Subthreshold attention-deficit/hyperactivity disorder is associated with functional impairments across domains: a comprehensive analysis in a large-scale community study

Rhinorrhea and watery eyes in infancy and risk of attention-deficit hyperactivity disorder in school-age children

Increased parasympathetic nervous system (PNS) activity is associated with attention-deficit/hyperactivity disorder (ADHD) inattentive symptoms, but not hyperactive-impulsive symptoms, and may contribute to inattentive subtype etiology. Guided by prior work linking infant rhinorrhea and watery eyes without a cold (RWWC) to PNS dysregulation, we examined associations between infant RWWC and childhood ADHD symptoms in a longitudinal cohort of Black and Latinx children living in the context of economic disadvantage (N = 301 youth: 158 females, 143 males). Infant RWWC predicted higher inattentive (relative risk [RR] 2.16, p < .001) but not hyperactive-impulsive (RR 1.53, p = .065) ADHD symptoms (DuPaul scale), administered to caregivers at child age 8-14 years. Stratified analyses revealed that these associations were present in females but not males, who were three times more likely to have higher ADHD current total symptoms if they had infant RWWC than if they did not. Additionally, associations between RWWC and inattention symptoms were observed only in females. RWWC may thus serve as a novel risk marker of ADHD inattentive-type symptoms, especially for females.

Impaired Reactive Control But Preserved Proactive Control in Hyperactive Children

OBJECTIVE

To examine the manifestation of cognitive control deficit of children with different levels of hyperactivity, an "at risk" dimension for ADHD.

METHOD

A group of children with high hyperactivity (N = 40) and another group of children with low levels of hyperactivity (N = 38) performed a modified stop-signal anticipation task, a revised Go/NoGo task, and the AX-continuous performance test (AX-CPT).

RESULTS

Children with higher levels of hyperactivity displayed: (1) significantly prolonged stop signal reaction time (SSRT) in the modified stop-signal anticipation task; (2) no notable differences in commission errors in the revised Go/NoGo task; (3) increased reaction time (RT) in stop-signal task and Go/NoGo task with increased probabilities of stop or NoGo signal; and (4) positive proactive behavioral index scores in AX-CPT.

CONCLUSION

The results suggested that children with heightened hyperactivity exhibited impaired reactive control, especially for responses already underway, but preserved proactive control. Further studies concerning these children are warranted.

ADHD-related sex differences in emotional symptoms across development

To investigate developmental changes in emotion dysregulation (ED) and associated symptoms of emotional lability, irritability, anxiety, and depression, among girls and boys with and without ADHD from childhood through adolescence. Data were collected from a sample of 8-18-year-old children with (n = 264; 76 girls) and without (n = 153; 56 girls) ADHD, with multiple time-points from a subsample of participants (n = 121). Parents and youth completed rating scales assessing child ED, emotional lability, irritability, anxiety, and depression. Mixed effects models were employed to examine effects and interactions of diagnosis, sex [biological sex assigned at birth], age among boys and girls with and without ADHD. Mixed effects analyses showed sexually dimorphic developmental patterns between boys and girls, such that boys with ADHD showed a greater reduction in ED, irritability, and anxiety with age compared to girls with ADHD, whose symptom levels remained elevated relative to TD girls. Depressive symptoms were persistently elevated among girls with ADHD compared to boys with ADHD, whose symptoms decreased with age, relative to same-sex TD peers. While both boys and girls with ADHD showed higher levels of ED during childhood (compared to their sex-matched TD peers), mixed effects analyses revealed substantial sexually dimorphic patterns of emotional symptom change during adolescence: Boys with ADHD showed robust improvements in emotional symptoms from childhood to adolescence while girls with ADHD continued to show high and/or increased levels of ED, emotional lability, irritability, anxiety and depression.

Data-driven profiles of attention-deficit/hyperactivity disorder using objective and ecological measures of attention, distractibility, and hyperactivity

In the past two decades, the traditional nosology of attention-deficit/hyperactivity disorder (ADHD) has been criticized for having insufficient discriminant validity. In line with current trends, in the present study, we combined a data-driven approach with the advantages of virtual reality aiming to identify novel behavioral profiles of ADHD based on ecological and performance-based measures of inattention, impulsivity, and hyperactivity. One hundred and ten Spanish-speaking participants (6-16 years) with ADHD (medication-naïve, n = 57) and typically developing participants (n = 53) completed AULA, a continuous performance test embedded in virtual reality. We performed hybrid hierarchical k-means clustering methods over the whole sample on the normalized t-scores of AULA main indices. A five-cluster structure was the most optimal solution. We did not replicate ADHD subtypes. Instead, we identified two clusters sharing clinical scores on attention indices, susceptibility to distraction, and head motor activity, but with opposing scores on mean reaction time and commission errors; two clusters with good performance; and one cluster with average scores but increased response variability and slow RT. DSM-5 subtypes cut across cluster profiles. Our results suggest that latency of response and response inhibition could serve to distinguish among ADHD subpopulations and guide neuropsychological interventions. Motor activity, in contrast, seems to be a common feature among ADHD subgroups. This study highlights the poor feasibility of categorical systems to parse ADHD heterogeneity and the added value of data-driven approaches and VR-based assessments to obtain an accurate characterization of cognitive functioning in individuals with and without ADHD.

Tools for the Diagnosis of ADHD in Children and Adolescents: A Systematic Review

CONTEXT

Correct diagnosis is essential for the appropriate clinical management of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents.

OBJECTIVE

This systematic review provides an overview of the available diagnostic tools.

DATA SOURCES

We identified diagnostic accuracy studies in 12 databases published from 1980 through June 2023.

STUDY SELECTION

Any ADHD tool evaluation for the diagnosis of ADHD, requiring a reference standard of a clinical diagnosis by a mental health specialist.

DATA EXTRACTION

Data were abstracted and critically appraised by 1 reviewer and checked by a methodologist. Strength of evidence and applicability assessments followed Evidence-based Practice Center standards.

RESULTS

In total, 231 studies met eligibility criteria. Studies evaluated parental ratings, teacher ratings, youth self-reports, clinician tools, neuropsychological tests, biospecimen, EEG, and neuroimaging. Multiple tools showed promising diagnostic performance, but estimates varied considerably across studies, with a generally low strength of evidence. Performance depended on whether ADHD youth were being differentiated from neurotypically developing children or from clinically referred children.

LIMITATIONS

Studies used different components of available tools and did not report sufficient data for meta-analytic models.

CONCLUSIONS

A valid and reliable diagnosis of ADHD requires the judgment of a clinician who is experienced in the evaluation of youth with and without ADHD, along with the aid of standardized rating scales and input from multiple informants across multiple settings, including parents, teachers, and youth themselves.

The ADHD Phenotype in Black and White Girls From Childhood to Adolescence: Results From the Community-Based Pittsburgh Girls Study

OBJECTIVE

The goal of the present study is to describe the ADHD phenotype from childhood to adolescence in Black and White girls in a community sample.

METHOD

Primary caregivers enrolled in the population-based, longitudinal Pittsburgh Girls Study reported on girls' ADHD symptoms and impairment from ages 7 to 17; diagnostic subtypes were estimated based on meeting symptom criteria.

RESULTS

The prevalence of any subtype of ADHD ranged from 6.4 to 9.2% and from 2.3 to 6.4% for Black and White girls respectively; the inattentive subtype was most endorsed. A relatively equal number of new diagnoses at each age was observed. Persistence of ADHD diagnoses was typically 1 to 2 years.

CONCLUSIONS

ADHD in the community is relatively common, with the inattentive subtype as the most common phenotype for Black and White girls. Research on developmentally sensitive periods for symptom exacerbation or new onset of ADHD in girls is needed.

