Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011

Association between prenatal antimicrobial use and offspring attention deficit hyperactivity disorder

BACKGROUND

Gut-brain cross-talk may play an important role in modulating neurodevelopment. Few studies have examined the association between antimicrobials that influence infant gut microbiota assemblage and attention deficit hyperactivity disorder (ADHD).

OBJECTIVE

To examine the association between maternal prenatal antimicrobial use and ADHD in offspring at 10 years of age.

METHODS

Data are from the Wayne County Health, Environment, Allergy and Asthma Longitudinal Study, a racially and socioeconomically diverse birth cohort in metropolitan Detroit, Michigan. Maternal antimicrobial use was extracted from the medical record. ADHD diagnoses were based on parental report at the 10-year study visit. Poisson regression models with robust error variance were used to calculate risk ratios (RR). Cumulative frequency of exposure to antibiotics, and effect modification were also evaluated.

RESULTS

Among the 555 children included in the analysis, 108 were diagnosed with ADHD. During pregnancy, 54.1% of mothers used antibiotics while 18.7% used antifungals. Overall, there was no evidence of an association between prenatal antibiotic exposure and ADHD (RR [95% CI] = 0.98 [0.75, 1.29]), but there was an increased risk of ADHD among those with mothers using 3+ courses of antibiotics (RR [95%CI] = 1.58 [1.10, 2.29]). Prenatal exposure to antifungals was associated with a 1.6 times higher risk of ADHD (RR [95% CI] = 1.60 [1.19, 2.15]). In examining effect modification by child sex for antifungal use, there was no evidence of an association among females (RR [95% CI] = 0.97 [0.42, 2.23]), but among males, prenatal antifungal use was associated with 1.82 times higher risk of ADHD (RR [95% CI] = 1.82 [1.29, 2.56]).

CONCLUSIONS

Maternal prenatal antifungal use and frequent prenatal antibiotic use are associated with an increased risk of ADHD in offspring at age 10. These findings highlight the importance of the prenatal environment and the need for careful use of antimicrobials.

Latent structure of working memory and emotion regulation in pediatric ADHD

Working memory is a key cognitive function that is often implicated in ADHD and may represent an underlying cognitive endophenotype of the disorder. Working memory is related to emotion regulation, which is a common area of impairment in children with ADHD. Given the high rate of comorbid diagnoses with ADHD, children with comorbid internalizing, externalizing, and developmental disorders may present with variable working memory profiles and subsequent emotion regulation deficits. This study aimed to adequately characterize the latent structure of working memory impairments and emotional regulation outcomes in a clinical sample of children ages 6-16 with ADHD. This study also examined the interplay between the identified working memory/emotion regulation patterns, demographic characteristics, and the role of comorbid diagnoses. Results highlighted two distinct, invariant, unrestricted classes of working memory/emotion regulation. Class 1 (Average; 62% of the sample) had significantly lower digit-span scores, and generally persevered emotion regulation functioning per parent/teacher report. Class 2 (Emotionally Dysregulated) had average working memory scores, and elevated emotion regulation problems. The working memory indicators had small correlations with parents (and not teacher) measures of emotion regulation. Finally, latent class membership did not differ by comorbid diagnosis, age, gender, or verbal IQ. Findings elucidate heterogeneity in common domains affected by ADHD and suggest that this heterogeneity may not be due to demographic/comorbidity factors. The role of varying information reports is discussed, and potential assessment and treatment implications are highlighted.

Research Review: A systematic review and meta-analysis of infant and toddler temperament as predictors of childhood attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with onset as early as preschool and impairment across the lifespan. Temperament factors, specifically those that theoretically map onto ADHD symptoms, may be early markers of risk for developing later childhood ADHD that could be identifiable in infancy or toddlerhood. This meta-analysis examined the associations between these early temperamental factors and later symptoms and diagnosis of ADHD and mapped early temperament constructs onto the three ADHD symptom dimensions.

METHODS

A systemic review of the literature was conducted to identify prospective longitudinal studies that included theoretically relevant temperament constructs (sustained attention, activity level, inhibition, and negative emotionality) examined from birth to 36 months old and ADHD (symptoms or diagnosis) in preschool or childhood. The association between each temperament construct and ADHD outcomes was examined using pooled standardized estimates in meta-analyses.

RESULTS

Forty-eight articles (n = 112,716 infants/toddlers) prospectively examined temperament and the relation to childhood ADHD symptoms or diagnosis. Activity level (k = 18) in infancy and toddlerhood was moderately associated with childhood ADHD (r = .39, CI = 0.27, 0.51, p < .001). Moderate effect sizes were also observed for sustained attention (k = 9; r = -.28, CI = -0.42, -0.12, p < .001) and negative emotionality (k = 33; r = .25, CI = 0.16, 0.34, p < .001) with ADHD. The specificity of each temperament construct for later ADHD symptom dimensions was such that activity level and negative emotionality were predictive of all three symptom dimensions (i.e., inattention, hyperactivity/impulsivity, and combined), whereas sustained attention was only associated with combined symptoms.

CONCLUSIONS

Infant and toddler temperament is an early risk factor for the development of childhood ADHD that could be utilized for early intervention identification. Yet, this systematic review found that relatively few prospective longitudinal studies have examined sustained attention (k = 9) and inhibition (k = 15) in infancy and toddlerhood in relation to later ADHD highlighting the need for further research.

Medicinal Cannabis for Paediatric Developmental, Behavioural and Mental Health Disorders

Parents of children with developmental, behavioural and mental health disorders are increasingly asking whether medicinal cannabis might be a therapeutic option for their child. This paper presents the current evidence for medicinal cannabis in this population. Preliminary evidence from open-label studies suggests the potential for medicinal cannabis to ameliorate some symptoms in children with autism spectrum disorder. However, only one double-blind placebo-controlled trial has been completed, with inconclusive findings. Synthetic, transdermal cannabidiol gel has demonstrated efficacy for reducing social avoidance in a sub-group of children with Fragile X syndrome. Studies of medicinal cannabis are planned or underway for children and/or adolescents with autism, intellectual disability, Tourette's syndrome, anxiety, psychosis, anorexia nervosa and a number of specific neurodevelopmental syndromes. High quality evidence from double-blind placebo-controlled trials is needed to guide clinical practice.

Prescription Stimulant Medical and Nonmedical Use Among US Secondary School Students, 2005 to 2020

Importance

Recent information on the prevalence of prescription stimulant therapy for attention-deficit/hyperactivity disorder (ADHD) and nonmedical use of prescription stimulants (NUPS) at the school-level among US secondary school students is limited.

Objective

To investigate the school-level prevalence of and association between stimulant therapy for ADHD and NUPS among US secondary school students.

Design, Setting, and Participants

This cross-sectional study used survey data collected between 2005 and 2020 as part of the Monitoring the Future study (data collected annually via self-administered survey in schools from independent cohorts). Participants were from a nationally representative sample of 3284 US secondary schools. The mean (SD) response rates were 89.5% (1.3%) for 8th-grade students, 87.4% (1.1%) for 10th-grade students, and 81.5% (1.8%) for 12th-grade students. Statistical analysis was performed from July to September 2022.

Main Outcome and Measure

Past-year NUPS.

Results

The 3284 schools contained 231 141 US 8th-, 10th-, and 12th-grade students (111 864 [50.8%, weighted] female; 27 234 [11.8%, weighted] Black, 37 400 [16.2%, weighted] Hispanic, 122 661 [53.1%, weighted] White, 43 846 [19.0%, weighted] other race and ethnicity). Across US secondary schools, the past-year prevalence of NUPS ranged from 0% to more than 25%. The adjusted odds of an individual engaging in past-year NUPS were higher at secondary schools with higher proportions of students who reported stimulant therapy for ADHD, after controlling for other individual-level and school-level covariates. Students attending schools with the highest rates of prescription stimulant therapy for ADHD had approximately 36% increased odds of past-year NUPS compared with students attending schools with no medical use of prescription stimulants (adjusted odds ratio, 1.36; 95% CI, 1.20-1.55). Other significant school-level risk factors included schools in more recent cohorts (2015-2020), schools with higher proportions of parents with higher levels of education, schools located in non-Northeastern regions, schools located in suburban areas, schools with higher proportion of White students, and schools with medium levels of binge drinking.

Conclusions and Relevance

In this cross-sectional study of US secondary schools, the prevalence of past-year NUPS varied widely, highlighting the need for schools to assess their own students rather than relying solely on regional, state, or national results. The study offered new evidence of an association between a greater proportion of the student body that uses stimulant therapy and a greater risk for NUPS in schools. The association between greater school-level stimulant therapy for ADHD and other school-level risk factors suggests valuable targets for monitoring, risk-reduction strategies, and preventive efforts to reduce NUPS.

