The feasibility of a strategy for the remote recruitment, consenting and assessment of recent referrals: a protocol for phase 1 of the On-Line Parent Training for the Initial Management of ADHD referrals (OPTIMA)

BACKGROUND

In the UK, children with high levels of hyperactivity, impulsivity and inattention referred to clinical services with possible attention-deficit/hyperactivity disorder (ADHD) often wait a long time for specialist diagnostic assessment. Parent training (PT) has the potential to support parents during this difficult period, especially regarding the management of challenging and disruptive behaviours that often accompany ADHD. However, traditional face-to-face PT is costly and difficult to organise in a timely way. We have created a low-cost, easily accessible PT programme delivered via a phone app, Structured E-Parenting Support (STEPS), to address this problem. The overall OPTIMA programme will evaluate the efficacy and cost-effectiveness of STEPS as a way of helping parents manage their children behaviour while on the waitlist. To ensure the timely and efficient evaluation of STEPS in OPTIMA, we have worked with children's health services to implement a remote strategy for recruitment, screening and assessment of recently referred families. Part of this strategy is incorporated into routine clinical practice and part is OPTIMA specific. Here, we present the protocol for Phase 1 of OPTIMA-a study of the feasibility of this remote strategy, as a basis for a large-scale STEPS randomised controlled trial (RCT).

METHODS

This is a single arm observational feasibility study. Participants will be parents of up to 100 children aged 5-11 years with high levels of hyperactivity/impulsivity, inattention and challenging behaviour who are waiting for assessment in one of five UK child and adolescent mental health or behavioural services. Recruitment, consenting and data collection will occur remotely. The primary outcome will be the rate at which the families, who meet inclusion criteria, agree in principle to take part in a full STEPS RCT. Secondary outcomes include acceptability of remote consenting and online data collection procedures; the feasibility of collecting teacher data remotely within the required timeframe, and technical difficulties with completing online questionnaires. All parents in the study will receive access to STEPS.

DISCUSSION

Establishing the feasibility of our remote recruitment, consenting and assessment strategy is a pre-requisite for the full trial of OPTIMA. It can also provide a model for future trials conducted remotely.

Severe deprivation in early childhood leads to permanent growth stunting: Longitudinal analysis of height trajectories from childhood-to-adulthood

BACKGROUND

Childhood institutional deprivation is associated with growth stunting in childhood but long-term effects in adulthood remain uncertain.

OBJECTIVE

To examine the impact of global institutional deprivation experienced in early childhood on subsequent growth with a special focus on final adult height and puberty timing.

PARTICIPANTS & SETTING

The study was originally set in the UK, though some adoptive families lived abroad by the time of the adult follow up. 165 individuals adopted by UK families before 43 months of age from Romanian orphanages after the fall of the Ceaușescu regime in the early 1990's were compared to 51 non-deprived UK adoptees, adopted before the age of 6 months.

METHODS

The English and Romanian Adoptees (ERA) study is a 20-year longitudinal natural experiment on the effects of institutional deprivation on development. Key growth milestones were extracted from growth curve modelling of height data collected at ages 4, 6, 11, 15 and 23 years using a Bayesian approach to fit the JPA2 model.

RESULTS

Deprivation effects on height were present at the take-off point of accelerating adolescent growth and persisted into adulthood - the largest effects being for individuals who experienced over six months of deprivation. Deprivation was associated with earlier take-off and achievement of peak height velocity of adolescent growth acceleration - an effect driven largely by females' data and correlated with parent ratings of pubertal development.

CONCLUSIONS

Early deprivation appears to reset tempo of growth early in development leading to permanent growth stunting in adulthood and accelerated onset of puberty, specifically in females.

What Is the Health and Well-Being Burden for Parents Living With a Child With ADHD in the United Kingdom?