The Clinical Manifestation, Executive Dysfunction, and Caregiver Strain in Subthreshold Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Subthreshold attention-deficit/hyperactivity disorder (ADHD) has been suggested to be a "morbid condition" which also needs medical attention.

METHODS

The present study recruited 89 children with subthreshold ADHD (sADHD), 115 children with diagnosed ADHD (cADHD), and 79 healthy controls (HC) to explore the clinical manifestation, executive functions (EFs) of sADHD, and the caregiver strain. The clinical manifestation was evaluated through clinical interviews and parent-reports. Executive functions were assessed both experimentally and ecologically. Caregiver strain was measured by a parent-reported questionnaire.

RESULTS

For the clinical manifestation, both sADHD and cADHD indicated impairments when compared with HC. The comorbidities and the scaled symptoms indicated that the externalizing behaviors were relatively less serious in sADHD than cADHD, whereas the internalizing behaviors between two groups were comparable. For ecological EFs, sADHD scored between cADHD and HC in inhibition and working memory. For experimental EFs, sADHD was comparable to cADHD in inhibition, shifting, and was worse than cADHD in verbal working memory. For the caregiver strain, all scores of sADHD were between that in cADHD and that in HC.

CONCLUSION

Our present findings supported the suggestion of subthreshold ADHD as "morbid condition," which should be treated with caution in clinical practice, especially for the internalizing behaviors and some key components of EFs.

ADHD symptoms and diurnal cortisol in adolescents: The importance of comorbidities

BACKGROUND

Altered regulation of diurnal cortisol has been associated with both dimensional symptoms and clinical diagnoses of attention deficit-hyperactivity disorder (ADHD). Indeed, a recent meta-analysis suggests that lower diurnal cortisol output may be a biomarker of attention deficit-hyperactivity disorder (ADHD); importantly, however, the influence of psychiatric comorbidities on this association has not been characterized. Approximately two-thirds of children with ADHD have at least one co-occurring neuropsychiatric condition, and altered HPA-axis function has been implicated in many of these conditions. Using dimensional measures of psychopathology, we examined whether comorbid symptoms influence the association of ADHD symptoms with daily cortisol output.

METHODS

138 adolescents (ages 11-15 years) completed measures of symptoms of psychopathology and provided saliva samples over two days. We analyzed whether ADHD symptoms were related to morning, afternoon, and evening cortisol, the cortisol awakening response (CAR) and cumulative daily cortisol (area under the curve with respect to ground [AUCg]) while accounting for symptoms of three psychiatric disorders that are commonly comorbid with ADHD: conduct disorder (CD), anxiety, and depression. In sensitivity analyses, we included symptoms of oppositional defiant disorder (ODD) in place of CD symptoms.

FINDINGS

After controlling for symptoms of CD, anxiety, and depression, ADHD symptoms were associated significantly with higher cumulative diurnal cortisol (AUCg), morning cortisol, and afternoon cortisol. Symptoms of CD, anxiety and depression were not associated significantly with any cortisol metrics; however, in sensitivity analyses, ODD symptoms were associated with lower AUCg and morning cortisol.

DISCUSSION

Our findings highlight the distinct influence of ADHD and externalizing symptoms on cortisol output. Further work is needed to examine the specificity of altered HPA-axis activity as a biomarker of ADHD and to elucidate whether symptoms of ADHD differ in their association with diurnal cortisol as a function of their severity.

Data-Driven Methods for Predicting ADHD Diagnosis and Related Impairment: The Potential of a Machine Learning Approach

Current diagnostic criteria for ADHD include several symptoms that highly overlap in conceptual meaning and interpretation. Additionally, inadequate sensitivity and specificity of current screening tools have hampered clinicians' ability to identify those at risk for related outcomes. Using machine learning techniques, the current study aimed to propose a novel algorithm incorporating key ADHD symptoms to predict concurrent and future (i.e., five years later) ADHD diagnosis and related impairment levels. Participants were 399 children with and without ADHD; multiple informant measures of ADHD symptoms, global impairment, academic performance, and social skills were included as part of an accelerated longitudinal design. Results suggested eight symptoms as most important in predicting impairment outcomes five years later: (1) Has difficulty sustaining attention in tasks or play activities, (2) Does not follow through on instructions and fails to finish work, (3) Has difficulty organizing tasks and activities, (4) Avoids tasks (e.g., schoolwork, homework) that require sustained mental effort, (5) Is often easily distracted, (6) Is often forgetful in daily activities, (7) Fidgets with hands or feet or squirms in seat, and (8) Interrupts/intrudes on others. The algorithm comprising this abbreviated list of symptoms performed just as well as or significantly better than one comprising all 18 symptoms in predicting future global impairment and academic performance, but not social skills. It also predicted concurrent and future ADHD diagnosis with 81-93% accuracy. Continued development of screening tools will be key to ensuring access to clinical services for youth at risk for ADHD.

Multi-Trajectories of Conduct Problems, Hyperactivity/Inattention, and Peer Problems Across Childhood: Results from the Growing Up in Scotland Birth Cohort

Using a person-centred approach, this study inspected multi-trajectories of conduct problems, hyperactivity/inattention and peer problems, and associated risk factors for group membership. The sample included 3,578 children (50.8% males) from a population birth cohort in Scotland (Growing Up in Scotland). The parental version of the Strengths and Difficulties Questionnaire (SDQ) was used when children were 4, 5, 6, 7, and 10 years old. Antecedent factors at the perinatal, child, and family levels were collected using parental reports, observation, and standardised assessments at 10, 24, and 36 months. A group-based multi-trajectory analysis was employed. Findings showed that a six-group model best fit the data. Identified groups included non-engagers, normative, decreasing externalising/low peer problems, low externalising/moderate peer problems, moderate externalising/increasing peer problems and multimorbid moderate-high chronic. Findings suggest multimorbidity between externalising behaviours and peer problems in the more elevated groups. Two common protective factors emerged across all groups: caregiver mental health and parent-infant attachment. Identified risk factors were specific to group membership. Risk factors for the most elevated group included single-parent status, social deprivation, previous neonatal intensive care unit admission, child sex, whilst children's expressive language was a protective factor. Taken together, findings contribute to the emerging literature modelling trajectories of externalising behaviours and peer problems simultaneously and have important practical implications for prevention of problems in childhood, by identifying targets at the perinatal, child, and family levels.

Multi-Trajectories of Conduct Problems, Hyperactivity/Inattention, and Peer Problems Across Childhood: Results from the Growing Up in Scotland Birth Cohort

Using a person-centred approach, this study inspected multi-trajectories of conduct problems, hyperactivity/inattention and peer problems, and associated risk factors for group membership. The sample included 3,578 children (50.8% males) from a population birth cohort in Scotland (Growing Up in Scotland). The parental version of the Strengths and Difficulties Questionnaire (SDQ) was used when children were 4, 5, 6, 7, and 10 years old. Antecedent factors at the perinatal, child, and family levels were collected using parental reports, observation, and standardised assessments at 10, 24, and 36 months. A group-based multi-trajectory analysis was employed. Findings showed that a six-group model best fit the data. Identified groups included non-engagers, normative, decreasing externalising/low peer problems, low externalising/moderate peer problems, moderate externalising/increasing peer problems and multimorbid moderate-high chronic. Findings suggest multimorbidity between externalising behaviours and peer problems in the more elevated groups. Two common protective factors emerged across all groups: caregiver mental health and parent-infant attachment. Identified risk factors were specific to group membership. Risk factors for the most elevated group included single-parent status, social deprivation, previous neonatal intensive care unit admission, child sex, whilst children's expressive language was a protective factor. Taken together, findings contribute to the emerging literature modelling trajectories of externalising behaviours and peer problems simultaneously and have important practical implications for prevention of problems in childhood, by identifying targets at the perinatal, child, and family levels.