Treatment of US Children With Attention-Deficit/Hyperactivity Disorder in the Adolescent Brain Cognitive Development Study

Importance

Characterizing the extent and pattern of unmet needs for treatment of children with attention-deficit/hyperactivity disorder (ADHD) could help target efforts to improve access to ADHD medications and outpatient mental health care.

Objective

To describe current ADHD medication use and lifetime outpatient mental health care among a large national sample of children with ADHD.

Design, Setting, and Participants

This study uses cross-sectional survey data from the first wave of the Adolescent Brain and Cognitive Development Study (n = 11 723), conducted from June 1, 2016, to October 15, 2018, among 1206 school children aged 9 and 10 years who met parent-reported Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for current ADHD. Statistical analysis was performed from March 23, 2022, to March 10, 2023.

Main Outcomes and Measures

Current ADHD medications including stimulants and nonstimulants, lifetime outpatient mental health care, or either treatment. Weighted results are reported.

Results

Among a sample of 11 723 children, 1206 had parent-reported ADHD (aged 9-10 years; 826 boys [68.2%]; 759 White, non-Hispanic children [62.2%]), 149 (12.9%) were currently receiving ADHD medications. Children receiving ADHD medications included a significantly higher percentage of boys (15.7% [121 of 826]) than girls (7.0% [28 of 108]), White children (14.8% [104 of 759]) than Black children (9.4% [22 of 206]), children of parents without a high school education (32.2% [9 of 36]) than of parents with a bachelor's degree or higher (11.5% [84 of 715]), and children with the combined subtype of ADHD (17.0% [83 of 505]) than with the inattentive subtype (9.5% [49 of 523]). Approximately 26.2% of children (301 of 1206) with parent-reported ADHD had ever received outpatient mental health care. Children receiving outpatient mental health care included a significantly higher percentage of children whose parents had a high school education (36.2% [29 of 90]) or some college (31.0% [109 of 364]) than a bachelor's degree or higher (21.3% [153 of 715]), children with family incomes of less than $25 000 (36.5% [66 of 176]) or $25 000 to $49 999 (27.7% [47 of 174]) than $75 000 or more (20.1% [125 of 599]), and children with the combined subtype of ADHD (33.6% [166 of 505]) than with the predominantly inattentive subtype (20.0% [101 of 523]) or the hyperactive-impulsive subtype (22.4% [34 of 178]) of ADHD.

Conclusions and Relevance

This cross-sectional study of children with parent-reported ADHD suggests that most were not receiving ADHD medications and had never received outpatient mental health care. Gaps in treatment, which were not directly associated with socioeconomic disadvantage, underscore the challenges of improving communication and access to outpatient mental health care for children with ADHD.

Use of Medication to Treat Attention-Deficit/Hyperactivity Disorder in Young Children: The Role of Maternal History of Psychotropic Medication Use

We examine whether, among children diagnosed with ADHD, are those whose mothers have a history of psychotropic medication use more likely to treat their ADHD with medication? Children born in Manitoba, Canada from 2000 to 2010 diagnosed with ADHD between their 4th and 8th birthday. Maternal psychotropic medication use was assessed from one year before the child's birth to the child's fourth birthday. Logistic regression models examine the relationship between maternal history of psychotropic medication use and the use of medication to treat ADHD in children. Among the 2384 children diagnosed with ADHD, the rate of ADHD medication use was higher for those whose mother had a history of psychotropic medication use (76.6%) than for those whose mothers did not (72.5%) (OR 1.24, 95% CI 1.03, 1.49). Children whose mothers have a history of psychotropic medication use are more likely to have their ADHD treated with medication.

Increased delay from initial concern to diagnosis of autism spectrum disorder and associated health care resource utilization and cost among children aged younger than 6 years in the United States

BACKGROUND: Prolonged delays between first caregiver concern and autism spectrum disorder (ASD) diagnosis have been reported, but associations between length of time to diagnosis (TTD) and health care resource utilization (HCRU) and costs have not been studied in a large sample of children with ASD. OBJECTIVE: To address these informational gaps in the ASD diagnostic pathway. METHODS: This retrospective, observational, single cohort analysis of Optum's administrative claims data from January 1, 2011, to December 31, 2020, included commercially insured children who had 2 or more claims for an ASD diagnosis (earliest diagnosis designated as the index date), were between the ages of older than 1.5 years and 6 years or younger at index date, and were continuously enrolled for up to 48 months before and for 12 months after the index date. Two cohorts (between the ages of older than 1.5 years and 3 years or younger and between the ages of older than 3 years and 6 years or younger at ASD diagnosis) were divided into shorter (less than median) and longer (greater than or equal to median) TTD around each cohort median TTD calculated from the first documented ASD-related concern to the earliest ASD diagnosis, because TTD may vary by age at diagnosis. This exploratory analysis compared all-cause and ASD-related HCRU and costs during a 12-month period preceding ASD diagnosis among children with shorter vs longer TTD. RESULTS: 8,954 children met selection criteria: 4,205 aged 3 years or younger and 4,749 aged older than 3 years at diagnosis, with median TTD of 9.5 and 22.1 months, respectively. In the year preceding ASD diagnosis, children with longer TTD in both age cohorts experienced a greater number of all-cause and ASD-related health care visits compared with those with shorter TTD (mean and median number of office or home visits were approximately 1.5- and 2-fold greater in longer vs shorter TTD groups; P < 0.0001). The mean all-cause medical cost per child in the year preceding ASD diagnosis was approximately 2-fold higher for those with longer vs shorter TTD ($5,268 vs $2,525 in the younger and $5,570 vs $2,265 in the older cohort; P < 0.0001 for both). Mean ASD-related costs were also higher across age cohorts for those with longer vs shorter TTD ($2,355 vs $859 in the younger and $2,351 vs $1,144 in the older cohort; P < 0.0001 for both). CONCLUSIONS: In the year prior to diagnosis, children with longer TTD experienced more frequent health care visits and greater cost burden in their diagnostic journey compared with children with shorter TTD. Novel diagnostic approaches that could accelerate TTD may reduce costs and HCRU for commercially insured children. DISCLOSURES: This study was funded by Cognoa, Inc. Optum received funding from Cognoa to conduct this study. Dr Salomon is an employee and holds stock options of Cognoa, Inc. Dr Campbell was an employee of Cognoa, Inc., at the time this study was conducted. Dr Duhig was an employee of Cognoa, Inc., at the time the study was conducted and holds stock options. Dr Vu, Ms Kruse, Mr Gaur, and Ms Gupta are employees and/or stockholders of Optum. Dr Tibrewal was an employee of Optum at the time the research for this study was conducted. Dr Taraman is an employee and holds stock options of Cognoa, Inc., receives consulting fees from Cognito Therapeutics, volunteers as a board member of the American Academy of Pediatrics California and Orange County Chapter, is a paid advisor for MI10 LLC, and owns stock options of NTX, Inc., and HandzIn.

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015.

OBJECTIVES

To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate.

SELECTION CRITERIA

We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non-serious, general behaviour, and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel-group trials and first-period data from cross-over trials formed the basis of our primary analyses. We undertook separate analyses using end-of-last period data from cross-over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach.

MAIN RESULTS

We included 212 trials (16,302 participants randomised); 55 parallel-group trials (8104 participants randomised), and 156 cross-over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross-over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male-female ratio was 3:1. Most trials were carried out in high-income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias.

PRIMARY OUTCOMES

methylphenidate versus placebo or no intervention may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -0.88 to -0.61; I² = 38%; 21 trials; 1728 participants; very low-certainty evidence). This corresponds to a mean difference (MD) of -10.58 (95% CI -12.58 to -8.72) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD-RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68).

SECONDARY OUTCOMES

methylphenidate may cause more adverse events considered non-serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher-rated general behaviour versus placebo (SMD -0.62, 95% CI -0.91 to -0.33; I² = 68%; 7 trials 792 participants; very low-certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI -0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The majority of our conclusions from the 2015 version of this review still apply. Our updated meta-analyses suggest that methylphenidate versus placebo or no-intervention may improve teacher-rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non-serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non-serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes.

Unpacking Inequities in ADHD Diagnosis: Examining Individual-Level Race/Ethnicity and State-Level Online Information-Seeking Patterns

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent, persistent, and costly mental health condition. The internet is an increasingly popular source for information related to ADHD. With a nationally representative sample (2018 NSCH), we aimed to separate individual- and state-level effects to examine inequities in ADHD diagnoses. We extracted state-level relative search volumes using "ADHD," "ADHD treatment," "ADHD medication," and "ADHD therapy" from Google Trends, and sociodemographic and clinical variables from the 2018 National Survey of Children's Health (N = 26,835). We examined state variation in ADHD-related information-seeking and applied multilevel modeling to examine associations among individual-level race/ethnicity, state-level information-seeking patterns, and ADHD diagnoses. Online information seeking related to ADHD varies by state and search term. Individual-level racial/ethnic background and state-level information-seeking patterns were associated with ADHD diagnoses; however, their cross-level interaction was not significant. This study adds to the strong body of evidence documenting geographical variation and diagnostic disparity in mental health and the growing literature on the impact of the digital divide on population health, indicating an urgent need for addressing inequities in mental health care. Increasing public interest in and access to empirically supported online information may increase access to care, especially among people of color.