Objective: To explore the burden associated with childhood ADHD in a large observational study. Methods: We recruited familes with at least one child (6-18 years) with ADHD via 15 NHS trusts in the UK, and collected data from all family members. We made careful adjustments to ensure a like-for-like comparison with two different control groups, and explored the impact of controlling for a positive parental/carer ADHD screen, employment, and relationship status. Results: We found significant negative impacts of childhood ADHD on parents'/carers' hours and quality of sleep, satisfaction with leisure time, and health-related quality of life (measured by the EuroQol-5D [EQ-5D]). We found a decrement in life satisfaction, mental well-being (as measured by the Short-Warwick Edinburgh Mental Well-Being Scale [S-WEMWBS]), and satisfaction with intimate relationships, but this was not always robust across the different control groups. We did not find any decrement in satisfaction with health, self-reported health status, or satisfaction with income. Conclusion: The study quantifies the impact on the health and well-being of parents living with a child with ADHD using a survey of families attending ADHD clinics in the United Kingdom.

The Differential Effect of Anxiety and ADHD Symptoms on Inhibitory Control and Sustained Attention for Threat Stimuli: A Go/No-Go Eye-Movement Study

Objective: This study examined the synergistic effects of ADHD and anxiety symptoms on attention and inhibitory control depending on the emotional content of the stimuli. Method: Fifty-four typically developing individuals (27 children/adolescents and 27 adults) completed an eye-movement based emotional Go/No-Go task, using centrally presented (happy, angry) faces and neutral/symbolic stimuli. Sustained attention was measured through saccade latencies and saccadic omission errors (Go trials), and inhibitory control through saccadic commission errors (No-Go trials). ADHD and anxiety were assessed dimensionally. Results: Elevated ADHD symptoms were associated with more commission errors and slower saccade latencies for angry (vs. happy) faces. In contrast, angry faces were linked to faster saccade onsets when anxiety symptoms were high, and this effect prevailed when both anxiety and ADHD symptoms were high. Conclusion: Social threat impacted performance in individuals with sub-clinical anxiety and ADHD differently. The effects of anxiety on threat processing prevailed when both symptoms were high.

The Limits of Motivational Influence in ADHD: No Evidence for an Altered Reaction to Negative Reinforcement

Functional magnetic resonance imaging studies have reported a diminished response in the brain’s reward circuits to contingent cues predicting future monetary gain in adolescents with attention-deficit/hyperactivity disorder (ADHD). The situation with regard to monetary loss is less clear, despite recognition that both positive and negative consequences impact ADHD behaviour. Here, we employ a new Escape Monetary Loss Incentive task in an MRI scanner, which allows the differentiation of contingency and valence effects during loss avoidance, to examine ADHD-related alterations in monetary loss processing. There was no evidence of atypical processing of contingent or non-contingent monetary loss cues in ADHD — either in terms of ratings of emotional and motivational significance or brain responses. This suggests that the ability to process contingencies between performance and negative outcomes is intact in ADHD and that individuals with ADHD are no more (or less) sensitive to negative outcomes than controls. This latter finding stands in stark contrast to recent evidence from a similar task of atypical emotion network recruitment (e.g. amygdala) in ADHD individuals to cues predicting another negative event, the imposition of delay, suggesting marked specificity in the way they respond to negative events.

Editorial: 'No pain - No gain' - Towards the inclusion of mental health costs in balanced "lockdown" decision-making during health pandemics

Since the beginning of the COVID-19 pandemic in early 2020, many governments have implemented national or regional lockdowns to slow the spread of infection. The widely anticipated negative impact these interventions would have on families, including on their mental health, were not included in decision models. The purpose of this editorial is, therefore, to stimulate debate by considering some of the barriers that have stopped governments setting the benefits of lockdown against, in particular, mental health costs during this process and so to make possible a more balanced approach going forward. First, evidence that lockdown causes mental health problems needs to be stronger. Natural experimental studies will play an essential role in providing such evidence. Second, innovative health economic approaches that allow the costs and benefits of lockdown to be compared directly are required. Third, we need to develop public health information strategies that allow more nuanced and complex messages that balance lockdown's costs and benefits to be communicated. These steps should be accompanied by a major public consultation/engagement campaign aimed at strengthening the publics' understanding of science and exploring beliefs about how to strike the appropriate balance between costs and benefits in public health intervention decisions.

