Family Burden of Raising a Child with ADHD

Experience of psychosocial rehabilitation; perspectives of depressed adolescents

Given the multifaceted character of depression and its related symptoms, an adolescent living with it is at increased risk for a wide range of adverse events. This research aimed to understand and characterize the psychosocial rehabilitation experiences of depressed teenage participants in the Greater Accra Region of Ghana. A cross-sectional semi-structured interview design influenced by an interpretive phenomenological analysis (IPA) technique was adopted. We employed a nonprobability, purposeful sampling approach to recruit twenty-one adolescents (6 males, 15 females) diagnosed with depression from the community after one month of discharge from admission and undergoing psychosocial rehabilitation. Using separate interviews, we gathered and analyzed data using interpretive phenomenological analysis to produce themes and sub-themes. These were presented with the participants' direct quotations. We discovered that the perspectives of adolescents' psychosocial rehabilitation experience include hopelessness and suicide ideation, coping difficulties, undesirable attitudes from support networks, challenges related to school, and isolation. Participants suggested appropriate therapeutic environments, encouraging support systems, and the media's role in preventing and treating depression among young people as rehabilitation approaches that could assist adolescents to remain lucid for longer intervals. These results shed light on the tragic realities faced by depressed adolescents. There is an urgent need to put well-defined structures in place to aid their rehabilitation and develop coping strategies for a better life.

A Systematic Review and Meta-analysis of Parental Depression, Antidepressant Usage, Antisocial Personality Disorder, and Stress and Anxiety as Risk Factors for Attention-Deficit/Hyperactivity Disorder (ADHD) in Children

Poor parental mental health and stress have been associated with children's mental disorders, including attention-deficit/hyperactivity disorder (ADHD), through social, genetic, and neurobiological pathways. To determine the strength of the associations between parental mental health and child ADHD, we conducted a set of meta-analyses to examine the association of parent mental health indicators (e.g., parental depression, antidepressant usage, antisocial personality disorder, and stress and anxiety) with subsequent ADHD outcomes in children. Eligible ADHD outcomes included diagnosis or symptoms. Fifty-eight articles published from 1980 to 2019 were included. We calculated pooled effect sizes, accounting for each study's conditional variance, separately for test statistics based on ADHD as a dichotomous (e.g., diagnosis or clinical cutoffs) or continuous measurement (e.g., symptoms of ADHD subtypes of inattentiveness and hyperactivity/impulsivity). Parental stress and parental depression were significantly associated with increased risk for ADHD overall and both symptoms and diagnosis. Specifically, maternal stress and anxiety, maternal prenatal stress, maternal depression, maternal post-partum depression, and paternal depression were positively associated with ADHD. In addition, parental depression was associated with symptoms of ADHD inattentive and hyperactive/impulsive subtypes. Parental antisocial personality disorder was also positively associated with ADHD overall and specifically ADHD diagnosis. Prenatal antidepressant usage was associated with ADHD when measured dichotomously only. These findings raise the possibility that prevention strategies promoting parental mental health and addressing parental stress could have the potential for positive long-term impacts on child health, well-being, and behavioral outcomes.

Association between children with attention-deficit hyperactivity disorder and parental mental health: Data from the 2011-2020 Korea National Health and Nutrition Examination Survey

BACKGROUND

The aim of this study was to investigate whether children's attention-deficit hyperactivity disorder (ADHD) is associated with parental mental health, using data from the Korean National Health and Nutrition Examination Survey (KNHANES).

METHODS

This cross-sectional study included 14,428 samples from KNHANES of parents with children younger than 19 years between 2011 and 2020. Mental health problems, measured as perceived stress, depressive symptoms, and suicidality, were assessed. Sociodemographic and health-related characteristics were collected as potential confounding factors. The association between children with ADHD and parental mental health problems was expressed as odds ratio and 95 % confidence interval with multivariate logistic regression using PROC SURVEYLOGISTIC.

RESULTS

Among the 14,428 participants, 202 (1.4 %) were classified as parents of children with ADHD. Mothers of children with ADHD reported higher perceived stress (aOR = 1.67, 95 % CI 1.09-2.56), depressive symptoms (aOR = 2.93, 95 % CI 1.59-5.40), and suicidality (aOR = 2.63, 95 % CI 1.29-5.38) than those of children without ADHD after adjusting for parents' age, gender, and parental education level, employment status, cohabitation status, drinking, smoking, and number of children. However, fathers' mental health problems were not significantly associated with having a child with ADHD.

LIMITATION

Because it was conducted the analysis using cross-sectional data, findings on causality are unclear.

CONCLUSIONS

The current findings suggest that parenting children with ADHD is associated with parental mental health problems. Parents of children with ADHD, especially mothers, need community support and public health attention to help alleviate their mental health problems.

[Parental strain, inattention/hyperactivity symptoms and parent-reported ADHD in children and adolescents: results of the KiGGS study]

BACKGROUND

A child's attention deficit hyperactivity disorder (ADHD) is associated with strain for the parents. In turn, psychosocial parental strain is associated with higher probabilities for the occurrence of inattention/hyperactivity symptoms (IHS) in their children. The aim of this paper is to assess the association between parental strain, IHS, and a parent-reported ADHD diagnosis of the children.

METHODOLOGY

Based on data from n = 4596 participants of the KiGGS cohort (wave 2: 2014-2017), the type and extent of parental strain was set in relation to IHS and an ADHD diagnosis of the child in cross-sectional analysis. Frequencies, means, beta coefficients, and odds ratios adjusted for sex, age, socioeconomic status, and migration background are reported.

RESULTS

In individual consideration, a greater number of parental strains were associated with IHS than with an ADHD diagnosis. In a multivariate analysis, financial worries and parenting problems/conflicts with the children were significant predictors of IHS and an ADHD diagnosis, respectively. In addition, four or more types of parental strain were associated with a higher likelihood of both IHS and an ADHD diagnosis.

DISCUSSION

Financial and child-rearing strain are relevant to parents of children with IHS and an ADHD diagnosis. Interrelationships between parental stress and a child's IHS or an ADHD diagnosis can be assumed. To relieve their burden, prevention can either aim at improving the situation of ADHD-affected families or at improving the family's handling of the child's ADHD.

Gray matter volume associations in youth with ADHD features of inattention and hyperactivity/impulsivity

BACKGROUND

Prior research has shown smaller cortical and subcortical gray matter volumes among individuals with attention-deficit/hyperactivity disorder (ADHD). However, neuroimaging studies often do not differentiate between inattention and hyperactivity/impulsivity, which are distinct core features of ADHD. The present study uses an approach to disentangle overlapping variance to examine the neurostructural heterogeneity of inattention and hyperactivity/impulsivity dimensions.

METHODS

We analyzed data from 10,692 9- to 10-year-old children from the Adolescent Brain Cognitive Development (ABCD) Study. Confirmatory factor analysis was used to derive factors representing inattentive and hyperactive/impulsive traits. We employed structural equation modeling to examine these factors' associations with gray matter volume while controlling for the shared variance between factors.

RESULTS

Greater endorsement of inattentive traits was associated with smaller bilateral caudal anterior cingulate and left parahippocampal volumes. Greater endorsement of hyperactivity/impulsivity traits was associated with smaller bilateral caudate and left parahippocampal volumes. The results were similar when accounting for socioeconomic status, medication, and in-scanner motion. The magnitude of these findings increased when accounting for overall volume and intracranial volume, supporting a focal effect in our results.