Discontinuation of methylphenidate after long-term exposure in nonhuman primates

Attention-deficit hyperactivity disorder (ADHD) is a common human neurobehavioral disorder that usually begins in early childhood. Methylphenidate (MPH) has been used extensively as a first-line medicine for the treatment of ADHD. Since ADHD is often diagnosed in early childhood and can persist for the entire lifespan, individuals may take MPH for many years. Given that in the course of one's lifetime a person may stop taking MPH for periods of time, or may implement lifestyle changes that may reduce the need for MPH entirely, it is important to understand how cessation of MPH affects the adult brain following long-term use of MPH. The blockage of the dopamine transporter (DAT) and the norepinephrine transporter (NET) by MPH may help with ADHD symptoms by boosting monoamine levels in the synapse. In the present study, microPET/CT was used to investigate possible neurochemical alterations in the cerebral dopamine system after cessation of long-term MPH administration in nonhuman primates. MicroPET/CT images were collected from adult male rhesus monkeys 6 months after they stopped receiving vehicle or MPH following 12 years of chronic treatment. The neurochemical status of brain dopaminergic systems was evaluated using the vesicular monoamine transporter 2 (VMAT2) ligand [¹⁸F]-AV-133 and a tracer for imaging dopamine subtype 2 (D₂) and serotonin subfamily 2 (5HT₂) receptors, [¹⁸F]-FESP. Each tracer was injected intravenously and ten minutes later microPET/CT images were obtained over 120 min. The binding potential (BP) of each tracer in the striatum was obtained using the Logan reference tissue model with the cerebellar cortex time activity curve (TAC) as an input function. Brain metabolism was also evaluated using microPET/CT images of [¹⁸F]-FDG. [¹⁸F]-FDG was injected intravenously, and ten minutes later, microPET/CT images were obtained over 120 min. Radiolabeled tracer accumulation in regions of interest (ROIs) in the prefrontal cortex, temporal cortex, striatum, and cerebellum were converted into standard uptake values (SUVs). Compared to the vehicle control group, the BPs of [¹⁸F] AV-133 and [¹⁸F]-FESP in the striatum were not significantly altered in MPH treated groups. Additionally, no significant differences were detected in the SUVs of [¹⁸F]-FDG in the MPH treated group compared with control. This study demonstrates that 6 months after cessation of long-term, chronic MPH treatment, there are no significant neurochemical or neural metabolic changes in the central nervous system (CNS) of non-human primates (NHPs) and suggests that microPET imaging is helpful in assessing the status of biomarkers of neurochemical processes linked to chronic CNS drug exposure. (Supported by NCTR).

County-level prevalence estimates of ADHD in children in the United States

PURPOSE

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood disorder often characterized by long-term impairments in family, academic, and social settings. Measuring the prevalence of ADHD is important as treatment options increase around the U.S. Prevalence data helps inform decisions by care providers, policymakers, and public health officials about allocating resources for ADHD. In addition, measuring geographic variation in prevalence estimates can facilitate hypothesis generation for future analytic work. Most U.S. studies of ADHD prevalence among children focus on national or demographic group rates.

METHODS

Using a small area estimation approach and data from the 2016 to 2018 National Survey of Children's Health, we estimated childhood ADHD prevalence estimates at the census regional division, state, and county levels. The sample included approximately 70,000 children aged 5-17 years.

RESULTS

The national ADHD rate was estimated to be 12.9% (95% Confidence Interval: 11.5%, 14.4%). Counties in the West South Central, East South Central, New England, and South Atlantic divisions had higher estimated rates of childhood ADHD (55.1%, 53.6%, 49.3%, and 46.2% of the counties had rates of 16% or greater, respectively) compared to counties in the Mountain, Mid Atlantic, West North Central, Pacific, and East North Central divisions (2.1%, 4%, 5.8%, 6.9%, and 11.7% of the counties had rates of 16% or greater, respectively).

CONCLUSIONS

These local-level rates are useful for decision-makers to target programs and direct sufficient ADHD resources based on communities' needs.

Source Localization of Somatosensory Neural Generators in Adults with Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder, where differences are often present relating to the performance of motor skills. Our previous work elucidated unique event-related potential patterns of neural activity in those with ADHD when performing visuomotor and force-matching motor paradigms. The purpose of the current study was to identify whether there were unique neural sources related to somatosensory function and motor performance in those with ADHD. Source localization (sLORETA) software identified areas where neural activity differed between those with ADHD and neurotypical controls when performing a visuomotor tracing task and force-matching task. Median nerve somatosensory evoked potentials (SEPs) were elicited, while whole-head electroencephalography (EEG) was performed. sLORETA localized greater neural activity post-FMT in those with ADHD, when compared with their baseline activity (p < 0.05). Specifically, greater activity was exhibited in BA 31, precuneus, parietal lobe (MNI coordinates: X = -5, Y = -75, and Z = 20) at 156 ms post stimulation. No significant differences were found for any other comparisons. Increased activity within BA 31 in those with ADHD at post-FMT measures may reflect increased activation within the default mode network (DMN) or attentional changes, suggesting a unique neural response to the sensory processing of force and proprioceptive afferent input in those with ADHD when performing motor skills. This may have important functional implications for motor tasks dependent on similar proprioceptive afferent input.

The Impact of Childhood Attention-Deficit/Hyperactivity Disorder (ADHD) on Children's Health-Related Quality of Life: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the association between children's health-related quality of life (HRQoL) and childhood attention-deficit/hyperactivity disorder (ADHD).

METHOD

Databases were systematically searched for peer-reviewed literature published between 2010 and 2022. Two reviewers independently screened and assessed the quality of included studies. Meta-analysis was conducted for studies that used the Pediatric Quality of Life Inventory (PedsQL).

RESULTS

Twenty-three studies were included, with most rated as "good" quality. Meta-analysis found "very large" effect in both parent- (Hedges' g -1.67, 95% CI [-2.57, -0.78]) and child-reported (Hedges' g -1.28, 95% CI [-2.01, -0.56]) HRQoL for children with ADHD compared to children without ADHD. No difference between parent- and child-reported HRQoL in children with and without ADHD was found. However, parent-reported HRQoL was lower than child-reported HRQoL among children with ADHD.

CONCLUSION

ADHD was associated with substantially poorer children's HRQoL. Among children with ADHD, parents rated their children's HRQoL lower than the children themselves.

Previous experience with delays affects delay discounting in animal model of ADHD

BACKGROUND

ADHD is a disorder where a common symptom is impulsive behaviour, a broad term associated with making sub-optimal choices. One frequently used method to investigate impulsive behaviour is delay discounting, which involves choosing between a small, immediate reinforcer and a delayed, larger one. Choosing the small immediate reinforcer is by itself, however, not sufficient for terming the choice impulsive, as all organisms eventually switch to choosing the small, immediate reinforcer when the delay to the larger reinforcer becomes long. This switch can be termed impulsive only when it occurs more frequently, or at shorter LL delays, than typically observed in normal controls. A poorly understood aspect is how choice is influenced by previous experience with delays. Using an animal model of Attention-Deficit/Hyperactivity Disorder, the Spontaneously Hypertensive Rat, we manipulated the order of exposure to delays in a delay discounting task. Following a preference test, the Ascending group experienced gradually increasing delays between choice and reinforcer while the Descending group were exposed to these delays in reverse order.

RESULTS

The results showed that the Descending group chose the small, immediate reinforcer over the larger delayed to a much larger extent than the Ascending group, and continued to do so even when the delay component was ultimately removed. Strain effects were found in the Ascending group, with SHRs switching to the small, immediate reinforcer earlier than controls as the delay to the larger reinforcer increased.

CONCLUSION

The data suggests that delay discounting is affected by history of exposure to delayed consequences. When reinforcement contingencies are incrementally changed from having no response-reinforcer delay to a long delay, discounting of delayed consequences is gradual. However, a sudden change from no delay to a long delay, without intermediate training, results in a rapid switch to the small, immediate reinforcer option, and this behaviour is somewhat resilient to the shortening and eventual removal of the large reinforcer delay. The implication is that attempting to reduce already existing impulsive behaviour in children with ADHD will require gradual habituation and not sudden changes in reinforcement contingencies.