Attention-Deficit/Hyperactivity Disorder: Restricted Phenotypes Prevalence, Comorbidity, and Polygenic Risk Sensitivity in the ABCD Baseline Cohort

OBJECTIVE

To evaluate the prevalence and major comorbidities of ADHD using different operational definitions in a newly available national dataset and to test the utility of operational definitions against genetic and cognitive correlates.

METHOD

The US Adolescent Brain Cognitive Development (ABCD) Study enrolled 11,878 children aged 9-10 years at baseline. ADHD prevalence, comorbidity, and association with polygenic risk score and laboratory-assessed executive functions were calculated at 4 thresholds of ADHD phenotype restrictiveness. Bias from missingness, sampling, and nesting were addressed statistically.

RESULTS

Prevalence of current ADHD for 9- to 10-year old children was 3.53% (95% CI 3.14%-3.92%) when Computerized Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-COMP) score and parent and teacher ratings were required to converge. Of ADHD cases so defined, 70% had a comorbid psychiatric disorder. After control for overlapping comorbidity and ruling out for psychosis or low IQ, 30.9% (95% CI 25.7%-36.7%) had a comorbid disruptive behavior disorder, 27.4% (95% CI 22.3%-33.1%) had an anxiety or fear disorder, and 2.1% (95% CI 1.2%-3.8%) had a mood disorder. Children in the top decile of polygenic load incurred a 63% increased chance of having ADHD vs the bottom half of polygenic load (p < .01)-an effect detected only with a stringent phenotype definition. Dimensional latent variables for irritability, externalizing, and ADHD yielded convergent results for cognitive correlates.

CONCLUSION

This fresh estimate of national prevalence of ADHD in the United States suggests that the DSM-5 definition requiring multiple informants yields a prevalence of about 3.5%. Results may inform further ADHD studies in the ABCD sample.

White matter disruptions related to inattention and autism spectrum symptoms in tuberous sclerosis complex

Tuberous sclerosis complex is a rare genetic multisystem condition that is associated with a high prevalence of neurodevelopmental disorders such as autism and attention-deficit/hyperactivity disorder. The underlying neural mechanisms of the emergence of these symptom domains in tuberous sclerosis complex remain unclear. Here, we use fixel-based analysis of diffusion-weighted imaging, which allows for the differentiation between multiple fibre populations within a voxel, to compare white matter properties in 16 participants with tuberous sclerosis complex (aged 11-19) and 12 age and sex matched control participants. We further tested associations between white matter alterations and autism and inattention symptoms as well as cognitive ability in participants with tuberous sclerosis complex. Compared to controls, participants with tuberous sclerosis complex showed reduced fibre density cross-section (FDC) in the dorsal branch of right superior longitudinal fasciculus and bilateral inferior longitudinal fasciculus, reduced fibre density (FD) in bilateral tapetum, and reduced fibre cross-section (FC) in the ventral branch of right superior longitudinal fasciculus. In participants with tuberous sclerosis complex, the extent of FDC reductions in right superior longitudinal fasciculus was significantly associated with autism traits (social communication difficulties and restricted, repetitive behaviours), whereas FDC reductions in right inferior longitudinal fasciculus were associated with inattention. The observed white matter alterations were unrelated to cognitive ability. Our findings shed light on the fibre-specific biophysical properties of white matter alterations in tuberous sclerosis complex and suggest that these regional changes are selectively associated with the severity of neurodevelopmental symptoms.

Deficits in attention, motor control and perception childhood to age 30 years: prospective case-control study of outcome predictors

OBJECTIVE

Investigate predictors of adverse outcome in children with and without attention-deficit/hyperactivity disorder (ADHD) combined with developmental coordination disorder (DCD) at 6 years of age.

DESIGN

Prospective population-based cohort study.

SETTING

Western Sweden.

PARTICIPANTS

From a screening-based population cohort of 589 individuals, 62 (11 female) diagnosed with ADHD+DCD at mean age 6.6 years, and a comparison group of 51 population-matched (10 female) children were followed prospectively.

OUTCOME MEASURES

Drawn from a clinical reassessment at age 9 years of 110 of the 113 individuals, neuropsychiatric symptoms, continuous performance test results and measures of motor function were used as predictors of outcome in linear regression models. Participants were followed in national registers up to 30-31 years of age for outcomes in adulthood. Predictors were regressed onto an adverse outcome score (range 0-7) comprising seven binary endpoints, and when applicable onto each continuous outcome separately (low educational attainment, low occupation level, psychiatric disorder, psychotropic medication prescription, sick pension, high dependence on social benefits and criminal conviction).

RESULTS

Of the 110 individuals, 3 had died. In univariable regression onto the adverse outcome score, the strongest predictors at age 9 years were symptoms of conduct disorder, oppositional defiant disorder, ADHD and motor dysfunction, with an R² around 25%, followed by autistic traits (R²=15%) and depressive symptoms (R²=8%). Combining these six strongest predictors in a multivariable model yielded an adjusted R²=38%. Subgroup analyses were similar, except for a strong association of autistic traits with the adverse outcome score in females (n=20, R²=50%).

CONCLUSION

Several neurodevelopmental symptoms, including ADHD severity at age 9 years, accounted for a considerable amount of the variance in terms of adulthood adverse outcome. Broad neurodevelopmental profiling irrespective of diagnostic thresholds should inform research and clinical practice. The study highlights the importance of considering associated comorbidities and problems in ADHD.

Clinical characteristics, neuroimaging findings, and neuropsychological functioning in attention-deficit hyperactivity disorder: Sex differences

Recent clinical studies, in both children/adolescents and adults, have shown the extreme neuropsychological heterogeneity of attention-deficit hyperactivity disorder (ADHD): specific neuropsychological deficits have been found only in a minority of individuals, with no direct correlation between discrete cognitive performances and the trajectory of clinical symptoms. Deficits in specific neuropsychological functions may be common in ADHD, but nevertheless no cognitive or neuropsychological profile may fully explain the disorder. Sex differences in the ADHD presentation, both at a neuropsychological and clinical level, also contribute to this clinical and neuropsychological heterogeneity. At a neuropsychological level, females with ADHD may show greater working memory problems, poorer vocabulary skills and worse visual spatial reasoning. Structural and functional imaging study also show discrete differences across sex; however, the great majority of clinical studies mainly or exclusively include male participants with insufficient data to draw firm conclusions on sex differences within the disorder. Here, we report the recent literature data, discussing still open research questions about the clinical presentation, neuroimaging findings, and neuropsychological functioning in ADHD with a focus on the impact of sex differences-a deeper insight in these unresolved issues may have relevant clinical and therapeutic implications for tailored, effective, and long-lasting interventions.

Cognitive Control Deficits in Children With Subthreshold Attention-Deficit/Hyperactivity Disorder

Subthreshold Attention-Deficit/Hyperactivity Disorder (ADHD) is defined as a neurobiological condition with some core inattentive or hyperactive/impulsive symptoms of ADHD which do not meet the full diagnosis clinically. Although it has been well documented that deficits in cognitive control, a high-level cognitive construct closely related to attention, are frequently found among children with ADHD, whether subthreshold ADHD is also associated with similar deficits remains unclear. In this study, we examined the attention functions and the cognitive control capacity (CCC) in children with ADHD (n = 39), those with subthreshold ADHD (n = 34), and typically developing peers (TD, n = 36). The results showed that the ADHD and subthreshold ADHD groups exhibited similar patterns of the impaired executive function of attention (revealed as an augment in flanker conflict effect) and reduced cognitive control capacity, and no significant difference was found between the two groups. These findings suggest that although children with subthreshold ADHD have not met the full criteria of ADHD, they showed reduced efficiency in cognitive control and attention function, similar to children with ADHD.