CONCLUSIONS

Inattentive and hyperactivity/impulsivity traits show common volume deficits in regions associated with visuospatial processing and memory while at the same time showing dissociable differences, with inattention showing differences in areas associated with attention and emotion regulation and hyperactivity/impulsivity associated with volume differences in motor activity regions. Uncovering such biological underpinnings within the broader disorder of ADHD allows us to refine our understanding of ADHD presentations.

Family Functioning in Children With ADHD and Subthreshold ADHD: A 3-Year Longitudinal Study

OBJECTIVE

To compare family functioning over time for elementary school children with Attention-Deficit/Hyperactivity Disorder (ADHD; N = 179) and subthreshold ADHD (ST-ADHD; N = 86), to children without ADHD (Control; N = 212).

METHOD

ADHD was assessed using the Conners 3 ADHD Index and Diagnostic Interview Schedule for Children IV. At baseline, 18-month follow-up and 36-month follow-up, parents completed measures assessing a range of family functioning domains.

RESULTS

At baseline, the ADHD group reported higher psychological distress, less parenting self-efficacy, less parenting consistency, and more stressful life events; and both groups reported poorer family quality of life (QoL) and greater parenting anger. Trajectories were largely similar to controls (i.e., stable over time), but unlike controls, ADHD and ST-ADHD groups showed lessening parent-partner support and parenting warmth, respectively; and both groups showed worsening aspects of family QoL.

CONCLUSION

Families of children with ADHD and ST-ADHD report persistently poor or worsening family functioning; highlighting a need for tailored psycho-social supports.

Economic Burden and Service Utilization of Children With Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis

OBJECTIVES

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children. This study aims to systematically synthesize the literature on service utilization and costs for children with ADHD.

METHODS

The search included 9 databases for peer-reviewed primary studies in English from 2007 to 2023. Two independent reviewers conducted title/abstract and full-text screenings and quality assessment. Meta-analysis was conducted on direct medical costs.

RESULTS

Thirty-two studies were included. Children with ADHD have used more pharmaceuticals, mental health, and special education services than children without ADHD (counterparts). Nevertheless, one study found that children with ADHD were twice as likely to have unmet health needs than their counterparts. Annual health system costs per patient were highly varied and higher in children with ADHD ($722-$11 555) than their counterparts ($179-$3646). From a societal perspective, children with ADHD were associated with higher costs ($162-$18 340) than their counterparts ($0-2540). The overall weighted mean direct medical cost was $5319 for children with ADHD compared with $1152 for their counterparts when all studies with different sample sizes were considered together, with the difference being $4167. Limited literature on productivity losses associated with ADHD reported them as a substantial cost. ADHD in children had a "large" effect on the increment of direct medical costs.

CONCLUSIONS

ADHD was associated with increased service utilization and costs. However, unmet health needs or underuse among children with ADHD was also evident. Governments should endeavor to improve access to effective services for children with ADHD to mitigate the impact of ADHD.

Methods used to account for caregivers' sex and gender within studies examining the financial burden of caregivers of children and adolescents : Results from a scoping review

Background

Interest in the financial burden of informal caregivers has been growing. Unfortunately, it remains unclear which method(s) should be used when quantifying this burden.

Purpose

We conducted a scoping review aimed at identifying which methods have been used to conduct such work and quantified their performance. We were also interested in examining how sex and gender considerations were considered within selected studies.

Data Sources

Using a standardized approach, we identified studies published between 2012 and 2022 that aimed to document the financial burden of caregivers to child and adolescent patients. Our search strategy was applied to the MEDLINE, Embase, CINHAL, and Academic Search Premier databases.

Study Selection

Manuscript selection was performed by pairs of reviewers.

Data Extraction

Data extraction was performed by one reviewer with a second reviewer performing quality control. Results were reported using a narrative approach.

Data Synthesis

We identified 9801 unique citations, of which 200 were included in our review. Selected studies covered various disease area (eg, infection/parasitic diseases [n = 31, 16%]) and included quantitative (n = 180, 90%), qualitative (n = 4, 2%) and mixed study designs (n = 16, 8%). Most studies (n = 182, 91%) used questionnaires/surveys, either alone or in combination with other methods, to assess caregivers' financial burden. Less than half (n = 93, 47%) of studies reported on caregivers' sex and none reported on their gender.

Conclusion

We conducted an unrestricted review of published studies examining caregiver's financial burden which allowed us to identify general methodological trends observed in this literature. We believe this work may help improve future studies focusing on this important issue.

Poor Physical Health in Caregivers of Children with ADHD or ASD and its Association with Health Risk Behaviours: NHIS 2016-2018

BACKGROUND

There is a dearth of evidence regarding physical health problems and health risk behaviours (e.g., drinking, physical inactivity, smoking, and suboptimal sleep behaviour) in caregivers of children with attention deficit hyperactivity disorder or autism spectrum disorder (CCAA). The purposes of the current study were to examine differences in physical health problems between CCAA and caregivers of children without attention deficit hyperactivity disorder and autism spectrum disorder (CCWAA) and to explore health risk behaviours associated with those problems.

METHOD

Data from the 2016-2018 National Health Interview Survey were used in the current study. 10 common physical health problems were compared between CCAA and CCWAA by using multivariable logistic regressions. In addition, in order to detect associated health risk behaviours, decision tree analysis was performed for physical health problems in CCAA.

RESULTS

Of the 10 physical health problems, caregivers of children with ADHD showed significantly higher likelihood of experiencing nine (arthritis, asthma, back pain, high cholesterol, diabetes, heart problems, hypertension, neck pain, obesity), compared to CCWAA. Caregivers of children with autism spectrum disorder (ASD) showed significantly higher likelihoods of experiencing two physical health problems compared to CCWAA. The decision tree analysis revealed that age (> 42 years), and suboptimal sleep behaviour (not 7-8 hours), and smoking (current smoker) were the frequent predictors for physical health problems in CCAA.

CONCLUSION

The results of the current study represent an important milestone in further investigating physical health problems in CCAA.

Attitudes of parents of children with ADHD towards genetic testing: Data from a Turkish sample

This study aimed to examine the opinions of parents with children diagnosed with attention deficit/hyperactivity disorder about genetic tests. A total of 540 parents living in Turkey participated in the study face-to-face and online. A questionnaire form prepared by the researchers was used as the data collection instrument. Face-to-face data were collected in different institutions in the cities of İzmir, Bursa and Antalya, while online data were collected through Google Forms. The results revealed that parents' views on genetic testing differed according to the sex and age of the child, as well as the parents' level of education and income, and whether the parents had genetic testing during pregnancy (p < 0.05). In the analysis, it was determined that parents' knowledge and awareness levels about genetic tests were generally low, while parents who reported that they would consider having genetic tests had concerns about the storage of their DNA materials, family conflicts that could be caused by genetic tests, and the compatibility of genetic tests with their religious beliefs.

Efficacy and Safety of SPN-812 (Extended-Release Viloxazine) in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis

BACKGROUND

SPN-812 has been approved for attention-deficit/hyperactivity disorder (ADHD) treatment in children and adolescents.

OBJECTIVE

We aimed to analyze the efficacy and safety of different doses of SPN-812 for ADHD pediatric patients of different ages, verify its clinical efficacy, and evaluate its safety.

METHODS

Up until 30 August 2023, randomized controlled trials (RCTs) were searched in EMBASE, MEDLINE, the Cochrane Library, and clinicaltrials.gov to evaluate different doses of SPN-812 and a placebo.