Increased Prescribing of Psychotropic Drugs or School-Based Services for Children with Disabilities? Associations of These Self-control-Boosting Strategies with Juvenile Violence at the State Level

The increasing rates at which psychotropic drugs have been prescribed to children and adolescents in the USA in the last three decades (since the early 1990s) have prompted questions about whether this trend is associated with the "great American crime decline." Medicalization can be considered one of the strategies to remedy children's neuropsychological deficits and improve their self-control. Another possible remedy is school-based services for children with learning disabilities, mandated by the Individuals with Disabilities Education Improvement Act (IDEA) of 2004. Using state-level panel data analyses for years 1990-2014 (with the main focus on 2000-2014 outcomes), the current study estimates associations between these two developmental self-control remedies-medicalization and school-based services-and minor, moderate, and severe types of juvenile violence, while controlling for relevant covariates (both time-varying and time-invariant). The results of mixed-effects linear regression analyses accounting for powerful time trends show a strong association between increases in school-based services for children with learning disabilities and declines in all types of juvenile violence. Another strong and consistent finding that emerges in the analyses is the link between reductions in child poverty at the state level and decreases in juvenile violence, both contemporaneously and over time. Psychotropic drug prescribing to children (measured using Supplemental Security Income rolls of children with mental health conditions) exhibits inconsistent or insignificant effects. The findings of this study have substantial theoretical and policy implications and indicate the importance of strengthening school-based services for children with disabilities and reducing child poverty as essential violence prevention tools.

Prescribing Stimulants for Children and Adolescents With Attention-Deficit/Hyperactivity Disorder and Co-occurring Cannabis Use: Considerations for Managing a Clinical Dilemma

Attention-deficit/hyperactivity disorder (ADHD) is highly prevalent in the pediatric population, with 11% of children and adolescents having ever been diagnosed with the disorder.¹ The management of ADHD in the setting of co-occurring cannabis use, which is more prevalent in adolescents with ADHD than in the general population, is an increasingly common dilemma facing clinicians, in part due to recent changes in social acceptability, access, usage, and state-level legal status of cannabis.² Clinicians face several considerations, including the following: the confounding effects of cannabis use on assessment and management of ADHD symptoms; the potential reduction in risk of substance use when ADHD symptoms are well managed; and the increased risk of misuse and diversion of stimulants in patients with ongoing cannabis use.².

Machine Learning and MRI-based Diagnostic Models for ADHD: Are We There Yet?

OBJECTIVE

Machine learning (ML) has been applied to develop magnetic resonance imaging (MRI)-based diagnostic classifiers for attention-deficit/hyperactivity disorder (ADHD). This systematic review examines this literature to clarify its clinical significance and to assess the implications of the various analytic methods applied.

METHODS

A comprehensive literature search on MRI-based diagnostic classifiers for ADHD was performed and data regarding the utilized models and samples were gathered.

RESULTS

We found that, although most studies reported the classification accuracies, they varied in choice of MRI modalities, ML models, cross-validation and testing methods, and sample sizes. We found that the accuracies of cross-validation methods inflated the performance estimation compared with those of a held-out test, compromising the model generalizability. Test accuracies have increased with publication year but were not associated with training sample sizes. Improved test accuracy over time was likely due to the use of better ML methods along with strategies to deal with data imbalances.

CONCLUSION

Ultimately, large multi-modal imaging datasets, and potentially the combination with other types of data, like cognitive data and/or genetics, will be essential to achieve the goal of developing clinically useful imaging classification tools for ADHD in the future.

Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care

OBJECTIVE

The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of collaborative mental health care in the pediatric primary care setting.

METHOD

A search of the literature on this topic from 2001was conducted initially in 2016, yielding 2,279 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 2,467 total citations, of which 1,962 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 219 based on topic relevance. A follow-up search from 2016 was conducted in 2021, yielding 2 additional citations based on nonduplication from initial search and topic relevance.

RESULTS

The collaborative care approach, arising in the 1990s and gaining momentum in the 2000s, aims to extend behavioral health care to the primary care setting. The goal of collaborative care is to conserve the sparse specialty care workforce for severe and complex psychiatric disorders through shifting certain specialty mental health tasks (eg, assessment; patient self-management; brief psychosocial intervention; basic psychopharmacology; care coordination) to primary care. Collaborative care can be delivered on a spectrum ranging from coordinated to co-located to integrated care. Although each of these models has some empirical support, integrated care-a multidisciplinary team-based approach-has the strongest evidence base in improving clinical outcomes and patient satisfaction while constraining costs. Challenges to integrated care implementation include insufficient mental health education and insufficient specialist consultative and care coordination support for primary care practitioners; space, time, and reimbursement constraints in the primary care setting; discomfort among primary care practitioners in assuming mental health tasks previously undertaken by specialists; and continuing need for and unavailability of ongoing specialty mental health care for severe and complex cases. Essential supporting activities for effective collaborative care include patient and family engagement, professional education and training, evaluation/demonstration of impact, fiscal sustainability, and advocacy for model dissemination.

CONCLUSION

Health professionals who are educated in the collaborative care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.

Long-term outcomes of preterm infants in the first 6 years of life: a nationwide population-based study in Korea

This study examined the relationship between gestational age and long-term outcomes up to 6 years of age using population-based big data from the National Health Insurance Service in Korea. This retrospective observational cohort study used data from the National Health Information Database (2011-2017). All children born in Korea during 2011 (January 1-December 31) were eligible and were followed up until 2017. Gestational age groups were divided into extremely preterm (< 28 weeks), very preterm (28-31 weeks), moderate-to-late preterm (32-36 weeks), and full-term (37-41 weeks). The survival rate, neurodevelopmental diseases, hearing or visual impairment, and respiratory morbidities were compared for each gestational age group. In total, 370,301 children were included in the analysis. The total survival rate increased with increasing gestational age. Furthermore, the risk of neurodevelopmental diseases (i.e., epilepsy, cerebral palsy, delayed development, mental retardation, language disorder, developmental coordination disorder, autism spectrum disorder), hearing or visual impairment, and asthma-related inhaler prescription increased with decreasing gestational age, despite adjustment for covariates.

CONCLUSION

Lower gestational age was associated with an increase in a wide spectrum of adverse neurodevelopmental and respiratory outcomes in the first 6 years of life. Although morbidities were highest at the earliest gestational ages, moderate-to-late preterm children were significantly associated with increased adverse outcomes compared with full-term children. Our findings prove this under-recognized group's long-term follow-up and policy support.

WHAT IS KNOWN

• Infants born preterm are at high risk for neurodevelopmental and various medical health problems. • Nationwide research on long-term outcomes for moderate-to-late preterm birth is sparse.

WHAT IS NEW

• In this nationwide cohort study, lower gestational age at birth was inversely associated with increased adverse neurodevelopmental and respiratory outcomes in the first 6 years of life. • Long-term follow-up and policy support are required for moderate-to-late preterm children who are at risk of increased adverse outcomes compared with full-term births.

Sensorimotor integration and motor learning during a novel force-matching task in young adults with attention-deficit/hyperactivity disorder

Introduction

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that exhibits unique neurological and behavioral characteristics. Those with ADHD often have noted impairments in motor performance and coordination, including during tasks that require force modulation. The present study provides insight into the role of altered neural processing and SMI in response to a motor learning paradigm requiring force modulation and proprioception, that previous literature has suggested to be altered in those with ADHD, which can also inform our understanding of the neurophysiology underlying sensorimotor integration (SMI) in the general population.

Methods

Adults with ADHD (n = 15) and neurotypical controls (n = 15) performed a novel force-matching task, where participants used their right-thumb to match a trace template that varied from 2-12% of their Abductor Pollicis Brevis maximum voluntary contraction. This motor task was completed in pre, acquisition, and post blocks. Participants also completed a retention test 24 h later. Median nerve somatosensory-evoked potentials (SEPs) were collected pre and post motor acquisition. SEPs were stimulated at two frequencies, 2.47 Hz and 4.98 Hz, and 1,000 sweeps were recorded using 64-electrode electroencephalography (EEG) at 2,048 Hz. SEP amplitude changes were normalized to each participant's baseline values for that peak.

Results

Both groups improved at post measures (ADHD: 0.85 ± 0.09; Controls: 0.85 ± 0.10), with improvements maintained at retention (ADHD: 0.82 ± 0.11; Controls: 0.82 ± 0.11). The ADHD group had a decreased N18 post-acquisition (0.87 ± 0.48), while the control N18 increased (1.91 ± 1.43). The N30 increased in both groups, with a small increase in the ADHD group (1.03 ± 0.21) and a more pronounced increase in controls (1.15 ± 0.27).