Supporting Parents & Kids Through Lockdown Experiences (SPARKLE): A digital parenting support app implemented in an ongoing general population cohort study during the COVID-19 pandemic: A structured summary of a study protocol for a randomised controlled trial

Objectives

The COVID-19 related lockdowns and distancing measures have presented families with unprecedented challenges. A UK-wide cohort study tracking changes in families’ mental health since early lockdown (Co-SPACE) found a significant rise in primary school-aged children’s behaviour problems and associated family-related stress. Three-quarters of parents in Co-SPACE also reported wanting extra support. In SPARKLE, we will examine whether providing Co-SPACE families with a smartphone application delivering information and parenting support, Parent Positive, can reverse the negative effects of the pandemic on children and parents. The efficacy on child and parent outcomes and cost-effectiveness of Parent Positive will be examined. We will also test whether the effects are moderated by pre-existing levels of child conduct problems and usage of Parent Positive. Exploratory analyses will examine whether other baseline characteristics or lockdown circumstances moderate the effects of Parent Positive.

Trial design

SPARKLE is a two-arm superiority parallel group randomised controlled trial embedded in an existing large UK-wide self-selected community cohort – Co-SPACE. Those who consent to SPARKLE will be randomised 1:1 to either Parent Positive or Follow-up As Usual (FAU).

Participants

Co-SPACE (a UK-wide longitudinal cohort study) parents aged ≥18 who have children aged 4-10 years will be eligible for SPARKLE.

Intervention and comparator

Parent Positive: is a digital public health intervention that can be delivered rapidly at scale to support parents in managing their children’s behaviour to reduce conduct problems and levels of family conflict, which were exacerbated during the first lockdown, and which may increase further in future months as families need to cope with continuous uncertainty and further disruption to their daily lives. Co-designed with parents and based on decades of parenting research, Parent Positive consists of three elements: (i) Parenting Boosters: where advice, delivered in the form of narrated animations, videos, graphics and text is provided to help parents with eight common parenting challenges; (ii) Parenting Exchange: a facilitated parent-to-parent communication and peer support platform and; (iii) Parent Resources: giving access to carefully selected high-quality, evidence-based online parenting resources.

Follow-up as Usual: FAU was selected as a comparator because the public health nature meant that an active comparator was not appropriate due to the pragmatic, rapid implementation of the trial. Individuals randomised to FAU will receive no intervention for the first two months while the data for baseline (T1), T2 and T3 are collected. They will then be given full access to the app until 30th November 2021.

Main outcomes

Outcome measures will be collected remotely through Qualtrics according to the Co-SPACE schedule at baseline (T1), which will be the Co-SPACE survey data obtained immediately prior to randomisation, and then at one month (T2) and two months (T3) post-randomisation. Measures will be collected to assess group differences in child and parent outcomes, costs and service utilisation, and adverse events. Usage of Parent Positive will also be tracked. The primary outcome is parent-reported child conduct problems at one-month post-randomisation measured using the Strengths and Difficulties Questionnaire conduct problems subscale.

Randomisation

Enrolled participants will be allocated to Parent Positive or FAU at the ratio of 1:1 by simple randomisation using the Randomizer function within the Qualtrics programme. Neither blocking nor stratification will be used.

Blinding (masking)

It is not possible to blind parents enrolled in the study and Qualtrics will automatically inform parents of their group allocation. Blinded members of the research team and the senior statistician will not be given access to the Qualtrics system or the data in order to remain blinded until after the analysis is complete. We do not anticipate any serious harms associated with taking part in the intervention, therefore there will be no need to unblind any blinded staff during the study. The junior statistician will be unblinded throughout.

Numbers to be randomised (sample size)

A total of 616 will be recruited into the trial with 308 consenting parents randomised to each treatment arm.

Trial status

V1.0; 15.03.2021. Not yet recruiting. Anticipated start date: 1^st April 2021. Anticipated end date for recruitment: 31^st July 2021.

Trial registration

Clinicaltrial.gov: NCT04786080. The trial was prospectively registered on 8 March 2021.

Full protocol

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05226-4.

"School of hard knocks" - what can mental health researchers learn from the COVID-19 crisis?

Since the COVID-19 pandemic took hold in the first quarter of 2020, children and their families across the world have experienced extraordinary changes to the way they live their lives - creating enormous practical and psychological challenges for them at many levels. While some of these effects are directly linked to COVID-related morbidity and mortality, many are indirect - due rather to governmental public health responses designed to slow the spread of infection and minimise the numbers of deaths. These have often involved aggressive programmes of social distancing and quarantine, including extended periods of national social and economic lockdown, unprecedented in the modern age. Debates about the appropriateness of these measures have often referenced their potentially negative impact on people's mental health and well-being - impacts which both opponents and advocates appear to accept as being inevitable.