RESULTS

We pooled 1619 patients from five RCTs with a duration of 6-8 weeks. Patients (6-17 years old) in SPN-812 (100, 200, and 400 mg/d) groups were superior to the control group in all efficacy outcomes with lower attention-deficit/hyperactivity disorder rating scale-5 (ADHD-RS-5), Conners 3-parent short form composite T score (Conners 3-PS), Weiss functional impairment rating scale-parent (WFIRS-P), and increased clinical global impression-improvement (CGI-I) score (both p < 0.05). At the same time, only SPN-812 300 mg/d did not show a significantly high risk of the adverse events (AEs) such as somnolence and decreased appetite (p = 0.09). There was no significant difference between placebo and SPN-812 groups (100, 200, and 400 mg/d) in serious adverse events (SAEs) such as syncope. The subgroup analyses showed that, both in children and adolescents subgroups, SPN-812 showed better efficacy than the placebo. The two age subgroups showed a significantly higher risk of AEs and an insignificant risk of SAEs than the placebo.

CONCLUSION

At present, SPN-812 (100, 200, and 400 mg/d) is superior to the corresponding control in efficacy measures. However, the safety problem cannot be ignored.

Impact of a Publicly-Funded Pharmacare Program on Prescription Stimulant use Among Children and Youth: A Population-Based Observational Natural Experiment

OBJECTIVE

Stimulants are first-line pharmacotherapy for individuals with attention-deficit hyperactivity disorder. However, disparities in drug coverage may contribute to inequitable treatment access. In January 2018, the government of Ontario, Canada, implemented a publicly-funded program (OHIP+) providing universal access to medications at no cost to children and youth between the ages of 0 and 24. In April 2019, the program was amended to cover only children and youth without private insurance. We studied whether these policy changes were associated with changes in prescription stimulant dispensing to Ontario children and youth.

METHODS

We conducted a population-based observational natural experiment study of stimulant dispensing to children and youth in Ontario between January 2013 and March 2020. We used interventional autoregressive integrated moving average models to estimate the association between OHIP+ and its subsequent modification with stimulant dispensing trends.

RESULTS

The implementation of OHIP+ was associated with a significant immediate increase in the monthly rate of stimulant dispensing of 53.6 individuals per 100,000 population (95% confidence interval [CI], 36.8 to 70.5 per 100,000) and a 14.2% (95% CI, 12.8% to 15.6%) relative percent increase in stimulant dispensing rates between December 2017 and March 2019 (1198.6 vs. 1368.7 per 100,000 population). The April 2019 OHIP+ program amendment was associated with an increase in monthly stimulant dispensing trends of 10.2 individuals per 100,000 population (95% CI, 5.0 to 15.5), with rates increasing 7.5% (95% CI, 6.2% to 8.7%) between March 2019 and March 2020 (1368.7 vs. 1470.8 per 100,000 population). These associations were most pronounced among males, children and youth living in the highest income neighbourhoods and individuals aged 20 to 24.

CONCLUSION

A publicly-funded pharmacare program was associated with more children and youth being dispensed stimulants.

Cost-Effectiveness of a Training Intervention for Adolescents with ADHD

OBJECTIVE

The aim of this study was to examine the costs and cost-effectiveness of a school-based training intervention delivered at varying levels of intensity with adolescents with attention-deficit/hyperactivity disorder (ADHD). Costs were examined in relation to post-treatment and 6-month follow-up effects of the Challenging Horizons Program (CHP), a training intervention for adolescents with ADHD.

METHOD

A total of 326 middle-school students (71% male; 77% White) with ADHD were randomized to an after-school version of the CHP (CHP-AS), a less-intensive mentoring version (CHP-M), or routine community care. Detailed time logs were maintained throughout the study and were used to estimate costs associated with each condition. Student grade point average (GPA) and parent-rated ADHD symptoms and organization skills were collected at post-treatment and 6-month follow-up.

RESULTS

The cost analysis revealed that CHP-AS was more costly per student than CHP-M, both in terms of overall costs and direct expenses to the school. However, CHP-AS was less costly per hour of intervention provided to the youth than CHP-M. Incremental cost-effectiveness ratios revealed that CHP-M may be the more cost-effective option for post-treatment effects, yet CHP-AS may be the more cost-effective option in the long term for sustained gains in organization skills and GPA.

CONCLUSIONS

This study provides stakeholders important information to make decisions regarding allocation of finite monetary resources to meet their prioritized goals.

The global prevalence of attention deficit hyperactivity disorder in children and adolescents: An umbrella review of meta-analyses

BACKGROUND

Emerging epidemiological data suggest that hundreds of primary studies have examined the prevalence of ADHD in children and adolescents and dozens of systematic view and meta-analyses studies have been conducted on the subject. The purpose of this umbrella review is to provide a robust synthesis of evidence from these systematic reviews and meta-analyses.

METHODS

We systematically searched PubMed, Web of Science, PsychINFO, and Scopus to find pertinent studies. The study was preregistered with PROSPERO (CRD42023389704). The quality of the studies was assessed using a Measurement Tool to Assess Systematic Reviews (AMSTAR). Prevalence estimates from the included studies were pooled using invariance variance weighted random-effect meta-analysis.

RESULTS

Thirteen meta-analytic systematic reviews (588 primary studies) with 3,277,590 participants were included in the final analysis. A random effect meta-analysis of these studies showed that the global prevalence of ADHD in children and adolescents was 8.0 % (95%CI 6.0-10 %). The prevalence estimate was twice higher in boys (10 %) compared to girls (5 %). Of the three subtypes of ADHD, the inattentive type of ADHD (ADHD-I) was found to be the most common type of ADHD followed by the hyperactive (ADHD-HI) and the combined types (ADHD-C).

CONCLUSION

Findings from our compressive umbrella review suggest that ADHD is highly prevalent in children and adolescents with boys twice more likely to experience the disorder than girls. Our results underpin that priority should be given to preventing, early identifying, and treating ADHD in children and adolescents.

Attention-deficit hyperactivity disorder and youth's emotion dysregulation: A systematic review of fMRI studies

A number of adverse outcomes are associated with emotion dysregulation, and ADHD secondary to emotion dysregulation is a frequent comorbidity that may result in poorer performance and quality of life among youth. Recent neuroimaging research has observed significant functional differences in youth with ADHD compared to healthy controls. Therefore, the aims of this systematic review were to summarize the literature on functional connectivity of emotion dysregulation in youth with ADHD, identify methodological challenges and limitations, and provide directions for future research. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed to conduct a systematic review across three databases, and 13 studies were identified for inclusion. Across the studies, 14 primary regions were examined; 12 of the 13 studies identified a significant association between functional connectivity of emotion dysregulation and youth with ADHD. Although studies varied in the structures investigated, the most notable differences appeared in the prefrontal cortex, orbitofrontal cortex, amygdala, and ventral striatum in ADHD participants. Future research concerning this topic may help contribute to the understanding of this association by utilizing longitudinal research designs, controlling for psychiatric comorbidities and emotion dysregulation severity, inclusion of more diverse samples and ensuring that studies are adequately powered.

