivity in the cortisol response to a
standard laboratory psychosocial stressor (Randazzo,
Dockray, & Susman, 2008). Overall, these results may be
interpreted from Raine’s theory (1996), which views the
cause of ADHD to stem from lack of fear and lack of
physiological arousal experienced by these children when
facing a challenge. Likewise, these results could also be
interpreted from the viewpoint of those research studies
that suggest that a low level of physiological arousal could
drive the child to search for sensations that could eventually
trigger a decrease in the hormonal response to stress after
repeated activation (Alink et al., 2008).
In line with our literature review, there has not yet been
any child research with a control group to compare
simultaneously the reactivity of the HPA axis to a laboratory
psychosocial stressor like the TSST-C among the three
ADHD diagnostic subtypes. In this sense, most reviewed
studies have included patients on treatment and/or diagnosed
with an only diagnostic subtype according to the DSM-IV-
TR criteria. Due to this gap in the literature, we suggest
the following hypothesis regarding the purpose of this study:
according to the literature review, when comparing the
cortisol response of the three ADHD diagnostic subtypes
without treatment against a control group only experimental
subjects belonging to the ADHD-HY group will show less
cortisol reactivity in relation to the rest of the groups
(experimental and control).
Materials and Method
Participants
This research study has selected a communitarian sample
of 66 boys and girls from seven nurseries and Elementary
Education schools in the metropolitan town of Fuengirola
in Málaga, Spain. This selection was based on the initial
evaluation of an original sample of 401 boys and girls
ranging in age from 5 to 8 years old. In order to diagnose
Attention Deficit Hyperactive Disorder (ADHD) and its
various subtypes according to the DSM-IV-TR criteria, a
multi-dimensional and multi-informant procedure (Cortés,
2006) was applied: firstly, the scores from the Teacher Report
Form (Achenbach & Rescorla, 2000, 2001) were filled and
completed in by each child’s class tutor, and secondly the
diagnostic criteria were compared to during the parents’
interview, in which an adapted version of the review of
 SALIVARY CORTISOL RESPONSE ON ADHD SUBTYPES
children disorders by Barkley (1998) was used. Following
this procedure, 15 boys and 18 girls diagnosed with ADHD
were selected for the experimental group, from which 10
children suffered from the prevalent inattentive ADHD type,
9 children from the prevalent ADHD hyperactive-impulsive
type and 14 children from a combination of both ADHD
symptomatology. The control group was composed of 33
healthy children (19 boys and 14 girls) who did not report
any ADHD symptomatology and were randomly chosen
among the participants in the study (see Table 1). Given
that psycho-stimulant treatments are known to alter basal
levels together with the cortisol response of this type of
samples (Lurie & O´Quinn, 1991), according to the
information provided by their families none of the children
included in the ADHD group were on any medical treatment.
A further inclusive criterion was for ADHD participants
not to have history of neither conduct nor oppositional
defiant disorder. These disorders have been associated to
alterations in basal levels and in the HPA axis reactivity to
stress (Alink et al., 2008; Kariyawasan et al., 2002) and
show a high comorbidity with ADHD (Coghill et al., 2008).
The parents or legal guardians of every child participating
in this research study had signed an informed consent form
prior to data collection. The study protocol counted on the
approval from the Department of Education in the Regional
Government of Malaga, which is dependant on the Ministry
of Education in the Andalusian Regional Government (Junta
de Andalucía), as well as from the relevant boards of
directors and school boards. The epidemiological results
of this project are shown in Cortés (2009).