Sex Differences in the Meaning of Parent and Teacher Ratings of ADHD Behaviors: An Observational Study

Objective: To test explanations for the underrecognition of female ADHD by examining differences in adult ratings of boys and girls matched for levels of directly observed ADHD behaviors. Method: In a secondary analysis of a population-based sample, 3- to 4-year-olds (n = 153, 79 male) and 8- to 9-year-olds (n = 144, 75 male) were grouped according to levels of directly observed ADHD behaviors (low/moderate/high). Groups were then compared with parent/teacher ADHD ratings. Results: There were no sex differences in levels of directly observed ADHD behaviors within groups. For preschoolers, parents' ratings of males, but not females, significantly increased across groups-mirroring levels of observed behaviors. For older children, both parent and teacher mean ratings were significantly higher for males than females across groups. Conclusion: Identified differences in adult ratings of males and females matched for directly observed behaviors may contribute to understanding the substantial ADHD underrecognition in females.

Shared genetic background between children and adults with attention deficit/hyperactivity disorder

Attention deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by age-inappropriate symptoms of inattention, impulsivity, and hyperactivity that persist into adulthood in the majority of the diagnosed children. Despite several risk factors during childhood predicting the persistence of ADHD symptoms into adulthood, the genetic architecture underlying the trajectory of ADHD over time is still unclear. We set out to study the contribution of common genetic variants to the risk for ADHD across the lifespan by conducting meta-analyses of genome-wide association studies on persistent ADHD in adults and ADHD in childhood separately and jointly, and by comparing the genetic background between them in a total sample of 17,149 cases and 32,411 controls. Our results show nine new independent loci and support a shared contribution of common genetic variants to ADHD in children and adults. No subgroup heterogeneity was observed among children, while this group consists of future remitting and persistent individuals. We report similar patterns of genetic correlation of ADHD with other ADHD-related datasets and different traits and disorders among adults, children, and when combining both groups. These findings confirm that persistent ADHD in adults is a neurodevelopmental disorder and extend the existing hypothesis of a shared genetic architecture underlying ADHD and different traits to a lifespan perspective.

Future preferences and prospection of future of outcomes: Independent yet specific associations with attention-deficit/hyperactivity disorder

INTRODUCTION

Symptoms of attention-deficit hyperactivity disorder (ADHD) and conduct problems have been associated with heightened temporal discounting of reward value resulting in a preference for immediate over delayed outcomes. We examined the cross-sectional relationship between future preference (including intertemporal choice) and prospection (the ability to bring to mind and imagine the experience of future personally-relevant events and outcomes) in adolescents with a range of ADHD symptoms and aggressive behaviour.

METHODS

A combination of behavioural tasks and self-reports measured intertemporal decision making, individual differences in preference for future outcomes and experience of prospection in a convenience sample of English adolescents aged 11-17 (n = 64, 43.8% males). Parents rated symptoms of ADHD and aggression.

RESULTS

& Conclusions: Factor analysis identified two factors: "Future Preference" and "Prospection". Significant negative bivariate correlations were found between ADHD and the scores of both factors and between aggression and Future Preference. A path model confirmed the independent significant association of ADHD with both factors but not with aggression. There was no evidence that Prospection was associated with Future Preference or that it reduced the associations between ADHD symptoms and Future Preference. These results provide further evidence that ADHD is associated with a tendency to prefer immediate over future outcomes. The same association with aggression seemed to be driven by the overlap with ADHD symptoms. We provide some of the first evidence that individuals with high ADHD symptoms have difficulty in prospecting about future episodes. However, this is unrelated to their preference for future outcomes.