Two meta-analyses of the association between atopic diseases and core symptoms of attention deficit hyperactivity disorder

Studies in the field of neuroscience and psychology have hypothesized that a causal association exists between atopic diseases and attention-deficit/hyperactivity disorder (ADHD). Previous systematic reviews and meta-analyses have reported a higher risk of ADHD in children with atopic diseases; however, the relationship between ADHD symptoms and atopic diseases remains unclear. We systematically reviewed observational cross-sectional and longitudinal studies to investigate the relationship between atopic diseases and ADHD symptom severity (hyperactivity/impulsivity and inattention). The majority of studies showed a statistically significant association between atopic diseases and both ADHD symptoms, with substantial heterogeneity in the outcome of hyperactivity/impulsivity. Remarkably decreased heterogeneity and statistical significance were observed in the second meta-analysis of ADHD-related behavior symptoms in atopic patients without ADHD. Our study indicated that atopic diseases not only associated with ADHD but also ADHD symptoms severity. This association was even observed in children with subthreshold ADHD, indicating that atopic diseases may play a role in the spectrum of ADHD symptom severity. Trial registration: This study was registered on PROSPERO (registration ID: CRD42020213219).

Synthesising the existing evidence for non-pharmacological interventions targeting outcomes relevant to young people with ADHD in the school setting: systematic review protocol

BACKGROUND

Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) have impairing levels of difficulty paying attention, impulsive behaviour and/or hyperactivity. ADHD causes extensive difficulties for young people at school, and as a result these children are at high risk for a wide range of poor outcomes. We ultimately aim to develop a flexible, modular 'toolkit' of evidence-based strategies that can be delivered by primary school staff to improve the school environment and experience for children with ADHD; the purpose of this review is to identify and quantify the evidence-base for potential intervention components. This protocol sets out our plans to systematically identify non-pharmacological interventions that target outcomes that have been reported to be of importance to key stakeholders (ADHD symptoms, organisation skills, executive-global- and classroom-functioning, quality of life, self-esteem and conflict with teachers and peers). We plan to link promising individual intervention components to measured outcomes, and synthesise the evidence of effectiveness for each outcome.

METHODS

A systematic search for studies published from the year 2000 that target the outcomes of interest in children and young people aged 3-12 will be conducted. Titles and abstracts will be screened using prioritisation software, and then full texts of potentially eligible studies will be screened. Systematic reviews, RCTs, non-randomised and case-series studies are eligible designs. Synthesis will vary by the type of evidence available, potentially including a review of reviews, meta-analysis and narrative synthesis. Heterogeneity of studies meta-analysed will be assessed, along with publication bias. Intervention mapping will be applied to understand potential behaviour change mechanisms for promising intervention components.

DISCUSSION

This review will highlight interventions that appear to effectively ameliorate negative outcomes that are of importance for people with ADHD, parents, school staff and experts. Components of intervention design and features that are associated with effective change in the outcome will be delineated and used to inform the development of a 'toolkit' of non-pharmacological strategies that school staff can use to improve the primary school experience for children with ADHD.

TRIAL REGISTRATION

PROSPERO number CRD42021233924.

Resting-State Brain Variability in Youth With Attention-Deficit/Hyperactivity Disorder

In this study, we sought to determine the nature of the abnormality in resting-state default mode network (DMN) activation and explore its correlation with functional connectivity in attention-deficit/hyperactivity disorder (ADHD). We obtained resting-state functional magnetic resonance images of youth with ADHD and typically developing counterparts from the publicly available ADHD-200 database. We used data from Peking University (232 scans) and New York University (172 scans); the scan repetition time was 2 s for both data collection sites. We applied generalized estimating equations to estimate the variability of the averaged blood-oxygen-level-dependent (BOLD) time series extracted from the DMN at rest. We performed network-based statistics to determine the association between the observed differences in BOLD signal variability and altered functional connectivity. We analyzed data from 105 youth with ADHD (age: mean 12.17, standard deviation 2.31, median 12.25; 15.2% female, 84.8% male) and 140 typically developing youth (age: mean 11.99, standard deviation 2.28, median 11.85; 47.1% female, 52.9% male), who aged 7-17 years. The imaging data were cross-sectionally collected for each participant at one time point. We observed a greater number of significant BOLD signal changes and higher-order polynomial significant associations in youth with ADHD. Moreover, there were significant between-group differences in BOLD signal change after the first 140 s, which coincided with decreased resting-state functional connectivity within the DMN in youth with ADHD. Increased variability of neural signaling was intermittently observed in the brains of youth with ADHD at rest, thereby indicating their default mode state was more unstable than that of typically developing youth.

Facial emotion recognition impairment predicts social and emotional problems in children with (subthreshold) ADHD

Children with attention-deficit/hyperactivity disorder (ADHD) symptoms often experience social and emotional problems. Impaired facial emotion recognition has been suggested as a possible underlying mechanism, although impairments may depend on the type and intensity of emotions. We investigated facial emotion recognition in children with (subthreshold) ADHD and controls using a novel task with children's faces of emotional expressions varying in type and intensity. We further investigated associations between emotion recognition accuracy and social and emotional problems in the ADHD group. 83 children displaying ADHD symptoms and 30 controls (6-12 years) completed the Morphed Facial Emotion Recognition Task (MFERT). The MFERT assesses emotion recognition accuracy on four emotions using five expression intensity levels. Teachers and parents rated social and emotional problems on the Strengths and Difficulties Questionnaire. Repeated measures analysis of variance revealed that the ADHD group showed poorer emotion recognition accuracy compared to controls across emotions (small effect). The significant group by expression intensity interaction (small effect) showed that the increase in accuracy with increasing expression intensity was smaller in the ADHD group compared to controls. Multiple regression analyses within the ADHD group showed that emotion recognition accuracy was inversely related to social and emotional problems, but not prosocial behavior. Not only children with an ADHD diagnosis, but also children with subthreshold ADHD experience impairments in facial emotion recognition. This impairment is predictive for social and emotional problems, which may suggest that emotion recognition may contribute to the development of social and emotional problems in these children.

Infant Attentional behaviors Are Associated With ADHD Symptomatology and Executive Function in Early Childhood

Objective: We explored associations between infant attentional behaviors as measured by the First Year Inventory (FYIv2.0) and dimensional ratings of ADHD symptomatology and executive function (EF) in early childhood. Methods: This study included parents (N = 229) who filled out the FYIv2.0 when their children were 12 months of age. When children were approximately 54 months (4.5 years) of age, parents completed reports of children's ADHD symptomatology and EF abilities. Correlation and regression analyses were conducted among measures. Results: We found significant associations among the variables of interest, both cross-sectionally and longitudinally, as well as gender differences. Notably, non-social sensory attention (NSA) was significantly related to 54-month ADHD symptom severity. All three 12-month attention variables were significantly related to 54-month EF. Conclusion: Results suggest that infant attentional behaviors predict later ADHD-related behaviors in early childhood. Future research should explore associations using laboratory-based measures and could inform early intervention efforts.