Discussion

Unique neural differences between groups were found after the acquisition of a novel force-matching motor paradigm, particularly relating to the N18 peak. The N18 differences suggest that those with ADHD have reduced olivary-cerebellar-M1 inhibition when learning a novel motor task dependent on force-modulation, potentially due to difficulties integrating the afferent feedback necessary to perform the task. The results of this work provide evidence that young adults with ADHD have altered proprioceptive processing when learning a novel motor task when compared to neurotypical controls.

Can We Expand the Pool of Youth Who Receive Telehealth Assessments for ADHD? Covariates of Service Utilization

BACKGROUND

During the COVID-19 pandemic, telehealth became widely utilized for healthcare, including psychological evaluations. However, whether telehealth has reduced or exacerbated healthcare disparities for children with Attention-Deficit/Hyperactivity Disorder (ADHD) remains unclear.

METHODS

Data (race, ethnicity, age, insurance type, ADHD presentation, comorbidities, and distance to clinic) for youth with ADHD (Mage = 10.97, SDage = 3.42; 63.71% male; 51.62% White) were extracted from the medical record at an urban academic medical center. Three naturally occurring groups were compared: those evaluated in person prior to COVID-19 (n =780), in person during COVID-19 (n = 839), and via telehealth during COVID-19 (n = 638).

RESULTS

Children seen via telehealth were significantly more likely to be older, White, have fewer comorbid conditions, and live farther from the clinic than those seen in person.

CONCLUSIONS

The current study suggests that telehealth has not eliminated barriers to care for disadvantaged populations. Providers and institutions must take action to encourage telehealth use among these groups.

Cannabis use in Attention - Deficit/Hyperactivity Disorder (ADHD): A scoping review

INTRODUCTION

Treatments for Adult ADHD include stimulants, two non-stimulant medications, as well as cognitive-behavioral therapy (CBT). These pharmacological agents are often associated with side effects, contributing to poor treatment adherence. Patients with ADHD have regularly stated that cannabis has helped improve their ADHD symptoms; however, scientific literature describing the effects of cannabis on symptoms of ADHD is scarce.

METHODS

We systematically searched MEDLINE, EMBASE, EMCARE, PsycINFO, Web of Science, Cochrane Library, and Clinicaltrials.gov. The searches included all publications in English up to June 27, 2022. We included both experimental and observational studies that assessed the effect of cannabis on ADHD symptomatology and neuropsychiatric outcomes. To synthesize our current understanding of the potential effects of cannabis use on ADHD symptoms and pathophysiology, and the effects of ADHD on cannabis use, data was extracted from each study regarding the characteristics of its population, methods used to assess both cannabis consumption and ADHD symptoms, and key findings.

RESULTS

Our scoping review included a total of 39 studies. Only one study employed a randomized and placebo-controlled design to directly measure the effect of cannabis on ADHD, and no significant effect was observed for the study's primary outcome, the QbTest (Est = -0.17, 95% CI -0.40 to 0.07, p = 0.16). Most of the literature consists of cross-sectional studies that evaluate the association between ADHD severity and cannabis use. 15 studies addressed the neuropsychiatric effects of cannabis on ADHD by employing either a battery of neuropsychiatric tests or neuroimaging. The concentration and amount of THC and CBD used were not well measured in most of the studies. Although some studies indicated that cannabis improved ADHD symptoms, most studies indicated it worsened or had no effect on ADHD symptoms.

CONCLUSIONS

Given the current evidence, cannabis is not recommended for people with ADHD. Limitations of the literature include the absence of objective measurements for cannabis exposure and ADHD symptoms, heterogenous definitions, oversampling, and small sample sizes.

Screening for inattention, hyperactivity and impulsivity in children with haemophilia: A quality improvement intervention

INTRODUCTION

Children with haemophilia have been reported with increased rates of inattention (IN) and hyperactivity/impulsivity (HI) and, therefore, are particularly vulnerable to poor social and academic outcomes.

AIM

To examine the benefit of utilizing a formal screening process for IN/HI in children with haemophilia during comprehensive clinic visits using a quality improvement approach.

METHODS

At a single haemophilia treatment centre, screening for psychosocial issues was expanded and formalised to include (1) the Conners 3^rd Edition (Conners3) screening tool for IN/HI symptoms administered during the standard psychosocial assessment (SPA) by the social worker and school advocacy coordinator, (2) formal pathways to diagnosis and intervention as indicated including psychology consultation, psychological testing, or referral to community-based mental health professionals, and in-person advocacy assistance in the patient's community school.

RESULTS

Forty-four patients, age 9.9 ± 4.8 years (range 3-16) were targeted. The initial screening approach was modified to improve the communication with caretakers during assessments and streamline diagnostic pathways if no, moderate or significant behavioural concerns were identified. Eleven patients had pre-existing mental health diagnoses. Thirteen of the remaining 33 patients (39.4%) received a new mental health diagnosis, ADHD in 8/33 (24.2%). Of the total cohort, 54.5% were found to have a mental health diagnosis. The rate of ADHD (29.5%) was significantly higher than reported in the general population.

CONCLUSION

The described process, developed through a QI approach, allowed formal and objective screening for IN/HI, streamlined a pathway to diagnosis and intervention, and identified undiagnosed disabilities in children with haemophilia improving their access to services.

Sensorimotor integration and motor learning during a novel visuomotor tracing task in young adults with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that has noted alterations to motor performance and coordination, potentially affecting learning processes and the acquisition of motor skills. This work will provide insight into the role of altered neural processing and sensorimotor integration (SMI) while learning a novel visuomotor task in young adults with ADHD. This work compared adults with ADHD (n = 12) to neurotypical controls (n = 16), using a novel visuomotor tracing task, where participants used their right-thumb to trace a sinusoidal waveform that varied in both frequency and amplitude. This learning paradigm was completed in pre, acquisition, and post blocks, where participants additionally returned and completed a retention and transfer test 24 h later. Right median nerve short latency somatosensory-evoked potentials (SEPs) were collected pre and post motor acquisition. Performance accuracy and variability improved at post and retention measures for both groups for both normalized (P < 0.001) and absolute (P < 0.001) performance scores. N18 SEP: increased in the ADHD group post motor learning and decreased in controls (P < 0.05). N20 SEP: increased in both groups post motor learning (P < 0.01). P25: increased in both groups post motor learning (P < 0.001). N24: increased for both groups at post measures (P < 0.05). N30: decreased in the ADHD group and increased in controls (P < 0.05). These findings suggest that there may be differences in cortico-cerebellar and prefrontal processing in response to novel visuomotor tasks in those with ADHD.NEW & NOTEWORTHY Alterations to somatosensory-evoked potentials (SEPs) were present in young adults with attention-deficit/hyperactivity disorder (ADHD), when compared with neurotypical controls. The N18 and N30 SEP peak had differential changes between groups, suggesting alterations to olivary-cerebellar-M1 processing and SMI in those with ADHD when acquiring a novel visuomotor tracing task. This suggests that short-latency SEPs may be a useful biomarker in the assessment of differential responses to motor acquisition in those with ADHD.

U.S. Ninth Graders' Math Course Placement at the Intersection of Learning Disability Status, Race, and Socioeconomic Status

This study integrates an intersectional framework with data on 15,000 U.S. ninth graders from the High School Longitudinal Study of 2009 to investigate differences in ninth-grade math course placement at the intersection of adolescents' learning disability status, race, and socioeconomic status (SES). Descriptive results support an increased liability perspective, with the negative relationship between a learning disability and math course placement larger for adolescents more privileged in terms of their race and/or SES. Adjusted results suggest that the lower math course placements of youth with learning disabilities are due to cumulative disadvantage rather than disability-related inequities in the transition to high school for youth of diverse racial and socioeconomic backgrounds. In addition to demonstrating the importance of intersectional perspectives, this study provides a roadmap for future studies by introducing the new perspective of increased liability to be used in conjunction with the widely employed perspective of multiple marginalization.

Combined Chronic Oral Methylphenidate and Fluoxetine Treatment During Adolescence: Effects on Behavior

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) can be comorbid with depression, often leading to the prescription of both methylphenidate (MP) and selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine (FLX). Moreover, these drugs are often misused as cognitive enhancers. This study examined the effects of chronic oral co-administration of MP and FLX on depressive- and anxiety-like behaviors.

METHODS

Adolescent rats received daily either water (control), MP, FLX, or the combination of MP plus FLX in their drinking water over the course of 4 weeks.

RESULTS

Data analysis shows a decrease in food consumption and body weight for rats exposed to FLX or the combination of MP and FLX. Sucrose consumption was significantly greater in FLX or MP+FLX groups compared to controls. FLX-treated rats showed no effect in the elevated plus maze (EPM; open arm time) and forced swim test (FST; latency to immobility). However, rats treated with the combination (MP+FLX) showed significant anxiolytic-like and anti-depressive-like behaviors (as measured by EPM and FST), as well as significant increases in overall activity (distance traveled in open field test). Finally, the combined MP+FLX treatment induced a decrease in anxiety and depressive- like behaviors significantly greater than the response from either of these drugs alone.