Adapted Trier Social Stress Test Version for
Children (TSST-C)
An adapted children’s version of the Trier Social Stress
Test (TSST-C) was used in this research as a standard
laboratory psychosocial stressor (Kirschbaum, Pirke, &
Hellhammer, 1993). The TSST-C incorporates both a
psychosocial stressor and a cognitive stressor in the format
of an interview applicable to children. The test is divided
into three subsequent steps: anticipation, public speaking,
and mental stress. After 30 minutes of rest period before
the start of the interview, the first step involves inviting
the child to enter a room where two research assistants are
awaiting him/her, introducing themselves as interviewers
responsible for assessing his/her performance. The researcher
kindly explains instructions to the child. The child is
instructed that he or she has four minutes to improvise a
story from a starting paragraph read by the researcher. After
this anticipation period, the second step involves asking
the child to stand in front of a microphone and a video-
camera to continue the narration of the story that the
researcher has begun and that the child needs to finish with
his or her own words. This step is required to last for at
least five minutes while it is being recorded. Should the
709
child interrupt his or her narration, he or she is encouraged
by the researcher to continue by answering a script of
predetermined questions. Once this step has concluded,
the third step involves asking the child to sit through a
cognitively stressor for yet another five minutes. Due to
the complexity of the original task of numeric extraction
(thought for this step and suggested for 7-10 years old),
which difficulty has been corroborated by teachers from
some of the participating schools, this task was substituted
by the Matching Familiar Figures Test-20 (MFFT-20) under
time restraint. After the MFFT-20, each child’s performance
was positively reinforced by telling him or her that he or
she did very well on the test. All tests needed to be
performed in the morning (due to school schedule conflicts)
where data were collected between 10:30 AM and 12:30
PM in all cases in order to minimize the interference of
the circadian rhythm of cortisol release. Saliva samples
were taken one minute before the child entered the interview
room (pretest values of free cortisol in saliva) and then
gradually one (+1), ten (+10), twenty (+20) and thirty (+30)
minutes after having concluded the stress-induction situation
in the waiting room.
Determination of Free Cortisol in Saliva
Salivette® saliva collection kits were used to obtain
saliva samples in children. Immediately after the samples
were obtained, they were frozen at -20ºC for a month before
being tested and assayed. In preparation for their assay,
the samples were centrifuged at 3.500 rpm for 10 minutes
in order to get a clear and watery supernatant of low
viscosity. In order to detect free cortisol, a fluorescence
immunoassay (DELFIA) was employed. The DELFIA is
described in detail in Dressendörfer, Kirschbaum, Rohde,
Stahl, and Strasburger (1992). The lower limit of detection
of this analysis is 0.43nmol/l. The inter and intra-assay
coefficient of variation was below 10% along the range
that was expected from the cortisol levels. The analyses
were conducted in the laboratory of the Department of
Biological Psychology in Dresden Technical University
(Germany).
Procedure
Before data collection, the parents of the selected children
were invited to attend an information session where they
were given a general explanation (both spoken and written)
on the research objectives and their participation in the
project. In order to reduce the anxiety caused by the
anticipation of the test, children were told by their parents
that they were going to participate in a school contest.
Furthermore, children were not told in advance on which
date they were going to take the test or they knew the details
involved in the study (e.g., interviewers, video-recording
and/or type of test). The day of the test, the TSST-C was
710 MALDONADO, TRIANES, CORTÉS, MORENO, AND ESCOBAR
individually administered to each participant from 10:30
AM to 12:30 PM. Each school used three different rooms:
a waiting room, an interview room and a third room to
collect the saliva samples after the stressful situation took
place.
Statistical Analysis
To begin with, the normality of the values of cortisol
data was assessed in each measure by using the
Kolmogorov-Smirnov test. The area under the curve with
respect to ground (AUCG) and with respect to increase
(AUCI) were estimated using the formula suggested by
Pruessner, Kirschbaum, Meinlschmid, and Hellhammer
(2003). AUCG and AUCI are two different approaches to
estimate the area under the curve of the cortisol response
to the TSST. They were suggested by Pruessner et al. (2003)
and widely employed in the literature of the field. While
the formula used for the estimation of the AUCG is especially
sensitive to the total response when comparing the response
from the two groups, the formula used for the estimation
of the AUCI is especially sensitive to increase changes. In
order to compare the distribution of the gender variable in
the different experimental groups, a chi-square test was
conducted (c2). In order to compare the distribution of the
age variable and the time of the test variable among the
different experimental groups, a T-Student test was conducted
together with an analysis of variance (ANOVA) of one factor.