Navigating unique challenges and advancing equitable care for children with ADHD in Africa: a review

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition that presents distinct challenges for African children due to a complex interplay of social, economic and cultural factors. This review examines the various obstacles faced by children with ADHD in Africa, focusing on the lack of awareness and stigma surrounding the disorder, limited access to mental health services, educational system constraints, economic limitations and cultural beliefs and practices. The review underscores the significance of public awareness campaigns and educational initiatives to dispel myths and misconceptions surrounding ADHD. These efforts should target the general public, educators, healthcare professionals, religious leaders and traditional healers. Crucial to addressing this issue is strengthening mental health services, especially in rural and underserved areas, through increased funding and the availability of trained mental health professionals specialised in ADHD diagnosis and treatment. Integrating mental health services into primary healthcare systems is proposed to enhance accessibility for children with ADHD. By training primary care providers to recognise ADHD symptoms and provide initial support and referrals, early identification and intervention can be facilitated. Addressing the affordability and accessibility of ADHD treatment is a priority, with policy recommendations including subsidising medications and therapies and providing financial assistance to families in need. A call for collaborative efforts between governments, nongovernmental organisations and pharmaceutical companies is advocated to ensure that ADHD treatment is affordable and widely available.

A Narrative Review of the Association between Prematurity and Attention-Deficit/Hyperactivity Disorder and Accompanying Inequities across the Life-Course

Preterm birth is associated with an increased risk of neurodevelopmental and neurobehavioral impairments including attention-deficit/hyperactivity disorder (ADHD), the most common neurobehavioral disorder of childhood. In this narrative review, we examine the known associations between prematurity and ADHD and highlight the impact of both prematurity and ADHD on multiple domains across the pediatric life-course. We develop a framework for understanding the health services journey of individuals with ADHD to access appropriate services and treatments for ADHD, the "ADHD Care Cascade". We then discuss the many racial and ethnic inequities that affect the risk of preterm birth as well as the steps along the "ADHD Care Cascade". By using a life-course approach, we highlight the ways in which inequities are layered over time to magnify the neurodevelopmental impact of preterm birth on the most vulnerable children across the life-course.

Effectiveness of Social Virtual Reality Training in Enhancing Social Interaction Skills in Children With Attention-Deficit/Hyperactivity Disorder: Protocol for a Three-Arm Pilot Randomized Controlled Trial

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Children with ADHD have challenges in understanding social cues and behavioral problems when entering a social setting. Virtual reality (VR) has been applied to improve cognitive behaviors in children with ADHD. Previous studies have not adopted VR to improve social interaction competence and appropriateness in children with ADHD. VR offers a more effective alternative to therapeutic strategies for children with ADHD.

OBJECTIVE

This study aims to examine the feasibility and effectiveness of social VR training in enhancing social interaction skills compared to traditional social skills training in children with ADHD. We hypothesize that participants in the social VR training group are likely to perform better on social interaction skills than those in the traditional social skills training group.

METHODS

In this nonblinded, 3-arm randomized controlled trial (RCT), 90 participants with ADHD recruited from the community will be randomized 1:1:1 to the social VR intervention group, traditional social skills training group, or waitlist control group. The child psychiatrist will conduct assessments for each participant at baseline and after the intervention. The Social Skills Rating Scale-Parent will be used to assess the social interaction skills of the participants before and after the intervention. Participants in the social VR intervention group and traditional social skills training group will receive twelve 20-minute training sessions for 3 weeks. The participants in the waitlist control group will receive no training. The primary outcome measure is training acceptability and compliance. The secondary outcome measures are the child psychiatrist's assessment and the Social Skills Rating Scale-Parent before and after the intervention. Another outcome measure is the Behavior Rating Inventory of Executive Function and Attention. Differences in the scale scores will be examined using a t test and an F test.

RESULTS

This study is set to commence in the fourth quarter of 2023. It is anticipated that participants in the social VR intervention group will exhibit superior social interaction skills than those in the traditional social skills training group.

CONCLUSIONS

To our knowledge, this RCT is the first study examining the feasibility and effectiveness of a social VR-based intervention for enhancing the social interaction skills of children with ADHD in Hong Kong. The VR-based social skills training is expected to provide a safer and more effective environment for children with ADHD to learn than the traditional approach. This study can lead to a full-scale RCT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05778526; https://clinicaltrials.gov/study/NCT05778526.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/48208.

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.

Needs assessment for behavioral parent training for ADHD in Brazil

Introduction

Attention-Deficit/Hyperactivity Disorder (ADHD) is a debilitating condition affecting children and their families worldwide. Behavioral parent training is a recommended form of empirically supported non-pharmacological intervention for young children with mild to moderate ADHD. However, access to such treatment is limited in many countries. Here we identify the treatment needs of Brazilian families with children demonstrating symptoms of ADHD, and the barriers families face in accessing behavioral treatment.

Methods

A qualitative needs assessment was undertaken with parents (n = 23), educators (n = 15), and healthcare providers (n = 16). Semi-structured telephone interviews were conducted, and common themes were identified through inductive coding of participants' responses.

Results

Participants reported a lack of accessible behavioral treatment, and delays in accessing treatment when available. The majority of parents had not received behavioral parent training, despite it being a recommended form of treatment. Parents, educators and healthcare providers strongly endorsed a need for practical tools to manage the behavior of children with ADHD.

Conclusion

Existing services might not meet the needs of children with ADHD and their families in Brazil. Easily accessed behavioral parent training programs are recommended to address the identified treatment gap for Brazilian children with ADHD and their families.

A Novel Rat Model of ADHD-like Hyperactivity/Impulsivity after Delayed Reward Has Selective Loss of Dopaminergic Neurons in the Right Ventral Tegmental Area

In attention deficit hyperactivity disorder (ADHD), hyperactivity and impulsivity occur in response to delayed reward. Herein we report a novel animal model in which male Sprague-Dawley rats exposed to repeated hypoxic brain injury during the equivalent of extreme prematurity were ADHD-like hyperactive/impulsive in response to delayed reward and attentive at 3 months of age. Thus, a unique animal model of one of the presentations/subtypes of ADHD was discovered. An additional finding is that the repeated hypoxia rats were not hyperactive in the widely used open field test, which is not ADHD specific. Hence, it is recommended that ADHD-like hyperactivity and ADHD-like impulsivity, specifically in response to delayed reward, be a primary component in the design of future experiments that characterize potential animal models of ADHD, replacing open field testing of hyperactivity. Unknown is whether death and/or activity of midbrain dopaminergic neurons contributed to the ADHD-like hyperactivity/impulsivity detected after delayed reward. Hence, we stereologically measured the absolute number of dopaminergic neurons in four midbrain subregions and the average somal/nuclear volume of those neurons. Repeated hypoxia rats had a significant specific loss of dopaminergic neurons in the right ventral tegmental area (VTA) at 2 weeks of age and 18 months of age, providing new evidence of a site of pathology. No dopaminergic neuronal loss occurred in three other midbrain regions. Fewer VTA dopaminergic neurons correlated with increased ADHD-like hyperactivity and impulsivity. Novel early intervention therapies to rescue VTA dopaminergic neurons and potentially prevent ADHD-like hyperactivity/impulsivity can now be investigated.