CONCLUSION

These behavioral results characterize the long-term effects of these drugs (orally administered) that are widely co-administered and co-misused and provide important insight into the potential neurobiological and neurochemical effects. Future research will determine the potential risks of the long-term use of MP and FLX together.

Latent class analysis to characterize neonatal risk for neurodevelopmental differences

BACKGROUND

Neonatal risk factors, such as preterm birth and low birth weight, have been robustly linked to neurodevelopmental deficits, yet it is still unclear why some infants born preterm and/or low birth weight experience neurodevelopmental difficulties while others do not. The current study investigated this heterogeneity in neurodevelopmental abilities by examining additional neonatal morbidities as risk factors, utilizing latent class analysis to classify neonates into groups based on similar neonatal risk factors, and including neonates from the full spectrum of gestational age.

METHODS

Neonates who received neonatal care at an academic public hospital during an almost 10-year period (n = 19,951) were included in the latent class analysis, and 21 neonatal indicators of health were used. Neonatal class, sex, and the interaction between neonatal class and sex were used to examine differences in neurodevelopment at 18 months of age in a typically developing population.

RESULTS

The best fitting model included five infant classes: healthy, hypoxic, critically ill, minorly ill, and complicated delivery. Scores on the parent-rated neurodevelopmental measure differed by class such that infants in the critically ill, minorly ill, and complicated delivery classes had lower scores. There was no main effect of sex on the neurodevelopmental measure scores, but the interaction between sex and neonatal class was significant for three out of five neurodevelopmental domains.

CONCLUSIONS

The current study extends the understanding of risk factors in neurodevelopment by including several neonatal medical conditions that are often overlooked and by using a person-centered, as opposed to variable-centered, approach. Future work should continue to examine risk factors, such as maternal health during pregnancy and medical interventions for newborns, in relation to neonatal risks and neurodevelopment by using a person-centered approach.

Neurodevelopmental Disorders: Past, Present, and Future

Recent decades have seen a dramatic increase in neurodevelopmental disorders and the attention paid to them. Since their emergence in the not-so-distant past, some neurodevelopmental disorders have undergone considerable redefinition and, beginning in the 21st century, there has been a massive increase in research. In this paper, we briefly review the history of some of them, address some of the issues that characterize their current management and relationship with neurological pathologies, and share some insights for the future.

Acute effects of concussion among adolescents with attention-deficit/hyperactivity disorder

Adolescents with ADHD have a greater lifetime history of concussion and experience concussion-like symptoms in the absence of a concussion, complicating concussion assessment and management. It is well established that individuals who experience greater acute symptoms following concussion are at risk for slower recovery and persistent symptoms. We examined whether youth with ADHD experience worse acute effects, within the first 72 h following concussion, compared to youth without ADHD. We hypothesized that youth with ADHD would perform worse on neurocognitive testing and endorse more severe symptoms acutely following injury, but the magnitude of change from pre injury to post injury would be similar for both groups, and thus comparable to baseline group differences. The sample included 852 adolescents with pre-injury and post-injury ImPACT results (within 72 h); we also conducted supplementary case-control analyses on a subset of youth with and without ADHD matched on demographics and pre-injury health history. For both samples, there were significant interaction effects for the Verbal Memory and Visual Motor Speed composites (p < 0.01, η²=.01-.07, small-medium effect), such that youth with ADHD showed a greater magnitude of diminished cognitive functioning from pre-injury to post-injury testing. There were no significant differences in the magnitudes of changes from pre injury to post injury with regard to overall symptom reporting (i.e., total symptom severity scores, total number of symptoms endorsed); however, there were group differences in endorsement rates for several individual symptoms. Further research is needed to determine whether such differential acute effects are associated with recovery time in youth with ADHD.

Referring Attention-Deficit/Hyperactivity Disorder: Gaining Perspective From Advanced Practice Providers in Primary Care

The objective of the current study is to identify provider, patient, and family characteristics associated with pediatric advanced practice provider (APP) decisions to refer to a subspecialist for diagnosis and management of attention-deficit/hyperactivity disorder (ADHD). We conducted a cross-sectional electronic survey of pediatric primary care APPs using member lists of professional organizations. T tests and chi-square analysis were conducted to identify group differences. Most respondents rated themselves as comfortable diagnosing and managing ADHD. We found no significant difference between groups based on comfort level or likelihood to refer. APPs working in suburban settings report significantly lower levels of comfort. Self-designation as the practice's primary provider for behavioral/mental health concerns had significantly higher levels of comfort and were less likely to refer. In a limited sample, most APPs reported comfort diagnosing and managing ADHD. Activities to identify and ameliorate gaps in ADHD knowledge and care need to consider this growing part of the workforce.

The impact of educational rewards on the diagnosis of autism spectrum disorder

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder that affects social interactions and communication. The prevalence of ASD has risen dramatically in recent years, but the underlying factors leading to this rise are not clear. In this paper, we test whether changes in state-level educational policy that impact school-level resources are associated with the rise in ASD diagnostic prevalence. Early identification of ASD can improve an array of outcomes for children, and school systems play an important role with identification of the condition. It is plausible that children attending schools with better resources from state governments are more likely to receive an ASD diagnosis and presumably appropriate services. We focus on one educational policy in particular, state-level rewards, which consist of a monetary transfer from state governments to school districts. To test the impact of educational rewards on ASD diagnosis, we rely on policy variation across states and time and estimate both two-way fixed effects (TWFE) models alongside recently advanced methods in the difference-in-differences (DiD) literature. Under a baseline TWFE specification we estimate that rewards policies are associated with a 18.46% increase in ASD diagnosis. Further, using DiD methods that account for bias in settings of differential policy timing, we find that the magnitude of the effect increases to 24.8%. We believe these findings to be suggestive evidence that educational rewards policies improved the likelihood of detection and diagnosis of ASD.

Effect of short-term methylphenidate on social impairment in children with attention deficit/hyperactivity disorder: systematic review

Attention Deficit/Hyperactivity disorder (ADHD) is one of the most common disorders in school-age children. In addition to learning difficulties associated with the disorder's core symptoms of inattention and hyperactivity, children with ADHD display substantial social impairments. Methylphenidate (MPH) in formulations such as Ritalin or Concerta mitigates inattention and hyperactivity, but the effects of the therapy on social behavior in children with ADHD are not clear. This review aims to determine the effectiveness of short term (up to 6 months) MPH treatment on three domains of social skills in children aged 6-14 with ADHD: (i) Recognition of nonverbal emotional expressions, which are a marker of inherent (unlearned) social understanding, (ii) theory of mind (ToM) components that relate to learned cognition and social communication, and (iii) social competence in everyday environments. 15 relevant studies were identified based on inclusion/exclusion criteria. The results show mixed effects: the overall social performance as evaluated by parents, teachers or peers, and some components of ToM, were found to improve following a weeks-long course of MPH treatment. However, the effects of the medication are less clear when evaluating momentary/nonverbal social responses such as reactions to emotional facial expressions. While the findings of this review indicate that an MPH medication regime of order weeks to months could improve, to a degree, social impairment in children with ADHD, more studies are required to identify the medications' mechanism and confirm such a conclusion.

Prevalence of neurodevelopmental disorders among US children and adolescents in 2019 and 2020

Background

Concerning the changes in the prevalence of neurodevelopmental disorders (NDDs), we estimate the prevalence of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), intellectual disorder (ID), and learning disability (LD) among US children and adolescents aged 3-17 years in 2019 and 2020.

Methods

The study includes 14,983 US children and adolescents aged 3-17 years in 2019 and 2020 from the National Health Interview Survey (NHIS). Parents were interviewed about whether their children ever and/or currently had NDDs diagnosed. Prevalence estimates of NDDs were calculated with a survey-based weighting scheme. Logistic regression models were used to estimate the associations between NDDs prevalence and subgroups.

Results

The weighted prevalence of ADHD, ASD, ID, and LD was 8.5% (95% CI: 7.9-9.2%), 2.9% (95% CI: 2.6-3.4%), 1.4% (95% CI: 1.2-1.7%), and 6.4% (95% CI: 5.8-7.0%), respectively. A higher prevalence of ADHD, ASD, ID, and LD was observed in boys, those who ever had anxiety or depression symptoms, those with lower family income, those living in a rented house, ever been bullied, and ever lived with anyone mentally ill.

Conclusion

The study found the prevalence of ADHD, ASD, ID, and LD was different by demographics, comorbidity/mental problems, household/parental characteristics, and stressful life events.