In order to compare the cortisol values among the baseline
measurement, the AUCG, and the AUCI, the T-Student test
was also used. In order to conduct the statistical analysis
of the endocrine response of cortisol to a psychosocial
stressor, two repeated measures ANOVAs were conducted
on two factors: a time factor with five repeated measures
(free cortisol in saliva) and the diagnostic group independent
factor (control vs. ADHD and control vs. ADHD subtypes).
Time of the test, gender and age were used as covariables.
A value of p < .05 was adopted as the indicator of statistical
significance in the results. All the results shown are mean
± SEM (except otherwise indicated). All the statistical
analyses were performed with the SPSS 12 statistical
program.
Table 1
Age, gender and time of the test among the different experimental groups
Control ADHD
Group Group
N 33 33
6,210,13 6,450,15
Age (Range)
(5-8) (5-8)
Ratio Boy/girl 19/14 15/18
Time of the test 11:280:005 11:340:05
Results
In a preliminary data analysis, the cortisol values in
saliva were observed to be distributed normally (therefore
non-transformed direct values obtained are presented) and
the gender variable was not homogeneously distributed in
each of the experimental groups (h2 = 11,028 p = 0,012)
and therefore it was included as a covariable in a further
analysis to control its effect (see Table 1). No statistically
significant differences were observed in the distribution of
the age and time of the test variables F(3,65) = 2,665, p =
0,056 and F(3,65) = 1,379, p = 0,257, respectively.
With the purpose of comparing the HPA axis response
to TSST-C of children diagnosed with ADHD with that of
controls, a first repeated measures ANOVA was conducted.
While this ANOVA threw statistically significant differences
in the time intra-subject factor (F(4,256) = 6,129; p = 0,005,
h2 = 0,087), the typical pattern of cortisol response–
powerful and with several minutes of latency - to this
laboratory psychosocial stressor was not observed (see
Fig. 1). Paired contrasts of data extracted from the total
sample only revealed decreased differences between the
+20 and +30 minute measurements in the total sample. A
statistically significant difference was also observed in
the inter-subject group factor (control group vs. ADHD;
F(1,64) = 7,497; p = 0,008, h2 = 0,105) and the
experimental group showed more reduced cortisol levels
in comparison with the control group. In relation to the
latter result, a statistically significant difference in both
the pre-test cortisol value (t = 2,050, p = 0,045, d = 0.502)
and the AUCG value between the control group and the
ADHD group (t = 2,759, p = 0,008, d = 0,679) was also
observed (see Table 2), unlike in the AUCI parameter (t =
1,373, p = 0,175). Therefore, the ADHD group showed
more reduced cortisol levels than the control group during
the entire test (see Figure 1). No statistically significant
interaction was observed between the time and group factors
(F(4,256) = 0,946; p = 0,438). In this first ANOVA, the
following covariables were included: gender, age and time
of the test. As none of these covariables showed a
statistically significant effect, they were excluded from
the final statistical analyses.
ADHD-IN ADHD-HY ADHD-CO Total
Subgroup Subgroup Subgroup Sample
10 9 14 66
6,600,22 5,770,36 6,780,18 6,330,14
(6-8) (5-8) (6-8) (5-8)
6/4 7/2 2/12 34/32
11:300:09 11:210:08 11:460:08 11:310:03
 SALIVARY CORTISOL RESPONSE ON ADHD SUBTYPES
Table 2
Pre-test levels, AUCG and AUCI of the cortisol response to the TSST-C from the various experimental groups
Control ADHD
Group Group
no=33 no=33
Pre-test Cortisol Levels 5,910,70 3,990,62
Cortisol AUCG 22,351,81 15,071,91
Cortisol AUCI 3,751,33 1,800,49
Figure 1. Average levels of cortisol (±SEM) in the control groups
(l; no=33), ADHD (n; no=33), ADHD-IN (s; no=10), ADHD-
HY (t; no=9) and ADHD-CO (¨; no=14).