For Which Children with ADHD is TBR Neurofeedback Effective? Comorbidity as a Moderator

We examined psychiatric comorbidities moderation of a 2-site double-blind randomized clinical trial of theta/beta-ratio (TBR) neurofeedback (NF) for attention deficit hyperactivity disorder (ADHD). Seven-to-ten-year-olds with ADHD received either NF (n = 84) or Control (n = 58) for 38 treatments. Outcome was change in parent-/teacher-rated inattention from baseline to end-of-treatment (acute effect), and 13-month-follow-up. Seventy percent had at least one comorbidity: oppositional defiant disorder (ODD) (50%), specific phobias (27%), generalized anxiety (23%), separation anxiety (16%). Comorbidities were grouped into anxiety alone (20%), ODD alone (23%), neither (30%), or both (27%). Comorbidity (p = 0.043) moderated acute effect; those with anxiety-alone responded better to Control than to TBR NF (d = - 0.79, CI - 1.55- - 0.04), and the other groups showed a slightly better response to TBR NF than to Control (d = 0.22 ~ 0.31, CI - 0.3-0.98). At 13-months, ODD-alone group responded better to NF than Control (d = 0.74, CI 0.05-1.43). TBR NF is not indicated for ADHD with comorbid anxiety but may benefit ADHD with ODD.Clinical Trials Identifier: NCT02251743, date of registration: 09/17/2014.

Adherence to antipsychotic laboratory monitoring guidelines in children and youth: a population-based study

Background

In 2011, the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) published guidelines for the metabolic monitoring of antipsychotic-treated children and youth. Population-based studies examining adherence to these guidelines are needed to ensure the safe use of antipsychotics in children and youth.

Methods

We conducted a population-based study of all Ontario residents aged 0 to 24 who were newly dispensed an antipsychotic between April 1, 2018, and March 31, 2019. We estimated prevalence ratios (PRs) and 95% confidence intervals (CI) associating sociodemographic characteristics with the receipt of baseline and follow-up (3- and 6-month) laboratory testing using log-Poisson regression models.

Results

Overall, 6,505 of 27,718 (23.5%) children and youth newly dispensed an antipsychotic received at least one guideline-recommended baseline test. Monitoring was more prevalent among individuals aged 10 to 14 years (PR 1.20; 95% CI 1.04 to 1.38), 15 to 19 years (PR 1.60; 95% CI 1.41 to 1.82), and 20 to 24 years (PR 1.71; 95% CI 1.50 to 1.94) compared to children under the age of 10. Baseline monitoring was associated with mental health-related hospitalizations or emergency department visits in the year preceding therapy (PR 1.76; 95% CI 1.65 to 1.87), a prior diagnosis of schizophrenia (PR 1.20; 95% CI 1.14 to 1.26) or diabetes (PR 1.35; 95% CI 1.19 to 1.54), benzodiazepine use (PR 1.13; 95% CI 1.04 to 1.24), and receipt of a prescription from a child and adolescent psychiatrist or developmental pediatrician versus a family physician (PR 1.41; 95% CI 1.34 to 1.48). Conversely, monitoring was less frequent in individuals co-prescribed stimulants (PR 0.83; 95% CI 0.75 to 0.91). The prevalence of any 3- and 6-month follow-up monitoring among children and youth receiving continuous antipsychotic therapy at these time points was 13.0% (1,179 of 9,080) and 11.4% (597 of 5,261), respectively. Correlates of follow-up testing were similar to those of baseline monitoring.

Conclusion

Most children initiating antipsychotic therapy do not receive guideline-recommended metabolic laboratory monitoring. Further research is needed to understand reasons for poor guideline adherence and the role of clinician training and collaborative service models in promoting best monitoring practices.

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.

A better cost:benefit analysis yields better and fairer results: EPA's lead and copper rule revision

When conducted on a societal level, cost-benefit analysis (CBA) can indicate policies that best allocate scarce public resources. Done incompletely, CBA can produce spurious, biased results. To estimate the potential health benefits of EPA's recent Lead and Copper Drinking Water Rule Revision (LCRR), we used EPA's exposure, compliance, and effect coefficient estimates to monetize 16 of the health endpoints EPA has determined are causally related to lead exposure. In addition, we monetized one health endpoint that EPA has used elsewhere: preterm birth. We estimated that the total annual health benefits of the LCRR greatly exceed EPA's estimated annual costs: $9 billion vs $335 million (2016$). Our benefit estimates greatly exceed EPA's benefit estimates. There are also nonhealth benefits because lead generally contaminates drinking water through the corrosion of plumbing components that contain lead. The LCRR therefore has 2 components: reducing how corrosive the water is and limited replacement of lead pipes. Reducing corrosion damage to drinking water and wastewater infrastructure and residential appliances that use water yields significant annualized material benefits also: $2-8 billion (2016$). Effectively, the health benefits are free. Finally, while actual exposure data are limited, the available data on lead-contaminated drinking water exhibits known risk patterns, disproportionately burdening low-income and minority populations and women. This economic analysis demonstrates that to maximize national benefits and improve equity, the LCRR should be as rigorous as possible.

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.

Psychological Health and Quality of Life among Ultra-orthodox Mothers of Children with Attention Deficit Hyperactivity Disorder: Impact of Occupational Experiences

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a common neuro-developmental health condition in children and adolescents. Parenting a child with ADHD can profoundly affect mothers' health. Research is limited regarding occupational experiences and their impact on health among mothers of children with ADHD (MoCwADHD). Ultra-orthodox MoCwADHD may have unique cultural circumstances that have not been studied.

AIMS

To broaden understanding of parental stress, psychological health, and quality of life (QoL) of ultra-orthodox MoCwADHD and explore a possible role of occupational experiences on these outcomes.

METHODS

Ultra-orthodox MoCwADHD (N = 114) completed a sociodemographic questionnaire and measurements to assess child ADHD symptomatology, mother's ADHD, parental stress, psychological health, QoL, and occupational experiences.

RESULTS

Participants displayed moderate parental stress, and 54.9 percent also showed psychological distress symptoms, similar to the literature on MoCwADHD in the general population. Frequency of engagement in health promoting occupations reflected patterns in line with cultural beliefs. Structure Equation Modeling showed that child ADHD negatively affected mothers' stress, psychological health and QoL. Importantly, occupational experiences directly and indirectly, via parental stress, impacted psychological health and QoL.

CONCLUSIONS

MoCwADHD impacts maternal health in the ultra-orthodox population and occupational experiences may be a modifiable target for promoting their health.

ADHD Symptoms Increased During the Covid-19 Pandemic: A Meta-Analysis

OBJECTIVE

Emerging research suggests that the Covid-19 pandemic has disproportionately and adversely affected children with Attention-Deficit/Hyperactivity Disorder (ADHD). The purpose of this meta-analysis is to consolidate the findings from studies that examined changes in ADHD symptoms from before to during the pandemic.

METHOD

Database searches of PsycINFO, ERIC, PubMed, and ProQuest were used to identify relevant studies, theses, and dissertations.

RESULTS

A total of 18 studies met specific inclusion criteria and were coded based on various study characteristics. Twelve studies examined ADHD symptoms longitudinally and six studies assessed ADHD symptoms retroactively and during the pandemic. Data from 6,491 participants from 10 countries were included. Results indicated that many children and/or their caregivers reported an increase in child ADHD symptoms during the Covid-19 pandemic.

CONCLUSIONS

This review points to a global increase in ADHD symptoms and has implications for the prevalence and management of ADHD during the post-pandemic recovery.