Risk Taking by Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD): a Behavioral and Psychophysiological Investigation of Peer Influence

Adolescents with ADHD demonstrate increased risk-taking behavior (RTB) like substance abuse and dangerous traffic conduct. RTB in adolescence is more likely under peer influence. The current investigation (1) tests the hypothesis that adolescents with ADHD are particularly susceptible to such influence and (2) tests whether groups differed in autonomic reactivity to peer influence. Adolescent boys between 12 and 19 years with (n = 81) and without (n = 99) ADHD performed the Balloon Analogue Risk Task twice. In the peer condition, a highly credible virtual peer manipulation that encouraged risk taking was added, in the solo condition this was absent. Autonomic reactivity was indexed by heart rate (HR), pre-ejection period (PEP) and respiratory sinus arrhythmia (RSA). All adolescents engaged in more risk taking in the peer condition relative to solo condition. Autonomic differences between groups were only found on PEP: a stronger sympathetic response to peer influence was observed in typically developing adolescents relative to adolescents with ADHD. Increased physiological stress (as indexed by PEP) in the peer relative to the solo condition predicted peer-induced risk taking in all adolescents. We conclude that susceptibility to peer influence is not exaggerated in ADHD but rather reflects a general tendency of adolescents. As adolescents experiencing peer influence as stressful are most susceptible to peer influence, we suggest that increasing resistance to peer influence may be an important treatment aim for these adolescents specifically.

Research Review: Do parent ratings of infant negative emotionality and self-regulation predict psychopathology in childhood and adolescence? A systematic review and meta-analysis of prospective longitudinal studies

BACKGROUND

Identifying low-cost and easy to implement measures of infant markers of later psychopathology may improve targeting of early intervention for prevention. Because of their early manifestation, relative stability and overlap with constructs central to affect-based dimensions of child and adolescent psychopathology, negative emotionality and self-regulation have been the focus of this research. We conducted a meta-analysis of longitudinal studies examining the prospective association between infant temperament measured with parent ratings and child/adolescent psychopathology.

METHODS

A systematic literature search for prospective longitudinal studies, which included measures of questionnaire-assessed infant temperament (negative emotionality, self-regulation, behavioural inhibition, surgency/extraversion, activity level) and symptoms of child or adolescent mental health (externalising, internalising) and neurodevelopmental problems (attention deficit/hyperactivity disorder [ADHD], autism spectrum disorder [ASD]), was conducted. Standardised estimates of association were calculated and pooled in meta-analyses.

RESULTS

Twenty-five studies (n = 28,425) met inclusion criteria. Small associations were seen between psychopathology aggregated across all domains and infant negative emotionality (r = .15; p < .001) and self-regulation (r = -.19; p = .007). Effects were also significant but weaker for behavioural inhibition (r = .10; p = .027) and activity level (r = .08; p = .016). Surgency/extraversion was not significantly associated with psychopathology in general (r = -.04; p = .094); however, it was negatively associated with ASD (r = -.10, p = .015). Significant correlations were observed with some outcomes isomorphic with predictors, internalising problems and behavioural inhibition (r = .10; p = .013), ADHD symptoms and activity level (r = .19; p = .009).

CONCLUSION

Questionnaire-based assessments of infant negative emotionality may have transdiagnostic potential to contribute to a risk index of later childhood psychopathology. Behavioural inhibition, surgency/extraversion and activity ratings may provide more specific predictive power. More data from prospective studies are required before the potential of self-regulation and surgency/extraversion can be properly gauged.

Editorial: 'People get ready': Are mental disorder diagnostics ripe for a Kuhnian revolution?

How is practical progress possible in child psychology and psychiatry? How does science advance to promote therapeutic innovation? The importance of the exciting stuff - new insights and ideas, studied using cutting edge and innovative technologies - is self-evident. However, the philosophy of science has shown us that less obvious and more mundane elements are also essential. This is because scientific progress is only possible where attempts to break new ground are solidly anchored in a stable shared framework of assumptions - a metatheory - about the general nature of the phenomenon being studied. This framework defines what questions are considered 'scientific' - questions that it 'makes sense' to ask from a scientific point of view and those that are considered out of bounds (scientists with less subtle minds even considering such to be nonquestions rather than different sorts of questions). Kuhn called this framework a paradigm and the research activity that originates from it, normal science (Kuhn, 1962, The Structure of Scientific Revolutions; Princeton, NJ: Princeton University Press). These frameworks also serve a vital regulatory function because they contain common concepts that embody shared points of reference that allow scientists to communicate with each other to share their ideas, hypotheses and findings (Habermas, 1979, Communication and the evolution of society; Boston: Beacon Press).