The association between nonpharmacological interventions and quality of life in children with attention deficit hyperactivity disorder: A systematic review

BACKGROUND

Attention deficit hyperactivity disorder is a common psychiatric disorder with a worldwide prevalence of about five percent among children and adolescents. This disorder affects most aspects of their lives e.g., academic performance and social relations, and their overall quality of life is reduced compared to healthy peers. The majority of children with ADHD are treated with medication that potentially has an insufficient effect and/or frequently occurring side effects.

OBJECTIVES

To enable nurses and other health care professionals to guide children with ADHD and their families in their choices of treatment, based on the best available literature on the association between nonpharmacological interventions and quality of life.

DATA SOURCES

A literature search was performed in the databases CENTRAL, Embase, PubMed, CINAHL, and PsycINFO. Seven randomized controlled trials were included in this systematic review. They examined the use of polyunsaturated fatty acids, physical activity, psychoeducation, cognitive therapy, cognitive training, hippotherapy, and behavioral therapy.

CONCLUSIONS

The study of behavioral therapy in the form of a sleep intervention detected an improvement in quality of life which was statistically significant compared to the control group.

IMPLICATIONS FOR PRACTICE

Children with ADHD and a sleep disorder may gain improvement in their quality of life from a sleep intervention.

Local Functional Connectivity as a Parsimonious Explanation of the Main Frameworks for ADHD in Medication-Naïve Adults

Objective: Neuroimaging studies in children with ADHD indicate that their brain exhibits an atypical functional connectivity pattern characterized by increased local connectivity and decreased distant connectivity. We aim to evaluate if the local and distant distribution of functional connectivity is also altered in adult samples with ADHD who have never received medication before. Methods: We compared local and distant functional connectivity between 31 medication-naïve adults with ADHD and 31 healthy controls and tested whether this pattern was associated with symptoms severity scores. Results: ADHD sample showed increased local connectivity in the dACC and the SFG and decreased local connectivity in the PCC. Conclusion: Results parallel those obtained in children samples suggesting a deficient integration within the DMN and segregation between DMN, FPN, and VAN. These results are consistent with the three main frameworks that explain ADHD: the neurodevelopmental delay hypothesis, the DMN interference hypothesis, and multi-network models.

[Increasing methylphenidate abuse: Tracking and profiles during 13-years]

BACKGROUND

Methylphenidate is indicated for attention deficit hyperactivity disorder (ADHD). Several studies have evaluated its abuse in specific populations (students, drug users) and few in the general population. This work describes the extent of its abuse in a region of more than 5 million inhabitants.

METHOD

Based on regional health insurance data from 2005 to 2017, the clustering method identifies different methylphenidate use profiles according to several characteristics (number of different prescribers and pharmacies, number of dispensations, number of defined daily dose dispensed). The groups characterised by high values of these variables will be qualified as "deviant".

RESULTS

In 13 years, the number of patients with at least one dispensation in the first quarter has been multiplied by 5.8 times. The proportion of adults has increased (20% in 2017) and their number has been multiplied by 10. Five groups are identified, three of them are characterised by "deviant" behaviour. Group 5 (n=11, 0.04%) has higher values than 4 (n=112, 0.4%) and 3 (n=407, 1.6%). These patients are older and more frequently use benzodiazepines and opiate substitution drugs. Groups 1 (n=13,132, 51%) and 2 (n=11,941, 46.7%) are more likely to be taken up by young subjects. The number of subjects with "deviant" behaviour increased until 2011 and after a decrease, the highest number of subjects concerned has been observed since 2015.

CONCLUSION

In view of the increase of subjects with "deviant" behaviour, it is necessary to make the medical community and patients aware on the risk of abuse of methylphenidate. The recent extension of the indication for ADHD in adults and the broadening of the conditions of prescription require increased vigilance.

State-Level Estimates of the Prevalence of Parent-Reported ADHD Diagnosis and Treatment Among U.S. Children and Adolescents, 2016 to 2019

OBJECTIVE

To provide state-level estimates of diagnosed ADHD and associated treatment among children in the United States in 2016 to 2019.

METHOD

This study used the National Survey of Children's Health to produce national and state-level estimates of lifetime diagnosis and current ADHD among all children aged 3 to 17 years (n=114,476), and national and state-level estimates of medication and behavioral treatment use among children with current ADHD.

RESULTS

The state-level estimates of diagnosed ADHD ranged from 6.1% to 16.3%. Among children with current ADHD, state-level estimates of ADHD medication usage ranged from 37.8% to 81.4%, and state-level estimates of behavioral treatment ranged from 38.8% to 61.8%.

CONCLUSION

There was substantial state-level variation for indicators of ADHD diagnosis and associated treatment. These state-level results can be used by policymakers, public health practitioners, health care providers, and other stakeholders to help address the service needs of children with ADHD in their states.

Examining the Unified Theory of Behavior Change Constructs Among Adolescents Taking Attention-Deficit/Hyperactivity Disorder Medicine: A Longitudinal Study

OBJECTIVE

To quantitatively validate the preintention factors, behavioral intentions, and implementation factors and examine the relationships theorized by the Unified Theory of Behavior Change (UTBC) model among adolescents with attention-deficit/hyperactivity disorder (ADHD).

METHODS

We conducted longitudinal analyses of data from 40 adolescents with ADHD, aged 11 to 15 years old, and their parents, including self-report of UTBC constructs using standardized measures. We collected pharmacy dispensing records for adolescents for the 4 months that followed. We used bivariate correlations to examine relationships between medication continuity, behavioral intentions, preintention factors, and the implementation factors. We conducted paired sample t-tests to compare adolescent and parent responses on UTBC items.

RESULTS

Adolescents (mean [standard deviation {SD}] age = 13.3 [1.2] years, 75% male, 77.5% non-Hispanic Black, 90% publicly insured) reported a mean total ADHD symptom score = 29.8/54 (SD = 10.94) and mean total impairment score = 18.7/52 (SD = 10.90) and had a mean percentage of days covered with medicine over 4 months = 0.21 (range = 0-0.97). Adolescent intention to take ADHD medicine every school day was significantly related to adolescents' subsequent medication continuity (r = 0.37, P < .05). Adolescent self-concept/image and confidence taking ADHD medicine were the most important factors related to the intention to take ADHD medicine every school day. Adolescents reported less belief and intention to take ADHD medicine and more barriers to taking ADHD medicine compared to their parents.

CONCLUSION

The UTBC model shed light on factors related to subsequent medication use, providing a plausible mechanism for additional research to intervene to promote future medication continuity.

Patterns of longitudinal medical treatment of pediatric patients ever-diagnosed with attention deficit hyperactive disorder: A community-based, retrospective, naturalistic study

BACKGROUND

Pharmacological treatment for ADHD exhibits much variation. Longitudinal prescription-filling trajectories are interesting objects to explore. The goal of this study is to identify distinct patterns of longitudinal prescription filling among pediatric patients who were ever diagnosed with ADHD.

METHODS

Longitudinal data of ADHD-specific prescription filling during 2010-2019 of children diagnosed with ADHD during 2000-2019 who were 4-17-years-old at the time of diagnosis was obtained. Clustering of prescription-filling vectors was performed using K-means.

RESULTS

Analysis of 57,110 prescription vectors yields five distinct patterns: high intensity treatment, from early childhood to late teens (5.7%); moderate intensity, from early childhood to late teens (13.3%); high intensity, from late childhood to late teens (6.1%); moderate intensity, from late childhood to late teens (14.2%); and low intensity, sporadic treatment (60.7%). These patterns correspond with observed clinical presentations.

CONCLUSIONS

Identifying longitudinal prescription-filling patterns substantiates and qualifies the variation in long-term efficacy of pharmacological treatment for ADHD in a treatment-as-usual community setting. Prescription-filling implies that symptoms are present, and that treatment is efficacious, as perceived by parents' and carers. Prolonged pharmacological treatment was perceived to have had a positive net value for 40% of the children, which under appropriate reservations, provides weak evidence of efficacy.

Local Functional Connectivity as a Parsimonious Explanation of the Main Frameworks for ADHD in Medication-Naïve Adults

OBJECTIVE

Neuroimaging studies in children with ADHD indicate that their brain exhibits an atypical functional connectivity pattern characterized by increased local connectivity and decreased distant connectivity. We aim to evaluate if the local and distant distribution of functional connectivity is also altered in adult samples with ADHD who have never received medication before.

METHODS

We compared local and distant functional connectivity between 31 medication-naïve adults with ADHD and 31 healthy controls and tested whether this pattern was associated with symptoms severity scores.

RESULTS

ADHD sample showed increased local connectivity in the dACC and the SFG and decreased local connectivity in the PCC.

CONCLUSION

Results parallel those obtained in children samples suggesting a deficient integration within the DMN and segregation between DMN, FPN, and VAN. These results are consistent with the three main frameworks that explain ADHD: the neurodevelopmental delay hypothesis, the DMN interference hypothesis and multi-network models.