Genome-wide analyses of ADHD identify 27 risk loci, refine the genetic architecture and implicate several cognitive domains

Attention-deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder with a major genetic component. Here, we present a genome-wide association study meta-analysis of ADHD comprising 38,691 individuals with ADHD and 186,843 controls. We identified 27 genome-wide significant loci, highlighting 76 potential risk genes enriched among genes expressed particularly in early brain development. Overall, ADHD genetic risk was associated with several brain-specific neuronal subtypes and midbrain dopaminergic neurons. In exome-sequencing data from 17,896 individuals, we identified an increased load of rare protein-truncating variants in ADHD for a set of risk genes enriched with probable causal common variants, potentially implicating SORCS3 in ADHD by both common and rare variants. Bivariate Gaussian mixture modeling estimated that 84-98% of ADHD-influencing variants are shared with other psychiatric disorders. In addition, common-variant ADHD risk was associated with impaired complex cognition such as verbal reasoning and a range of executive functions, including attention.

Computer-based multiple component cognitive training in children with ADHD: a pilot study

BACKGROUND

ADHD is associated with deficits in executive functions. Cognitive training is a promising nonpharmacological intervention for ADHD, however, there is insufficient evidence to guide the selection of training for individuals with ADHD. This pilot study aims to investigate the efficacy of executive function training targeting key executive dysfunctions in ADHD, compared with general executive function training which targets other executive functions.

METHODS

A total of 127 subjects (6-12 years) diagnosed with ADHD were allocated to receive one of two different cognitive trainings. ADHD symptoms and cognitive functions were evaluated using parent-rated scales and CANTAB cognitive assessments. All participants were required to complete 48 training sessions within a two-month period.

RESULTS

94 out of 127 children completed the required training and assessments. Both ADHD executive function training group and general executive function training group showed significant improvement in ADHD symptoms on the ADHD Rating Scale and in executive function on the assessment of CANTAB. There was no significant difference in improvements between the two groups. Subgroup analysis suggested that children who had ADHD-RS total scores less than or equal to 28 at baseline showed greater improvement following ADHD executive function training.

CONCLUSIONS

This study indicates that cognitive training can improve ADHD symptoms and executive function, with no difference in efficacy between targeted and generalized cognitive training. In addition, individuals with lower symptom severity may benefit more from training targeting key ADHD executive dysfunctions.

The Development and Usability of a Mobile App for Parents of Children with ADHD

BACKGROUND

Attention-Deficit/ Hyperactivity Disorder (ADHD) is one of the most prevalent mental health problems in children. Behavioral parent training (BPT) is the first-line treatment recommended by clinical guidelines; however, parental dropout is high. Mobile apps could be used as an adjunct to BPT in order to increase treatment adherence, homework compliance, and parental engagement. In this paper, we describe the development process of a mobile app for parents of children with ADHD.

METHODS

We conducted a study to investigate parents' perceived usability of the ADHD Coping Card.

RESULTS

The mobile app developed has a high usability. Future improvements in the app were suggested by parents.

CONCLUSIONS

Given the increasing importance of digital mental health interventions in psychotherapy, it is important that future research is conducted with a higher number of participants to investigate the key factors implicated in choosing such an intervention in the future, both by parents and by mental health specialists. A mobile app can be used as an add-on in psychotherapy with parents of children with ADHD. Digital health interventions could help surpass gaps in treatment access for child mental health problems.

Are Reading Interventions Effective for At-Risk Readers with ADHD? A Meta-Analysis

OBJECTIVE

Utilizing a multi-level meta-analytic approach, this review is the first to systematically quantify the efficacy of reading interventions for school-aged children with ADHD and identify potential factors that may increase the success of reading-related interventions for these children.

METHOD

18 studies (15 peer-reviewed articles, 3 dissertations) published from 1986 to 2020 (N = 564) were meta-analyzed.

RESULTS

Findings revealed reading interventions are highly effective for improving reading skills based on both study-developed/curriculum-based measures (g = 1.91) and standardized/norm-referenced achievement tests (g = 1.11) in high-quality studies of children with rigorously-diagnosed ADHD. Reading interventions that include at least 30 hours of intervention targeting decoding/phonemic awareness meet all benchmarks to be considered a Level 1 (Well-Established) Evidence-Based Practice with Strong Research Support for children with ADHD based on clinical and special education criteria.

CONCLUSIONS

Our findings collectively indicate that reading interventions should be the first-line treatment for reading difficulties among at-risk readers with ADHD.

Right Superior Frontal Gyrus Cortical Thickness in Pediatric ADHD

OBJECTIVE

We investigated the right Superior Frontal Gyrus (right-SFG) and Anterior Cingulate Cortex (ACC) in children with ADHD and their clinical relevance with Executive Function (EF) and ADHD symptom severity.

METHODS

About 26 children with ADHD and 24 typically developing children (TDC; 7‒16 years) underwent Magnetic Resonance Imaging (MRI) and completed an EF assessment battery.

RESULTS

Significantly thinner right-SFG in the ADHD group was found compared to the TDC group (t (48) = 2.81, p = .007, Cohen's d = 0.84). Linear regression models showed that 12.5% of inattention, 13.6% of hyperactivity, and 9.0% of EF variance was accounted for by the right-SFG thickness.

CONCLUSIONS

Differences in the right-SFG thickness were found in our ADHD group and were associated with parent ratings of inattentive and hyperactive symptoms as well with EF ratings. These results replicate previous findings of thinner right-SFG and are consistent with the delayed cortical maturation theory of ADHD.

Pediatric Caregiver Version of the Shared Decision Making Process Scale: Validity and Reliability for ADHD Treatment Decisions

OBJECTIVE

Shared decision making (SDM) is recommended for common pediatric conditions; however, there are limited data on measures of SDM in pediatrics. This study adapted the SDM Process scale and examined validity and reliability of the scale for attention-deficit/hyperactivity disorder (ADHD) treatment decisions.

METHODS

Cross-sectional survey of caregivers (n = 498) of children (aged 5-13) diagnosed with ADHD, who had made a decision about ADHD medication in the last 2 years. Surveys included the adapted SDM Process scale (scores range 0-4, higher scores indicate more SDM), decisional conflict, decision regret, and decision involvement. Validity was assessed by testing hypothesized relationships between these constructs. A subset of participants was surveyed a week later to assess retest reliability.

RESULTS

Pediatric Caregiver version of the SDM Process scale (M = 2.8, SD = 1.05) showed no evidence of floor or ceiling effects. The scale was found to be acceptable (<1% missing data) and reliable (intraclass correlation coefficient = 0.74). Scores demonstrated convergent validity, as they were higher for those without decisional conflict than those with decisional conflict (2.93 vs 2.46, P < .001, d = 0.46), and higher for caregivers who stated they made the decision with the provider than those who made the decision themselves (3.0 vs 2.7; P = .003). Higher scores were related to less regret (r = -0.15, P < .001), though the magnitude of the relationship was small.

CONCLUSIONS

The adapted Pediatric Caregiver version of the SDM Process scale demonstrated acceptability, validity and reliability in the context of ADHD medication decisions made by caregivers of children 5-13. Scores indicate pediatricians generally involve caregivers in decision making about ADHD medication.

Parental smoking exposure before and during pregnancy and offspring attention-deficit/hyperactivity disorder risk: A Chinese child and adolescent cohort study

Background

Previous studies revealed that maternal smoking exposure during pregnancy was an essential risk factor for offspring developing attention-deficit/hyperactivity disorder (ADHD). The impact of paternal smoking exposure 1 year before pregnancy on offspring ADHD risk is still unclear.

Methods

The present study included 2,477 school-age children and their parents from the Shanghai Child and Adolescent Health Cohort who had complete data for offspring ADHD diagnosis and parents' smoking exposure before and during pregnancy information. A multivariate logistic regression model and Firth's logistic regression model were used to determine the associations of paternal smoking and parental smoke exposure patterns before and during pregnancy with offspring ADHD risk.