Altered White-Matter Microstructure in Conduct Disorder Is Specifically Associated with Elevated Callous-Unemotional Traits

Adolescents with conduct disorder (CD) and elevated callous-unemotional (CU) traits have been reported to present with a more severe and persistent pattern of antisocial behaviour than those with low levels of CU traits. However, relatively few studies have investigated whether there are differences in brain structure between these subgroups.We acquired diffusion tensor imaging data and used tract-based spatial statistics (TBSS) to compare adolescents with CD and high levels of CU traits (CD/CU+; n = 18, CD and low levels of CU traits (CD/CU-; n = 17) and healthy controls (HC; n = 32) on measures of fractional anisotropy (FA), axial (AD), radial (RD) and mean (MD) diffusivity. Compared to CD/CU- adolescents, those with CD/CU+ presented increased FA and reduced RD and MD (lower diffusivity) in several tracts including: body and splenium of the corpus callosum, right inferior longitudinal fasciculus, ILF; right inferior fronto-occipital fasciculus, IFOF; left superior longitudinal fasciculus, SLF; left cerebral peduncle, bilateral internal capsule, left superior and posterior corona radiata, bilateral thalamic radiation and left external capsule. In addition, relative to CD/CU- individuals, adolescents with CD/CU+ showed lower diffusivity (indexed by reduced RD and MD) in left uncinate fasciculus and bilateral fornix. Finally, relative to healthy controls, CD/CU+ individuals showed lower diffusivity (reduced RD) in the genu and body of the corpus callosum and left anterior corona radiata. These results suggest that CD/CU+ individuals present with white-matter microstructural abnormalities compared to both CD/CU- individuals and age-matched healthy controls. This finding is consistent with emerging evidence suggesting that CD/CU+ represents a distinct subtype of CD, and illustrates the importance of accounting for heterogeneity within CD populations.

The reinforcing value of delay escape in attention deficit/hyperactivity disorder: An electrophysiological study

The delay aversion hypothesis argues that the tendency for impulsive choice (preference for smaller sooner over larger later rewards) is motivated by the escape of negative affective states associated with delay. This model predicts that individuals with ADHD find the imposition of delay before an outcome or event especially aversive and its escape reinforcing. Consistent with this, fMRI studies show that ADHD is associated with amygdala hyper-sensitivity to cues of delay. However, evidence that delay escape is reinforcing is lacking. Here we extend fMRI research by using electrophysiological methods to study the reinforcing properties of delay-escape in ADHD. Thirty controls and 25 adolescents with ADHD aged 10–15 years performed the Escape Delay Incentive (EDI) task- in which pre-target cues indicated three conditions: i) CERTAIN DELAY: delay would follow a response irrespective of response speed ii) CONDITIONAL DELAY: delay would only follow if the response was too slow and iii) NO DELAY: delay would follow the response whatever the speed. We focused on the Contingent Negative Variation (CNV), a cue-evoked marker of motivated response preparation, across two time windows (CNV1 and CNV2). We took measures of parent, teacher and self-rated ADHD symptoms, task performance (RT) and self-rated delay aversion. We isolated CNV components and compared these between ADHD and controls. Adolescents with ADHD displayed a larger CNV2 to the CONDITIONAL DELAY than the CERTAIN DELAY cues compared to controls. However, this effect was not mirrored at the performance level and was unrelated to self-reported delay aversion. Our study provides the first ERP evidence that delay escape differentially reinforcers neural activation of attention preparation in ADHD cases. Future studies should examine the impact of varying cognitive load on task EDI performance.

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Individuals with ADHD find cues predicting the imposition of delay aversive but evidence that delay escape is reinforcing is lacking

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We used the Escape-Delay Incentive Task to isolate the CNV, reflecting motivated attention preparation to escape delay cues

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Adolescents with ADHD displayed larger CNV2 to cues signalling the possibility to escape delay

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Results provide the first ERP evidence of the reinforcing value of delay escape in ADHD

Commentary: 'Ready or not here I come': developmental immaturity as a driver of impairment and referral in young-for-school-grade ADHD children. A reformulation inspired by Whitely et al. (2019)