With the purpose of dealing in depth with the analysis
of the differences found between the control group and
the ADHD group after the first analysis, a second repeated
measures ANOVA was carried out to compare the response
of the control group with that from the three diagnostic
subtypes of ADHD mentioned in this research. This ANOVA
threw statistically significant differences in both the time
intra-subjects factor (F(4,248) = 3,255; p = 0,013, h2 =
0,050) and the group inter-subjects factor (F(3,62) = 3,174;
p = 0,030, h2 = 0,133). The post-hoc contrasts indicated a
statistically significant difference between the control group
and the group of children diagnosed with the ADHD-HY
subtype (see Figure 1). The latter showed more reduce levels
than the control group and the rest of the groups of
diagnostic subtypes during the entire test. No statistically
significant interaction was observed between the time and
group factors (F(4,248) = 0,606; p = 0,837). While there
was observed statistically significant differences in the AUCG
(F(3,65) = 3,201; p = 0,029, h2=0,134), there were no
statistically significant differences in the pre-test cortisol
levels (F(3,65) = 1,710; p = 0,174) or in the AUCI (F(3,65)
= 0,677; p = 0,576) between the control group and the
ADHD-HY subtype, as shown in Table 2. The covariables
– gender, age and time of the test – did not show significant
effects in this case either, and were therefore excluded from
the final analyses.
711
ADHD-IN ADHD-HY ADHD-CO
Subgroup Subgroup Subgroup
no=10 no=9 no=14
3,810,77 3,080,60 4,071,31
16,653,54 10,761,98 16,703,50
2,370,89 1,280,79 1,740,85
Discussion
This research study has been the first with a control
group to compare simultaneously the cortisol response to
the TSST-C among a group of non-treated children diagnosed
with the three diagnostic subtypes of ADHD included in
the DSM-IV-TR and without the comorbide presence of
neither a conduct nor an oppositional defiant disorder. The
result that first captured our attention was the absence of a
response to a standard psychosocial stressor from all
experimental groups as well as the control group. Secondly,
it was observed that the ADHD group, in particular the
ADHD-HY subtype showed significantly more reduced
cortisol levels than the control group and the rest of the
experimental participants during the entire stressful situation.
With regards to our first finding, i.e. the absence of a
significant response from the free cortisol levels with a
latency of about 15-20 minutes in relation to the starting
moment of the stressful period (Buske-Kirschbaum et al.,
1997; Buske-Kirschbaum et al., 2003) could be interpreted
as a result of the so-called “stress hyporesponsiveness period”
of the HPA axis that some researchers have observed among
the same childhood ages as a response to similar situations
of laboratory stress (Gunnar & Donzella, 2002; Gunnar &
Fisher, 2006). According to these researchers, this period
goes from the first year of life (Gunnar & Donzella, 2002)
up to childhood and approximately the beginning of
adolescence (Gunnar & Fisher, 2006; Gunnar & Quevedo,
2007). An increase in the negative regulation of the HPA
axis and a reduction in the adrenal cortex sensitivity to the
ACTH have been suggested as the main causes for a
reduction in the response of this hormonal system (Lashansky
et al., 1991). In relation to this, and as far as we are
concerned, this is the first research study to apply the TSST-
C in a sample with an average age of six without observing
any response from the HPA axis. However, this result must
be taken carefully as there is a possibility that the resting
period that was included in the original design – together
with the fact that data was collected in the morning – might
have altered or hindered the observation of a weak response
from the HPA axis among participants.