Results

Children whose fathers smoked before pregnancy had a higher risk of developing ADHD [odds ratio (OR) = 2.59, 95% confidence interval (CI): 1.35-4.98] compared to those whose fathers had never been exposed to smoking. Similarly, parents who were exposed to smoking or second-hand smoke before pregnancy had 1.96 times (OR = 1.96, 95% CI: 1.19-3.22) more likely to have offspring with ADHD. Moreover, children whose parents were exposed to smoking both before and during pregnancy were 2.01 times (OR = 2.01, 95% CI: 1.29-3.12) more likely to develop ADHD.

Conclusion

Paternal smoking before pregnancy and parental smoking exposure 1 year ahead of and throughout pregnancy were all risk factors for offspring developing ADHD.

The Impact of ADHD on Maternal Quality of Life

Childhood attention-deficit/hyperactivity disorder (ADHD) is associated with substantial burden to caregiver quality of life (QoL). However, a paucity of work has focused on quantifying QoL among caregivers of adolescents with a history of ADHD. The purpose of the current study was (1) to quantify maternal QoL in a sample of mothers of adolescents with and without childhood ADHD; and (2) to examine predictors (i.e., parent and child characteristics and behavior) associated with maternal QoL. Participants included mothers of adolescents with (N = 110) and without ADHD (N = 90) ranging in age from 13 to 18 (M = 16.09, 92% male). The Quality Adjusted Life-Year (QALY) was used to calculate maternal QoL using two health domains (i.e., anxiety/depression and disruption in daily activities) commonly impacted by raising youth with ADHD. QALYs are valued monetarily to estimate disease burden. Mothers of adolescents with childhood ADHD experienced significantly worse QoL relative to mothers in the comparison group. Maternal depression, as well as adolescent age, ADHD status, and discipline problems significantly predicted lower levels of maternal QALY health status index, with ADHD being the strongest predictor. This is equal to a reduction in 1.96 QALYs when summed over the course of a child's lifetime and is associated with a loss of $98,000 to $196,000. Results of the investigation help to further elucidate the health impacts incurred by families of adolescents with ADHD and have important public health implications. Further, parental QoL should be considered when conceptualizing the financial and negative health impact of ADHD.

Factors Contributing to Employment Status over Time for Caregivers of Young People with Mental Health Disorders

This study utilized the conservation of resources theory to guide the examination of employment outcomes for caregivers of children with emotional and/or behavioral disorders. The sample included 2455 caregivers whose children received services through federally funded systems of care. Of special interest was whether receiving services and supports predicted change in employment status. We examined change in employment between baseline data collection and the six-month follow-up including: (1) gaining employment, and (2) retaining employment. Findings indicated that the relationship between service/supports and caregiver employment differed depending on initial employment status, and type of service received. Accessing any service was associated with gaining employment. For families who accessed any services, receiving behavioral aide services was associated with gaining employment. Caregivers of children who used residential services were less likely to lose employment. Several child, caregiver, and demographic variables also predicted employment status over time. Taken together, the findings suggest that caregivers of children with emotional and behavioral challenges are at risk for downward cycles of resource loss, and that services and supports have the potential to mitigate that risk.

Treatment patterns among children and adolescents with attention-deficit/hyperactivity disorder in the United States - a retrospective claims analysis

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral disorder affecting approximately 10.0% of children and 6.5% of adolescents in the United States (US). A comprehensive assessment of the current treatment landscape is warranted to highlight potential unmet needs of children and adolescents with ADHD. Therefore, this study described treatment patterns and healthcare costs among commercially insured children and adolescents with ADHD in the US.

METHODS

Children and adolescents with ADHD initiating pharmacological treatment indicated for ADHD were identified from IBM MarketScan Commercial Database (2014-2018). A treatment sequence algorithm was used to examine treatment patterns, including discontinuation (≥ 180 days following the last day of supply of any ADHD treatment), switch, add-on, and drop (discontinuation of an agent in combination therapy), during the 12-month study period following the index date (i.e., first observed ADHD treatment). Total adjusted annual healthcare costs were compared between patients with and without treatment changes.

RESULTS

Among 49,756 children and 29,093 adolescents included, mean age was 9 and 15 years, respectively, and 31% and 38% were female. As the first treatment regimen observed, 92% of both children and adolescents initiated a stimulant and 11% initiated combination therapy. Over half of the population had a treatment change over 12 months-59% of children and 68% of adolescents. Treatment discontinuation over 12 months was common in both populations-21% of children and 36% of adolescents discontinued treatment. Healthcare costs increased with the number of treatment changes observed; children and adolescents with treatment changes (i.e., 1, 2, or ≥ 3) incurred an incremental annual cost of up to $1,443 and $2,705, respectively, compared to those without a treatment change (p < 0.001). Costs were largely driven by outpatient visits.

CONCLUSIONS

Over a 12-month period, treatment changes were commonly observed and were associated with excess costs, highlighting the unmet treatment needs of children and adolescents with ADHD in the US.

Does Child Anxiety Exacerbate or Protect Against Parent–Child Relationship Difficulties in Children with Elevated ADHD Symptoms?

Pediatric ADHD is associated with parent–child relationship difficulties. However, the extent to which these relations are attributable to specific ADHD symptom clusters (i.e., inattentive vs. hyperactive/impulsive), and the extent to which child anxiety symptoms may exacerbate or protect against these difficulties, remains unclear. To address these gaps in the literature, the current study combined multi-informant measures (parent, teacher, child) with a clinically-evaluated and carefully-phenotyped sample of 188 children with and without ADHD and anxiety (ages 8–13; 63 girls). Results indicated that child-reported anxiety (β = .46) and teacher-reported inattentive (β = .71) symptoms, and their interaction (β = -1.06), along with child age and IQ (β = -.14 to -.15), predict the extent to which parents perceive themselves as confident and competent parents (all p < .05). In contrast, only comorbid oppositional-defiant disorder conferred risk for increased parent-reported relational frustration, and we were unable to detect any reliable child-level demographic, diagnostic, or behavioral predictors of parent-reported discipline practices. These findings were robust to control for child demographic characteristics, clinical diagnoses, and intellectual functioning, with sensitivity analyses highlighting the importance of assessing ADHD inattentive vs. hyperactive/impulsive symptoms separately for understanding parenting outcomes. Taken together, the current findings suggest that child ADHD and anxiety symptoms may influence specific rather than broad-based aspects of the parent–child relationship, and produce differently valenced outcomes in the presence vs. absence of the other condition. Interestingly, it appears that the combination of greater child inattention and anxiety, rather than elevations in either symptom domain independently, predict adverse parenting outcomes in terms of reduced parental confidence.

Parent-administered pediatric tuina for the treatment of attention deficit hyperactivity disorder symptoms: Process evaluation of a pilot randomized controlled trial

BACKGROUND

A pilot randomized controlled trial (RCT) was conducted in mainland China to examine the feasibility, acceptability, and preliminary effects of parent-administered pediatric tuina on attention deficit hyperactivity disorder (ADHD) symptoms in preschool children. An embedded process evaluation was performed to explore barriers and facilitators in the implementation, identify additional questions, and refine the study design for a future fully powered study.