The search for objective biological tests, sufficiently reliable, and predictive enough to be diagnostic of psychiatric disorders, continues apace - yet their discovery remains a distant dream. It seems increasingly unlikely that current diagnostic structures and concepts map biologically in a straight forward way - with heterogeneity within, and sharing across, existing diagnostic boundaries being the biological rule rather than the exception. Indeed, it now appears that the science of biological psychiatry is more likely to redraw those boundaries than it is to confirm and mark them (Sonuga-Barke, Journal of Child Psychology and Psychiatry, 2016, 57, 1). Clinical identification of childhood psychiatric disorders therefore remains, for the foreseeable future at least, an exercise in regulated social perception - reliant on the fallible and subjective judgements of parents, teachers and clinicians. Social perception of this sort is an active and motivated process and therefore prone, like all social perception, to bias and distortions - both systematic and idiosyncratic. Progress has certainly been made over the last 50 years in reducing such judgement bias by, for instance filtering perceptions through the lens of standardised instruments (questionnaires and interviews) with carefully operationalised items and a degree of reliability and validity. However, such instruments often play only a peripheral role in actual diagnostic encounters and when they are used, there is still sufficient ambiguity to leave open plenty of room for interpretation. When we acknowledge that psychiatric diagnoses are social constructions - we are not saying that symptoms of inattention, impulsivity and hyperactivity are not real or do not cluster together in meaningful ways or that they do not cause real distress and disability but that their interpretation and meaning are often informed by social constructs such as ethnic or gender norms and stereotypes (Meyer, Stevenson, & Sonuga-Barke, Journal of Attention Disorders, 2019).

Editorial: 'It's a family affair' - the social drivers of child and adolescent resilience

Studies of risk and vulnerability processes may provide important ways of identifying new treatment targets - based on the principle that mending something is much easier if you know in what way it is broken. However, in our field, knowing its source may not always tell us about how to remediate impairment. Studies focusing on resilience may be more informative from this perspective. In this editorial I discuss four papers that highlight the value of resilience studies from a translational perspective - in particular contrasting the strengths and limitations of observational and experimental designs.

Discovery of the first genome-wide significant risk loci for attention deficit/hyperactivity disorder

Attention deficit/hyperactivity disorder (ADHD) is a highly heritable childhood behavioral disorder affecting 5% of children and 2.5% of adults. Common genetic variants contribute substantially to ADHD susceptibility, but no variants have been robustly associated with ADHD. We report a genome-wide association meta-analysis of 20,183 individuals diagnosed with ADHD and 35,191 controls that identifies variants surpassing genome-wide significance in 12 independent loci, finding important new information about the underlying biology of ADHD. Associations are enriched in evolutionarily constrained genomic regions and loss-of-function intolerant genes and around brain-expressed regulatory marks. Analyses of three replication studies: a cohort of individuals diagnosed with ADHD, a self-reported ADHD sample and a meta-analysis of quantitative measures of ADHD symptoms in the population, support these findings while highlighting study-specific differences on genetic overlap with educational attainment. Strong concordance with GWAS of quantitative population measures of ADHD symptoms supports that clinical diagnosis of ADHD is an extreme expression of continuous heritable traits.

Discovery of the first genome-wide significant risk loci for attention deficit/hyperactivity disorder

Attention deficit/hyperactivity disorder (ADHD) is a highly heritable childhood behavioral disorder affecting 5% of children and 2.5% of adults. Common genetic variants contribute substantially to ADHD susceptibility, but no variants have been robustly associated with ADHD. We report a genome-wide association meta-analysis of 20,183 individuals diagnosed with ADHD and 35,191 controls that identifies variants surpassing genome-wide significance in 12 independent loci, finding important new information about the underlying biology of ADHD. Associations are enriched in evolutionarily constrained genomic regions and loss-of-function intolerant genes and around brain-expressed regulatory marks. Analyses of three replication studies: a cohort of individuals diagnosed with ADHD, a self-reported ADHD sample and a meta-analysis of quantitative measures of ADHD symptoms in the population, support these findings while highlighting study-specific differences on genetic overlap with educational attainment. Strong concordance with GWAS of quantitative population measures of ADHD symptoms supports that clinical diagnosis of ADHD is an extreme expression of continuous heritable traits.