Our second discovery seems to be of particular relevance
given that it was obtained from an experimental sample
712 MALDONADO, TRIANES, CORTÉS, MORENO, AND ESCOBAR
composed of non-treated children diagnosed with ADHD
– according to the international criteria to diagnose the
three main subtypes of this disorder mentioned in the DSM-
IV-TR –, ruling out the possible confusion that the presence
of further comorbide psychopathological disorders of an
externalising type would have represented. While the formal
hypothesis previously introduced as an objective cannot
be answered given the absence of reactivity among all
participant groups, our results do allow us to state that
the ADHD group – in particular children diagnosed with
ADHD-HY – presented a significantly reduced cortisol
response during the course of a stressful situation (such
as the one triggered by the TSST-C) in comparison with
children who do not suffer from this disorder or children
diagnosed with a different ADHD subtype. These reduced
cortisol levels were a constant during the entire test albeit
the variables gender, age and time of the test being
statistically controlled. In relation to the latter, it is worth
stressing the differences observed between the control group
and the ADHD-HY group with regards to the AUCG but
not to the AUCI. According to Pruessner et al. (2003), the
AUCG is a particularly close approximation to the level
of total production of the hormone under study as the AUCI
parameter is to increases during the observation time. To
sum up, the above results support and cover the isolated
observations made by some researchers of this ADHD-
HY subtype (Blomqvist et al., 2007; Hong et al., 2003;
Kaneko et al., 1993; Shin & Lee, 2007; Yang et al., 2007).
Such results can be compatible with a variety of hypotheses
that explain the origin of these differences (Alink et al.,
2008).
However, this research study presents some limitations
that prevent the results from being totally generalised. In
the first place, the limited number of children composing
each experimental group, and in particular, each ADHD
subgroup. Nevertheless, it is important to stress again that
none of the children involved in this research had ever taken
typical medication for their disorder (psycho-stimulant
medicines), and that participants with a comorbide diagnosis
of either conduct disorder or oppositional defiant disorder
were excluded from the research, which made it very
difficult to make up the sample. Moreover, the effect size
of all significant contrasts obtained was either medium or
high according to the criterion established by Cohen (1988).
In the second place, the administration of the TSST-C in
the morning could have also been affected by the well-
known diurnal rhythm of the cortisol levels, with a peak
30 min. after waking up, moderated levels for the first hours
in the morning and eventually more reduced values during
the day until reaching the nadir in the first hours of sleep.
However, as it has been observed, the time of the test was
statistically controlled in all contrasts and tests were taken
in the short period of two hours in the morning, so that
this limitation could only affect the detection of slight
changes in the response. In the third place, the fact of taking
students from the class to the waiting room could have also
altered or hindered the observation of the cortisol response
to the TSST-C, as it prompted anticipated responses among
children. Finally, the gender variable had to be controlled
statistically due to the non-homogeneous distribution of
boys and girls in the experimental groups.
To conclude, this research supports the existence of a
reduced response of the HPA axis in the ADHD to an
experimental stressful situation. This reduced response is
especially remarkable in the subgroup of children diagnosed
with ADHD-HY, i.e. children with predominance of
impulsivity and hyperactivity symptoms. This result suggests
that further research on the cortisol awakening response as
well as on the diurnal rhythm of cortisol release from
children diagnosed with ADHD could bear a heuristic
interest. However, and in line with discoveries made by
expert researchers of this field (Gunnar & Fisher, 2006),
there is evidence to suggest that our modified version of
the TSST-C (as well as some other similar laboratory
paradigms) might not be the optimal way to study the
reactivity of the HPA axis response on boys and girls in
such a low age rank (as there was in our research). In
relation to this, it seems necessary to keep searching for
situations with ecological validity to allow us to analyse
the HPA axis response to psychological stress in children
in a non-invasive way.
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Received October 31, 2008
Revision received January 2, 2009
Accepted January 19, 2009