At-risk early adolescents profiles in the community: A cluster analysis using the strengths and difficulties questionnaire

Early adolescence, with its several changes and demands, represents a delicate period of life. Several studies highlighted that during early adolescence, emotional and behavioral problems tend to increase. Using a person-centered approach, the present study explored the emotional and behavioral functioning profiles in a sample of Italian preadolescent students. Participants were 2959 youths (1533 males and 1426 females; age 10-14 years); they completed the Strengths and Difficulties Questionnaire (SDQ) and the Inventory of Callous Unemotional traits (ICU). Findings revealed four different profiles: "no psychopathology" (41.5%), "low psychopathology with sub-threshold hyperactivity" (33%), "predominantly internalizing" (19%), and "predominantly externalizing" (6.5%). The two latter clusters are characterized by high levels of SDQ Total Score. The "predominantly internalizing" is distinguished by a higher prevalence of females, and the "predominantly externalizing" by a higher prevalence of males and higher CU traits. A person-oriented approach allowed for identifying subgroups of early adolescents who may significantly vary in their configuration of internalizing and externalizing problems. Such subgroups may reflect youths for whom the creation of prevention and intervention programs could be more tailored.

Characterisation of neurodevelopmental and psychological outcomes in CHD: a research agenda and recommendations from the cardiac neurodevelopmental outcome collaborative

The Neurodevelopmental and Psychological Outcomes Working Group of the Cardiac Neurodevelopmental Outcome Collaborative was formed in 2018 through support from an R13 grant from the National Heart, Lung, and Blood Institute with the goals of identifying knowledge gaps regarding the neurodevelopmental and psychological outcomes of individuals with CHD and investigations needed to advance science, policy, clinical care, and patient/family outcomes. Accurate characterisation of neurodevelopmental and psychological outcomes in children with CHD will drive improvements in patient and family outcomes through targeted intervention. Decades of research have produced a generalised perspective about neurodevelopmental and psychological outcomes in this heterogeneous population. Future investigations need to shift towards improving methods, measurement, and analyses of outcomes to better inform early identification, prevention, and intervention. Improved definition of underlying developmental, neuropsychological, and social-emotional constructs is needed, with an emphasis on symptom networks and dimensions. Identification of clinically meaningful outcomes that are most important to key stakeholders, including patients, families, schools and providers, is essential, specifically how and which neurodevelopmental differences across the developmental trajectory impact stakeholders. A better understanding of the discontinuity and patterns of neurodevelopment across the lifespan is critical as well, with some areas being more impactful at some ages than others. Finally, the field needs to account for the impact of race/ethnicity, socio-economic status, cultural and linguistic diversity on our measurement, interpretation of data, and approach to intervention and how to improve generalisability to the larger worldwide population of patients and families living with CHD.

Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review

IMPORTANCE

Reported increases in attention-deficit/hyperactivity disorder (ADHD) diagnoses are accompanied by growing debate about the underlying factors. Although overdiagnosis is often suggested, no comprehensive evaluation of evidence for or against overdiagnosis has ever been undertaken and is urgently needed to enable evidence-based, patient-centered diagnosis and treatment of ADHD in contemporary health services.

OBJECTIVE

To systematically identify, appraise, and synthesize the evidence on overdiagnosis of ADHD in children and adolescents using a published 5-question framework for detecting overdiagnosis in noncancer conditions.

EVIDENCE REVIEW

This systematic scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews and Joanna Briggs Methodology, including the PRISMA-ScR Checklist. MEDLINE, Embase, PsychINFO, and the Cochrane Library databases were searched for studies published in English between January 1, 1979, and August 21, 2020. Studies of children and adolescents (aged ≤18 years) with ADHD that focused on overdiagnosis plus studies that could be mapped to 1 or more framework question were included. Two researchers independently reviewed all abstracts and full-text articles, and all included studies were assessed for quality.

FINDINGS

Of the 12 267 potentially relevant studies retrieved, 334 (2.7%) were included. Of the 334 studies, 61 (18.3%) were secondary and 273 (81.7%) were primary research articles. Substantial evidence of a reservoir of ADHD was found in 104 studies, providing a potential for diagnoses to increase (question 1). Evidence that actual ADHD diagnosis had increased was found in 45 studies (question 2). Twenty-five studies showed that these additional cases may be on the milder end of the ADHD spectrum (question 3), and 83 studies showed that pharmacological treatment of ADHD was increasing (question 4). A total of 151 studies reported on outcomes of diagnosis and pharmacological treatment (question 5). However, only 5 studies evaluated the critical issue of benefits and harms among the additional, milder cases. These studies supported a hypothesis of diminishing returns in which the harms may outweigh the benefits for youths with milder symptoms.

CONCLUSIONS AND RELEVANCE

This review found evidence of ADHD overdiagnosis and overtreatment in children and adolescents. Evidence gaps remain and future research is needed, in particular research on the long-term benefits and harms of diagnosing and treating ADHD in youths with milder symptoms; therefore, practitioners should be mindful of these knowledge gaps, especially when identifying these individuals and to ensure safe and equitable practice and policy.

Gray matter networks associated with attention and working memory deficit in ADHD across adolescence and adulthood

Attention-deficit/hyperactivity disorder (ADHD) is a childhood-onset neuropsychiatric disorder and may persist into adulthood. Working memory and attention deficits have been reported to persist from childhood to adulthood. How neuronal underpinnings of deficits differ across adolescence and adulthood is not clear. In this study, we investigated gray matter of two cohorts, 486 adults and 508 adolescents, each including participants from ADHD and healthy controls families. Two cohorts both presented significant attention and working memory deficits in individuals with ADHD. Independent component analysis was applied to the gray matter of each cohort, separately, to extract cohort-inherent networks. Then, we identified gray matter networks associated with inattention or working memory in each cohort, and projected them onto the other cohort for comparison. Two components in the inferior, middle/superior frontal regions identified in adults and one component in the insula and inferior frontal region identified in adolescents were significantly associated with working memory in both cohorts. One component in bilateral cerebellar tonsil and culmen identified in adults and one component in left cerebellar region identified in adolescents were significantly associated with inattention in both cohorts. All these components presented a significant or nominal level of gray matter reduction for ADHD participants in adolescents, but only one showed nominal reduction in adults. Our findings suggest although the gray matter reduction of these regions may not be indicative of persistency of ADHD, their persistent associations with inattention or working memory indicate an important role of these regions in the mechanism of persistence or remission of the disorder.

Effectiveness of Specific Techniques in Behavioral Teacher Training for Childhood ADHD: A Randomized Controlled Microtrial

Objective: Behavioral teacher training is the most effective classroom-based intervention for children with attention-deficit/hyperactivity disorder (ADHD). However, it is currently unknown which components of this intervention add to its effectiveness and for whom these are effective.

Method: In this microtrial, teachers of 90 children with impairing levels of ADHD symptoms (6–12 years) were randomly assigned to one of three conditions: a short (2 sessions), individualized intervention consisting of either (A) antecedent-based techniques (stimulus control), (B) consequent-based techniques (contingency management) or (C) waitlist. Primary outcome was the average of five daily assessments of four individualized problem behaviors, assessed pre and post intervention and three months later. Moderation analyses were conducted to generate hypotheses on child, teacher and classroom factors that may contribute to technique effectiveness.

Results: Multilevel analyses showed that both antecedent- and consequent-based techniques were equally and highly effective in reducing problem behaviors compared to the control condition (Cohen’s d =.9); effects remained stable up to three months later. Child’s age and class size were moderators of technique effectiveness. For younger children, consequent-based techniques were more effective than antecedent-based techniques, whereas for older children the effect was in the opposite direction. Further, beneficial effects of antecedent-based techniques increased when the number of students per class decreased, whilst effectiveness of consequent-based techniques did not depend on class size.

Conclusions: This study shows that both antecedent- and consequent-based techniques are highly effective in reducing problem behavior of children with ADHD. Interventions may be adapted to the child’s age and class size.