Tracking emotions in the brain - Revisiting the Empathic Accuracy Task

Many empathy tasks lack ecological validity due to their use of simplistic stimuli and static analytical approaches. Empathic accuracy tasks overcome these limitations by using autobiographical emotional video clips. Usually, a single measure of empathic accuracy is computed by correlating the participants' continuous ratings of the narrator's emotional state with the narrator's own ratings.

In this study, we validated a modified empathic accuracy task. A valence-independent rating of the narrator's emotional intensity was added to provide comparability between videos portraying different primary emotions and to explore changes in neural activity related to variations in emotional intensity over time. We also added a new neutral control condition to investigate general emotional processing. In the scanner, 34 healthy participants watched 6 video clips of people talking about an autobiographical event (2 sad, 2 happy and 2 neutral clips) while continuously rating the narrator's emotional intensity.

Fluctuation in perceived emotional intensity correlated with activity in brain regions previously implicated in cognitive empathy (bilateral superior temporal sulcus, temporoparietal junction, and temporal pole) and affective empathy (right anterior insula and inferior frontal gyrus). When emotional video clips were compared to neutral video clips, we observed higher activity in similar brain regions. Empathic accuracy, on the other hand, was only positively related to activation in regions that have been implicated in cognitive empathy.

Our modified empathic accuracy task provides a new method for studying the underlying components and dynamic processes involved in empathy. While the task elicited both cognitive and affective empathy, successful tracking of others' emotions relied predominantly on the cognitive components of empathy. The fMRI data analysis techniques developed here may prove valuable in characterising the neural basis of empathic difficulties observed across a range of psychiatric conditions.

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Activity in affective and cognitive empathy related regions during emotional videos.

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Activity in similar regions related to changes in perceived emotional intensity.

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Only regions implicated in cognitive empathy were associated with empathic accuracy.

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No difference between video clips that did and did not elicit affect sharing.

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Empathic accuracy related to self-rated perspective-taking but not empathic concern.

A comparison of the clinical effectiveness and cost of specialised individually delivered parent training for preschool attention-deficit/hyperactivity disorder and a generic, group-based programme: a multi-centre, randomised controlled trial of the New Forest Parenting Programme versus Incredible Years

The objective of this study is to compare the efficacy and cost of specialised individually delivered parent training (PT) for preschool children with attention-deficit/hyperactivity disorder (ADHD) against generic group-based PT and treatment as usual (TAU). This is a multi-centre three-arm, parallel group randomised controlled trial conducted in National Health Service Trusts. The participants included in this study were preschool children (33-54 months) fulfilling ADHD research diagnostic criteria. New Forest Parenting Programme (NFPP)-12-week individual, home-delivered ADHD PT programme; Incredible Years (IY)-12-week group-based, PT programme initially designed for children with behaviour problems were the interventions. Primary outcome-Parent ratings of child's ADHD symptoms (Swanson, Nolan & Pelham Questionnaire-SNAP-IV). Secondary outcomes-teacher ratings (SNAP-IV) and direct observations of ADHD symptoms and parent/teacher ratings of conduct problems. NFPP, IY and TAU outcomes were measured at baseline (T1) and post treatment (T2). NFPP and IY outcomes only were measured 6 months post treatment (T3). Researchers, but not therapists or parents, were blind to treatment allocation. Analysis employed mixed effect regression models (multiple imputations). Intervention and other costs were estimated using standardized approaches. NFPP and IY did not differ on parent-rated SNAP-IV, ADHD combined symptoms [mean difference - 0.009 95% CI (- 0.191, 0.173), p = 0.921] or any other measure. Small, non-significant, benefits of NFPP over TAU were seen for parent-rated SNAP-IV, ADHD combined symptoms [- 0.189 95% CI (- 0.380, 0.003), p = 0.053]. NFPP significantly reduced parent-rated conduct problems compared to TAU across scales (p values < 0.05). No significant benefits of IY over TAU were seen for parent-rated SNAP, ADHD symptoms [- 0.16 95% CI (- 0.37, 0.04), p = 0.121] or parent-rated conduct problems (p > 0.05). The cost per family of providing NFPP in the trial was significantly lower than IY (£1591 versus £2103). Although, there were no differences between NFPP and IY with regards clinical effectiveness, individually delivered NFPP cost less. However, this difference may be reduced when implemented in routine clinical practice. Clinical decisions should take into account parental preferences between delivery approaches.