Neuroprotection in late life attention-deficit/hyperactivity disorder: A review of pharmacotherapy and phenotype across the lifespan

For decades, psychostimulants have been the gold standard pharmaceutical treatment for attention-deficit/hyperactivity disorder (ADHD). In the United States, an astounding 9% of all boys and 4% of girls will be prescribed stimulant drugs at some point during their childhood. Recent meta-analyses have revealed that individuals with ADHD have reduced brain volume loss later in life (>60 y.o.) compared to the normal aging brain, which suggests that either ADHD or its treatment may be neuroprotective. Crucially, these neuroprotective effects were significant in brain regions (e.g., hippocampus, amygdala) where severe volume loss is linked to cognitive impairment and Alzheimer's disease. Historically, the ADHD diagnosis and its pharmacotherapy came about nearly simultaneously, making it difficult to evaluate their effects in isolation. Certain evidence suggests that psychostimulants may normalize structural brain changes typically observed in the ADHD brain. If ADHD itself is neuroprotective, perhaps exercising the brain, then psychostimulants may not be recommended across the lifespan. Alternatively, if stimulant drugs are neuroprotective, then this class of medications may warrant further investigation for their therapeutic effects. Here, we take a bottom-up holistic approach to review the psychopharmacology of ADHD in the context of recent models of attention. We suggest that future studies are greatly needed to better appreciate the interactions amongst an ADHD diagnosis, stimulant treatment across the lifespan, and structure-function alterations in the aging brain.

Mind-Wandering and Childhood ADHD: Experimental Manipulations across Laboratory and Naturalistic Settings

The conceptual overlap between mind-wandering and attention-deficit/hyperactivity disorder (ADHD)-related impairments is considerable, yet little experimental research examining this overlap among children is available. The current study aims to experimentally manipulate mind-wandering among children with and without ADHD and examine effects on task performance. Participants were 59 children with ADHD and 55 age-matched controls. Participants completed a novel mind-wandering sustained attention to response task (SART) that included non-self-referential and self-referential stimuli to experimentally increase self-referential mind-wandering, reflected by increases in reaction time variability (RTV) following self-referential stimuli. The ADHD group participated in a classroom study with analogue conditions aimed at encouraging self-referential future-oriented thinking (free play/movie before and after class work) compared to a control condition (newscast) and a cross-over methylphenidate trial. The significant interaction between ADHD status and self-referential stimuli on SART performance indicated that self-referential stimuli led to greater RTV among children with ADHD (within-subject d = 1.29) but not among controls. Methylphenidate significantly reduced RTV among youth with ADHD across self-referential (d = 1.07) and non-self-referential conditions (d = 0.72). In the ADHD classroom study, the significant interaction between mind-wandering condition and methylphenidate indicated that methylphenidate led to higher work completion (ds > 5.00), and the free-play mind-wandering condition had more consistent detrimental effects on productivity (ds ≥ 1.25) than the movie mind-wandering condition. This study is the first to manipulate mind-wandering and assess effects among children with ADHD using a behavioral task. Results provide evidence that children with ADHD are uniquely susceptible to mind-wandering interference.

ADHD misdiagnosis: Causes and mitigators

ADHD diagnoses increase discontinuously by a child's school starting age, with young-for-grade students having much higher ADHD diagnostic rates. Whether these higher rates reflect over-diagnosis or under-diagnosis remains unknown. To decompose this diagnostic discrepancy, we exploit differences in parent and teacher pre-diagnostic assessments within a regression discontinuity strategy based on school starting age. We show that being young-for-grade or male generates over-assessment of symptoms specifically from teacher assessment. However, under-assessments of the oldest students in a grade, especially the oldest females, account for a large part of the observed school starting age assessment gap. We argue that this difference by sex and higher school starting age effects in lower-income schools may exacerbate known gaps in educational attainment by gender and socioeconomic status. Importantly, we fail to find evidence that teachers who receive special education training make such errors.

Body Mass Indices of Girls with and without ADHD: Developmental Trajectories from Childhood to Adulthood

OBJECTIVE

We examined the predictive relation between childhood-diagnosed ADHD and trajectories of body mass index (BMI) from childhood to adulthood in an all-female sample, accounting for socioeconomic status (SES), childhood comorbidities (e.g., depression/anxiety), and stimulant usage. Childhood executive functioning (i.e., planning, sustained attention, and response inhibition) was also evaluated as a possible predictor of BMI trajectories.

METHOD

We utilized longitudinal data from a full sample of 140 girls diagnosed with ADHD in childhood and 88 comparison girls matched on age and ethnicity. Girls were 6-12 years old at the first assessment and followed prospectively for 16 years. Data were collected on their BMI and stimulant medication usage across four evaluation waves. Using latent growth curve modeling, we evaluated the BMI trajectories of girls with ADHD and the comparison sample from childhood to adulthood.

RESULTS

Although there was no significant difference in initial childhood BMI, girls with ADHD increased in BMI at a significantly faster rate than comparison girls across development, even when adjusting for covariates. Significant differences in BMI first emerged in adolescence; by adulthood, 40.2% of the ADHD sample met criteria for obesity versus 15.4% of the comparison sample. When covarying ADHD diagnosis, executive functioning measures were not significantly predictive of BMI increase. Adjusting for stimulant medication usage within the ADHD sample did not alter core findings.

CONCLUSIONS

We discuss health-related implications for girls with ADHD, potential underlying mechanisms, and how our findings may inform both ADHD and obesity interventions.

A phenome-wide association study of polygenic scores for attention deficit hyperactivity disorder across two genetic ancestries in electronic health record data

Testing the association between genetic scores for Attention Deficit Hyperactivity Disorder (ADHD) and health conditions, can help us better understand its complex etiology. Electronic health records linked to genetic data provide an opportunity to test whether genetic scores for ADHD correlate with ADHD and additional health outcomes in a health care context across different age groups. We generated polygenic scores (ADHD-PGS) trained on summary statistics from the latest genome-wide association study of ADHD (N = 55,374) and applied them to genome-wide data from 12,383 unrelated individuals of African-American ancestry and 66,378 unrelated individuals of European ancestry from the Vanderbilt Biobank. Overall, only Tobacco use disorder (TUD) was associated with ADHD-PGS in the African-American ancestry group (Odds ratio [95% confidence intervals] = 1.23[1.16-1.31], p = 9.3 × 10-09 ). Eighty-six phenotypes were associated with ADHD-PGS in the European ancestry individuals, including ADHD (OR[95%CIs] = 1.22[1.16-1.29], p = 3.6 × 10-10 ), and TUD (OR[95%CIs] = 1.22[1.19-1.25], p = 2.8 × 10-46 ). We then stratified outcomes by age (ages 0-11, 12-18, 19-25, 26-40, 41-60, and 61-100). Our results suggest that ADHD polygenic scores are associated with ADHD diagnoses early in life and with an increasing number of health conditions throughout the lifespan (even in the absence of ADHD diagnosis). This study reinforces the utility of applying trait-specific PGSs to biobank data, and performing exploratory sensitivity analyses, to probe relationships among clinical conditions.

Transgenerational Factors Associated With Military Service: Comparison of Children of Veterans and Nonveterans in a Nationally Representative Sample

OBJECTIVE

While the psychological effects of military service on the children of active-duty personnel have been studied extensively, little is known about the potential effects of military service for children of veterans after service has ended.

METHOD

Using nationally representative data from the 2018-2019 National Survey of Children's Health, school-age children of veteran families (n = 4,028) were compared with children of nonveteran families (n = 38,228). Owing to large sample sizes, effect sizes (relative risk and Cohen's d), rather than p values, were used to identify substantial differences in caregiver-reported sociodemographic, clinical, and school performance factors between children and caregivers in families with and without a veteran caregiver. Multivariate analyses were used to adjust for socioeconomic factors that could increase health service use.

RESULTS

Children of veteran families were more likely to have higher family incomes, health insurance, and married caregivers, but were also reported to have higher rates of clinically recognized externalizing behavioral conditions (attention-deficit disorder/attention-deficit/hyperactivity disorder or conduct disorder) (17.6% vs 12.7%; relative risk 1.42; 95% CI 1.21-1.66) and adverse childhood experiences; no substantial differences were reported in clinically recognized anxiety or depression. After adjustment for potentially confounding factors, children in veteran families were still more likely to be reported to have externalizing problems (odds ratio 1.34; 95% CI 1.02-1.77).

CONCLUSION

After adjustment for socioeconomic advantages that may increase health service use, children of veteran families demonstrate substantially higher rates of clinically recognized externalizing problems. While explanations for this require further study, service systems working with veterans may consider integrating child-focused screening/services.