The Effects of Family Transitions on Depressive Symptoms: Differences among Young Adults with and without Childhood Symptoms of Attention-Deficit/ Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is tied to higher levels of depression, but the social factors that shape these associations are not well understood. This study considers whether family transitions affect depressive symptoms differently for young adults with and without childhood symptoms of ADHD at subthreshold or diagnostic levels. Between-within regression analysis of nationally representative longitudinal survey data shows that transitions into cohabitation and parenthood affect depressive symptoms differently for young adults with and without childhood symptoms of ADHD. Specifically, within-person effects indicate that transitions into cohabitation and parenthood are tied to decreases in depressive symptoms, but only for young adults without childhood symptoms of ADHD. In contrast, transitions into marriage are tied to decreases in depressive symptoms, and transitions out of coresidential unions are tied to increases in depressive symptoms, regardless of childhood symptoms of ADHD. The results suggest that some family transitions may work to widen ADHD disparities in depression, under-scoring the importance of family contexts for shaping mental health throughout the life course.

ADHD at Age 7 and Functional Impairments at Age 10

BACKGROUND AND OBJECTIVES

Attention-deficit/hyperactivity disorder (ADHD) cohort studies have typically involved clinical samples and have usually recruited children across wide age ranges, limiting generalizability across complexity and developmental stage. We compared academic, emotional-behavioral and social functioning at age 10, and predictors of outcomes, in a nonreferred cohort of children recruited at age 7, between those with full-syndrome (FS) ADHD and controls with no ADHD.

METHODS

This was a prospective cohort study with a 3-year follow-up period. Children were recruited from 43 socioeconomically diverse schools in Melbourne, Australia. Multi-informant outcomes at age 10 were academic functioning (Wide Range Achievement Test 4; Social Skills Improvement System), emotional-behavioral functioning (Strengths and Difficulties Questionnaire total), and social functioning (Strengths and Difficulties Questionnaire peer problems). Outcomes were compared across the groups by using adjusted random-effects linear regression analyses.

RESULTS

In total, 477 children (62% male) were recruited at a mean (SD) age of 7.3 years (0.4). There were 179 participants with FS ADHD, 86 with ST ADHD, and 212 controls. Sample retention was 78.2% at 3-year follow-up. Both the FS and ST groups were functioning worse than controls on almost all outcome measures. The best predictors of outcome for children with ADHD were working memory (academic outcome, P < .001), ADHD symptom severity (emotional-behavioral outcome, parent: P < .001; teacher: P < .01), and autism spectrum disorder symptoms (emotional-behavioral outcome, parent P = .003; social outcome, parent P = .001).

CONCLUSIONS

Children with FS and ST ADHD at age 7 experience persisting functional impairments across domains at age 10. The predictors identified at age 7 present potential targets for intervention to ameliorate impairments.

Cognitive and electrophysiological markers of adult full syndrome and subthreshold attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) has been often referred to as an executive function deficit disorder with a specific electrophysiological signature. Although previous research suggests that individuals with subthreshold symptoms also suffer from severe impairments in daily life, only few studies have investigated cognitive and neural alterations in this group. Here, we explored impairments in executive functions and their electrophysiological correlates in a sample of adults with full syndrome (N = 113) and subthreshold (N = 46) ADHD compared to controls (N = 42). Results suggest that adults with full syndrome ADHD exhibit more executive function deficits than controls, while there were no electrophysiological differences found between groups. Also, we observed only small differences in neuropsychological variables between subthreshold ADHD and controls and no evidence for altered neural activity in the resting state. While subthreshold ADHD was not associated with altered executive functions or abnormal electrophysiological activity, this group reported significant psychological impairments and comorbidity.

ADHD symptoms and their neurodevelopmental correlates in children born very preterm

This study investigated the association between attention-deficit/hyperactivity disorder (ADHD) symptomatology in preschool-aged children who were born very preterm (<33 weeks) and cognitive outcomes, clinical risk and socio-demographic characteristics. 119 very preterm children who participated in the Evaluation of Preterm Imaging Study at term-equivalent age were assessed at a mean age of 4.5 years. Parents completed the ADHD Rating Scale IV, a norm-referenced checklist that evaluates ADHD symptomatology according to diagnostic criteria, and the Behavior Rating Inventory of Executive Function-Preschool version. Children completed the Wechsler Preschool and Primary Scales of Intelligence and the Forward Digit Span task. Longitudinal data including perinatal clinical, qualitative MRI classification, socio-demographic variables and neurodevelopmental disabilities were investigated in relation to ADHD symptomatology. All results were corrected for multiple comparisons using false discovery rate. Results showed that although the proportion of very preterm children with clinically significant ADHD did not differ from normative data after excluding those with neurodevelopmental disabilities, 32.7% met criteria for subthreshold ADHD inattentive type and 33.6% for combined type, which was higher than the expected 20% in normative samples. Higher ADHD symptom scores (all) were associated with greater executive dysfunction (inhibitory self-control, flexibility, and emergent metacognition, corrected p<0.001 for all tests). Higher inattentive ADHD symptom scores were associated with lower IQ (ρ = -0.245, p = 0.011) and higher perinatal clinical risk (more days on mechanical ventilation (ρ = 0.196, p = 0.032) and more days on parenteral nutrition (ρ = 0.222, p = 0.015). Higher hyperactive ADHD symptom scores instead were associated with lower socio-economic status (ρ = 0.259, p = 0.004). These results highlight the importance of monitoring and supporting the development of very preterm children throughout the school years, as subthreshold ADHD symptoms represent risk factors for psychosocial problems and for receiving a future clinical diagnosis of ADHD.

The clinical relevance of asking young psychiatric patients about childhood ADHD symptoms

Aim: The aim of this study was to explore the relevance of asking young psychiatric patients about childhood symptoms of attention deficit hyperactivity disorder (ADHD).Method: A total of 180 young adults (18-25 years of age) from a general psychiatric out-patient clinic in Uppsala filled in the Child and Adolescent Psychiatric Screening Inventory-Retrospect (CAPSI-R) as part of the diagnostic procedure. The study population was divided into groups based on number and subtype of reported ADHD symptoms, inattention (IN) or hyperactivity/impulsivity (HI). The clinical characteristics associated with different symptoms of ADHD were explored.Results: The groups with five or more self-reported ADHD childhood symptoms, of either IN or HI, had more psychiatric comorbid conditions, a significantly higher co-occurrence of substance use disorders and personality disorders, and experienced more psychosocial and environmental problems.Conclusion: High level of self-reported ADHD childhood symptoms in young psychiatric patients identified a group more burdened with psychiatric comorbid conditions and more psychosocial problems. This group should be offered a thorough diagnostic assessment of ADHD.

Mouse movement measures enhance the stop-signal task in adult ADHD assessment

The accurate detection of attention-deficit/hyperactivity disorder (ADHD) symptoms, such as inattentiveness and behavioral disinhibition, is crucial for delivering timely assistance and treatment. ADHD is commonly diagnosed and studied with specialized questionnaires and behavioral tests such as the stop-signal task. However, in cases of late-onset or mild forms of ADHD, behavioral measures often fail to gauge the deficiencies well-highlighted by questionnaires. To improve the sensitivity of behavioral tests, we propose a novel version of the stop-signal task (SST), which integrates mouse cursor tracking. In two studies, we investigated whether introducing mouse movement measures to the stop-signal task improves associations with questionnaire-based measures, as compared to the traditional (keypress-based) version of SST. We also scrutinized the influence of different parameters of stop-signal tasks, such as the method of stop-signal delay setting or definition of response inhibition failure, on these associations. Our results show that a) SSRT has weak association with impulsivity, while mouse movement measures have strong and significant association with impulsivity; b) machine learning models trained on the mouse movement data from "known" participants using nested cross-validation procedure can accurately predict impulsivity ratings of "unknown" participants; c) mouse movement features such as maximum acceleration and maximum velocity are among the most important predictors for impulsivity; d) using preset stop-signal delays prompts behavior that is more indicative of impulsivity.

DSM-5 and Other Symptom Thresholds for ADHD: Which Is the Best Predictor of Impairment in College Students?

OBJECTIVE

Approximately 5% of adults have ADHD. Despite recommendations regarding the diagnosis of emerging adults, there is not a strong consensus regarding the ideal method for diagnosing ADHD in both emerging and mature adults. We were interested in determining whether a threshold of four, five, or six ADHD symptoms would be associated with significantly different levels of functional impairment and be more or less indicative of a potential ADHD diagnosis.

METHOD

We examined the relation between functional impairment and these ADHD symptom thresholds in 2,577 college students.

RESULTS

Our findings suggest that none of these symptom thresholds are differentially better at predicting functional impairment.

CONCLUSION

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) threshold of five symptoms for ages 17 years and older is not necessarily predictive of ADHD-related impairment in college students and may not be preferable to other thresholds. Options for resolving this diagnostic dilemma are discussed.

Prevalence, comorbidity, functioning and long-term effects of subthreshold oppositional defiant disorder in a community sample of preschoolers

To study the prevalence of subthreshold oppositional defiant disorder (ST ODD)-less than 4 symptoms, but nonetheless an impairing form of oppositional defiant disorder (ODD)-its coexistence with other homotypic externalizing and heterotypical internalizing problems in children and associated impairment, as well as the long-term effect of this condition. A population-based sample of 622 preschoolers (5.0% boys) was followed up from preschool to preadolescence. Parents were interviewed when the children were 3, 6 and 9 years old with the Diagnostic Interview for Preschoolers/Children and Adolescents versions following DSM-5 and the children's functioning was assessed by trained clinicians. ST ODD diagnosis is highly prevalent (19.4-25.5%), highly comorbid [homo- (1.9-18.4%) and heterotypical (5.8-23.7%)], resulting in functional impairment across child development in a similar way for both genders. ST is also a risk factor condition that predicts the presence of psychological problems and impairment in childhood and preadolescence from preschool age. A broader clinical assessment and intervention similar to that provided full syndrome cases is needed for children presenting subthreshold forms of ODD.

Are subsyndromal manifestations of attention deficit hyperactivity disorder morbid in children? A systematic qualitative review of the literature with meta-analysis

We conducted a qualitative review (n = 15 manuscripts) and meta-analysis (n = 9 manuscripts) of the extant literature to evaluate the prevalence and morbidity of subthreshold Attention Deficit Hyperactivity Disorder (ADHD). Our qualitative review showed that a sizable minority (mean: 17.7%) of clinically referred and non-referred children met a priori definitions of subthreshold ADHD. Those affected exhibited significantly higher rates of family dysfunction, cognitive impairment, executive dysfunction, interpersonal and school deficits, temperament problems, psychiatric comorbidity, and juvenile delinquency compared to children with no ADHD symptoms. These deficits were highly consistent with those observed in children with full threshold ADHD. These findings indicate that children with subthreshold ADHD symptoms are at significantly greater risk for negative outcomes in a wide range of non-overlapping functional domains worthy of further clinical and scientific consideration.

A Randomized Effectiveness Trial of a Behavioral Teacher Program Targeting ADHD Symptoms

OBJECTIVE

This study investigated the effectiveness of the Positivity & Rules Program (PR program), a behavioral teacher program targeting ADHD symptoms in the classroom involving both student-focused and classroom-focused programs.

METHOD

Primary school children with ADHD symptoms ( N = 114) were randomly assigned to the PR program ( n = 58) or control group ( n = 56). Teacher and parent ratings were used to assess behavioral, social, and emotional functioning at baseline, during and after the intervention. Intervention effects were assessed using intention-to-treat multilevel analyses.

RESULTS

Teachers reported positive effects on ADHD symptoms and social skills (.01 < f² > .36). Effects did not generalize to the home setting.

CONCLUSION

The PR program holds promise for improving classroom behavior in children with ADHD symptoms and might prevent escalation of problem behavior.

Do different factors influence whether girls versus boys meet ADHD diagnostic criteria? Sex differences among children with high ADHD symptoms

We investigate if different factors influence whether girls versus boys meet diagnostic criteria for attention-deficit/hyperactivity disorder(ADHD) among children with high ADHD symptoms. Participants were 283 children aged 7-12 from a population-based study. Girls and boys meeting diagnostic criteria for ADHD, based on an objective investigator-based interview, were compared to children who did not meet criteria despite high symptoms on a rating-scale measure of ADHD. We assessed factors that could differentially relate to diagnosis across girls and boys including ADHD symptoms, co-occurring behavioural/emotional problems and impairment, and sex-effects in rater perceptions of ADHD symptoms. While overall similar factors distinguished girls and boys who met diagnostic criteria from high-symptom peers, effect sizes were larger in girls. Emotional problems were particularly salient to distinguishing diagnosed versus high-symptom girls but not boys. Parents rated boys meeting diagnostic criteria as more impaired than high-symptom boys but did not do so for girls, and under-rated diagnosed girls' hyperactive/impulsive symptoms compared to more objective interview assessment, with the opposite observed in boys. Results suggest girls' ADHD may need to be made more prominent by additional behavioural/emotional problems for them to meet full diagnostic criteria and that sex differences in parental perceptions of ADHD behaviours and impairment exist.

The Contribution of Sensory Sensitivity to Emotional Lability in Children with ADHD Symptoms

Emotional lability and sensory sensitivity have been shown to contribute to the overall clinical picture in children with attention deficit hyperactivity disorder (ADHD; Dunn & Bennett, 2002; Sobanski et al., 2010). Further, both of these characteristics have been individually demonstrated to contribute to poorer quality of life, increased functional impairment, and poorer treatment response (Anastopoulos et al., 2010; Boterberg & Warreyn, 2016). However, to date, no study has evaluated the relationship among all three of these factors. The current study hypothesized that increased sensory sensitivity would moderate the relationship between hyperactive/impulsive symptoms of ADHD and emotional lability in youth. Results indicate that heightened sensory sensitivity strengthens the relationship between hyperactive/impulsive symptoms of ADHD and emotional lability in children with three or more clinically impairing ADHD symptoms. This dimensional approach was taken in accordance with growing evidence that even children with sub-threshold ADHD experience significant functional impairment and high rates of sensory sensitivity (Hong et al., 2014). These findings suggest that clinicians treating children with ADHD symptoms and emotional lability should consider assessing for sensory sensitivity as integration of multi-sensory techniques or referral to concurrent occupational therapy may significantly improve treatment outcomes and quality of life for these children and their families.

Testing the exacerbation and attenuation hypotheses of the role of anxiety in the relation between ADHD and reactive/proactive aggression: A 10-year longitudinal study

Both anxiety and aggression commonly co-occur with ADHD symptoms. Two competing hypotheses describing the role of anxiety in aggression associated with ADHD symptoms have previously been advanced. The exacerbation hypothesis proposes that the presence of anxiety increases the risk of aggression in the context of ADHD symptoms. The attenuation hypothesis proposes that the presence of anxiety protects against aggression in the context of ADHD symptoms. We tested these hypotheses using moderated cross-lagged panel models in the Zurich project on social development from childhood to adulthood (z-proso) sample using both self-report (3 waves) and informant-report (8 waves) data spanning ages 7-17. We found evidence that anxiety protects against both reactive and proactive aggression; however, the effect was direct: there was no evidence for anxiety moderating the strength of ADHD symptom-aggression links. Results suggest that anxiety likely plays an important role in inhibiting aggression but does not interact with ADHD symptoms in the manner predicted by either the exacerbation or attenuation hypothesis.

Sport concussion and attention deficit hyperactivity disorder in student athletes: A cohort study

Background

Attention deficit hyperactivity disorder (ADHD) is associated with impulsive behavior and inattention, making it a potential risk factor for sport-related concussion (SRC). The objectives of this study were to determine whether ADHD is an antecedent risk factor for SRC and whether ADHD complicates recovery from SRC in youth athletes.

Methods

Student athletes with a history of SRC were evaluated for the presence of ADHD using diagnostic interview and to determine whether ADHD symptoms began before or after SRC. Concussion-specific measures of concussive symptoms and cognitive function were compared in SRC + ADHD and SRC + No ADHD groups to assess SRC recovery between groups.

Results

ADHD was overrepresented in youth with SRC compared with population rates. ADHD was found to be an antecedent risk factor for SRC, with age at ADHD onset earlier than the date of SRC. Student athletes with SRC and ADHD reported more concussive symptoms compared with athletes without ADHD and were more likely to have a history of greater than one concussion.

Conclusions

The results of this study support our hypothesis that ADHD is an antecedent risk factor for SRC and may contribute to a more complicated course of recovery from SRC. Future research should focus on determining whether screening, diagnosis, and treating ADHD in youth athletes may prevent SRC. Providers that care for youth athletes with ADHD should be aware of the vulnerabilities of this population toward SRC and its complications.

Emotional Lability in Preschoolers With Symptoms of ADHD

OBJECTIVE

The aim of this study was to examine occurrence of emotional lability (EL) in preschoolers with ADHD symptoms versus controls.

METHOD

The study was part of the Norwegian Mother and Child Cohort Study (MoBa) at the Norwegian Institute of Public Health. In the present study, 495 preschoolers were clinically examined. Symptoms of ADHD, anxiety, and oppositional defiant disorder (ODD) were measured with the Preschool Age Psychiatric Assessment Interview. An EL measure was obtained from the Emotional Control subscale of the Behavior Rating Inventory of Executive Function-Preschool Version (BRIEF-P), which parents and teachers completed.

RESULTS

EL was significantly more frequent in the ADHD group compared with controls (25% vs. 7%, p < .001). By parent report, EL correlated significantly with ADHD-, anxiety-, and ODD symptoms. By teacher report, EL was significantly correlated only with hyperactivity-impulsivity.

CONCLUSION

EL appears identifiable in young preschoolers and was particularly associated with ODD in children with ADHD symptoms.

Augmented Go/No-Go Task: Mouse Cursor Motion Measures Improve ADHD Symptom Assessment in Healthy College Students

Attention deficit/hyperactivity disorder (ADHD) is frequently characterized as a disorder of executive function (EF). However, behavioral tests of EF, such as go/No-go tasks, often fail to grasp the deficiency in EF revealed by questionnaire-based measures. This inability is usually attributed to questionnaires and behavioral tasks assessing different constructs of EFs. We propose an additional explanation for this discrepancy. We hypothesize that this problem stems from the lack of dynamic assessment of decision-making (e.g., continuous monitoring of motor behavior such as velocity and acceleration in choice reaching) in classical versions of behavioral tasks. We test this hypothesis by introducing dynamic assessment in the form of mouse motion in a go/No-go task. Our results indicate that, among healthy college students, self-report measures of ADHD symptoms become strongly associated with performance in behavioral tasks when continuous assessment (e.g., acceleration in the mouse-cursor motion) is introduced.

Further Insight into the Effectiveness of a Behavioral Teacher Program Targeting ADHD Symptoms Using Actigraphy, Classroom Observations and Peer Ratings

Objective: The Positivity and Rules program (PR program), a low-level behavioral teacher program targeting symptoms of attention-deficit/hyperactivity disorder (ADHD), has shown positive effects on teacher-rated ADHD symptoms and social functioning. This study aimed to assess whether program effects could be confirmed by instruments assessing classroom behavior other than teacher-ratings, given teachers' involvement with the training. Methods: Participants were 114 primary school children (age = 6-13) displaying ADHD symptoms in the classroom, who were randomly assigned to the treatment (n = 58) or control group (n = 65). ADHD symptoms were measured using classroom observations and actigraphy, and peer acceptance was measured using peer ratings. Intention-to-treat multilevel analyses were conducted to assess program effects. Results: No beneficial program effects were found for any of the measures. Conclusion: The earlier beneficial program effects on both ADHD symptoms and social functioning reported by teachers, may be explained by a change in the perception of teachers rather than changes in the child's behavior. Other methodological explanations are also discussed, such as differences between instruments in the sensitivity to program-related changes. The current study underlines the importance of using different measures of classroom behavior to study program effects. ClinicalTrials.gov registration number: NCT02518711.

Subthreshold and threshold attention deficit hyperactivity disorder symptoms in childhood: psychosocial outcomes in adolescence in boys and girls

OBJECTIVE

To examine the association between different levels of childhood attention deficit hyperactivity disorder (ADHD) symptoms and sex differences in psychosocial outcomes during adolescence.

METHOD

Swedish children (n = 4635) were screened for neuropsychiatric symptoms at age 9 or 12. ADHD symptoms were divided into three levels: screen-negative, screen-intermediate, and screen-positive. At follow-up (age 15), parents and teenagers filled out questionnaires regarding (i) hyperactivity/inattention, (ii) peer problems, (iii) school problems, (iv) internalizing problems, (v) antisocial behaviour, (vi) alcohol misuse, and (vii) drug misuse. All outcomes were controlled for symptoms of diagnostic categories other than ADHD.

RESULTS

Increasing levels of ADHD symptoms in childhood were associated with higher proportions of adolescents who displayed negative psychosocial outcomes. More girls than boys reported internalizing problems (all levels) and risky drug use (screen-intermediate and screen-positive only). More boys reported antisocial behaviour at the screen-negative and screen-intermediate levels, but at the screen-positive level, similar proportions of girls and boys displayed antisocial behaviour.

CONCLUSION

The findings support the view that ADHD symptoms, as well as their negative outcomes, are dimensionally distributed in the population and that adolescent girls and boys display different risk profiles. The findings confirm that ADHD symptoms are associated with higher risk of drug misuse in girls.

Endocrine disruptors alter social behaviors and indirectly influence social hierarchies via changes in body weight

BACKGROUND

In humans, the causal link between socioeconomic status (SES) and body weight (BW) is bidirectional, as chronic stress associated with low SES may increase risk of obesity and excess weight may worsen career opportunities resulting in lower SES. We hypothesize that environmental factors affecting BW and/or social stress might reprogram physiological and social trajectories of individuals.

OBJECTIVES

To analyze interactions between BW and social behaviors in mice perinatally exposed to one of several environmental endocrine disruptors.

METHODS

CD-1 mice were fed 0.2 mg/kg BW/day tetrabromobisphenol-A (TBBPA), 2,2,4,4-tetrabromodiphenyl ether (BDE-47), bisphenol S (BPS), or oil (vehicle) from pregnancy day 8 through postpartum day 21. Three male offspring (triad) from each litter were housed together until week 15 and subjected to a Sociability Test and Tube Tests. Cages were then rearranged so that animals of the same social rank from the four exposure groups were housed together in tetrads. Social hierarchy in tetrads was again analyzed by Tube Tests.

RESULTS

In Sociability Tests, the mean velocity of all exposed animals increased when they encountered a stranger mouse and less time was spent with conspecifics. BW and social dominance of animals in triads and tetrads were inversely associated. BDE-47 and BPS caused transient decreases in BW.

CONCLUSIONS

Developmental exposure to environmental xenobiotics shifted behavior towards increased anxiety and decreased interest in social interactions. Our mouse model reproduces negative associations between social hierarchy status and BW. These results suggest that manipulation of BW by endocrine disruptors may affect social ranking.