METHODS

The process evaluation comprises the following parts: (a) self-reported questionnaires on parents (n = 43), traditional Chinese medicine (TCM) practitioners (n = 2), outcome assessor (n = 1), and research assistant (n = 1); (b) parent logbook on parent-administered pediatric tuina (n = 32); and (c) focus group interview sessions (n = 15). Accomplishment of the self-report questionnaires was voluntary for all participants and compulsory for research personnel and TCM practitioners. The parent logbook on the intervention was filled out by all participants in the intervention group. Participants of focus group interviews were selected via purposive sampling, and data were analyzed with template analysis. Qualitative findings were summarized in tables, while the mean was calculated to reflect the quantitative findings.

RESULTS

Perceived benefits, acceptability of parents and children, and professional support from the research team facilitated the implementation of the intervention. Meanwhile, the TCM pattern identification using online mode may limit the accuracy and lead to parents doubting the precision of the TCM pattern. This limitation was regarded as a major barrier. Parents perceived improvements in terms of children's appetite, sleep quality, and parent-child relationship. Participants were generally satisfied with the settings of parent-administered pediatric tuina and showed satisfactory adherence to the implementation.

CONCLUSIONS

Implementation of parent-administered pediatric tuina intervention is feasible and acceptable. The intervention can be refined by improving the TCM pattern identification procedure and adjusting outcome settings in a fully powered study in the future.

Attention Deficit Hyperactivity Disorder Assessment Based on Patient Behavior Exhibited in a Car Video Game: A Pilot Study

Symptoms of Attention Deficit Hyperactivity Disorder (ADHD) include excessive activity, difficulty sustaining attention, and inability to act in a reflective manner. Early diagnosis and treatment of ADHD is key but may be influenced by the observation and communication skills of caregivers, and the experience of the medical professional. Attempts to obtain additional measures to support the medical diagnosis, such as reaction time when performing a task, can be found in the literature. We propose an information recording system that allows to study in detail the behavior shown by children already diagnosed with ADHD during a car driving video game. We continuously record the participants’ activity throughout the task and calculate the error committed. Studying the trajectory graphs, some children showed uniform patterns, others lost attention from one point onwards, and others alternated attention/inattention intervals. Results show a dependence between the age of the children and their performance. Moreover, by analyzing the positions by age over time using clustering, we show that it is possible to classify children according to their performance. Future studies will examine whether this detailed information about each child’s performance pattern can be used to fine-tune treatment.

Social gradients in ADHD by household income and maternal education exposure during early childhood: Findings from birth cohort studies across six countries

Objective

This study aimed to examine social gradients in ADHD during late childhood (age 9–11 years) using absolute and relative relationships with socioeconomic status exposure (household income, maternal education) during early childhood (<5 years) in seven cohorts from six industrialised countries (UK, Australia, Canada, The Netherlands, USA, Sweden).

Methods

Secondary analyses were conducted for each birth cohort. Risk ratios, pooled risk estimates, and absolute inequality, measured by the Slope Index of Inequality (SII), were estimated to quantify social gradients in ADHD during late childhood by household income and maternal education measured during early childhood. Estimates were adjusted for child sex, mother age at birth, mother ethnicity, and multiple births.

Findings

All cohorts demonstrated social gradients by household income and maternal education in early childhood, except for maternal education in Quebec. Pooled risk estimates, relating to 44,925 children, yielded expected gradients (income: low 1.83(CI 1.38,2.41), middle 1.42(1.13,1.79), high (reference); maternal education: low 2.13(1.39,3.25), middle 1.42(1.13,1.79)). Estimates of absolute inequality using SII showed that the largest differences in ADHD prevalence between the highest and lowest levels of maternal education were observed in Australia (4% lower) and Sweden (3% lower); for household income, the largest differences were observed in Quebec (6% lower) and Canada (all provinces: 5% lower).

Conclusion

Findings indicate that children in families with high household income or maternal education are less likely to have ADHD at age 9–11. Absolute inequality, in combination with relative inequality, provides a more complete account of the socioeconomic status and ADHD relationship in different high-income countries. While the study design precludes causal inference, the linear relation between early childhood social circumstances and later ADHD suggests a potential role for policies that promote high levels of education, especially among women, and adequate levels of household income over children’s early years in reducing risk of later ADHD.

Eliciting preferences for continuing medication among adult patients and parents of children with attention-deficit hyperactivity disorder

BACKGROUND

Adherence to medication for attention-deficit hyperactivity disorder (ADHD) is less than optimal. Previous studies have primarily focused on qualitative assessment of factors that influence medication adherence.

OBJECTIVE

This study aimed to quantify the factors that influence patient and parent preferences for continuing ADHD medication.

METHOD

A discrete-choice experiment was conducted to investigate preferences. Adults, and parents of children, with ADHD were presented with eight hypothetical choice tasks of three options (Medication A, Medication B, No Medication) described by six attributes related to medication outcomes. Preferences were estimated using a mixed multinomial logit model.

RESULTS

Overall, respondents' preferences (n = 216) for continuing medication were negative (mean [β] = -1.426, p < .001); however, a significant heterogeneity in preferences was observed amongst respondents (standard deviation = 0.805, p < .001). Improvements in education, aggressive behaviour, social behaviour and family functioning, and side effects and stigma, influenced respondents' decision to continue taking medication. The respondents were willing to continue medication if they experienced positive effects, but side effects (even moderate) were the strongest concern for not continuing medication. While side effects were the most important factor for both adult patients and parents of children with ADHD, improvement in education was relatively more important for adults and improvement in aggressive behaviour, social behaviour and family functioning was relatively more important for parents of children with ADHD. Parents were more likely to not continue a medication with severe side effects even at the highest level of improvement in education.

CONCLUSIONS

Side effects are the most important factor that influenced preferences for continuing medication for both adults with ADHD, as well as parents of children with ADHD. While overall the respondents preferred not to take/give medication, discrete-choice experiment showed that the relative importance of factors that influenced continuation of medications was different for the two groups.

PATIENT AND PUBLIC INVOLVEMENT

Adults, and parents of children, with ADHD participated in this study by completing the online questionnaire. The questionnaire was based on findings of research in the literature, as well as earlier focus groups conducted with adults, and parents of children, with ADHD. The face validity of the questionnaire was determined by asking parents of children, and adults, with ADHD (n = 3) to complete the survey and participate in a short discussion on their understanding of the questions and their recommendations on improving the clarity of the survey.

Examining the effects of ADHD symptoms and parental involvement on children's academic achievement

OBJECTIVE

Our understanding of the role of parental involvement in academic outcomes for children with ADHD is limited, with mixed evidence suggesting a positive association between parental involvement and academic achievement for pediatric ADHD but limited evidence regarding how this varies based on ADHD symptom severity, ADHD symptom domains, or co-occurring ODD symptoms. In this context, the present study aimed to examine the effects of parental involvement, ADHD symptoms, and comorbid ODD on children's overall, reading, and math achievement.

METHOD

A well-characterized clinically-evaluated sample of 162 children recruited through a university-based children's learning/behavioral health clinic and community resources (ages 8-13; 50 girls; 69% Caucasian/Non-Hispanic) were administered standardized academic achievement tests, with parents and teachers completing measures of parental involvement and ADHD symptoms, respectively.

RESULTS

Inattention, but not hyperactivity-impulsivity, was associated with lower academic achievement in all tested models (β= -.16 to -.22, all p < .03). Surprisingly, parental involvement had significant negative associations with math and overall academic achievement (β= -.13 to -.26, both p< .05) and did not moderate the relations between ADHD symptoms and academic achievement in any tested model. Comorbid ODD symptoms did not significantly predict academic achievement or interact with parental involvement in any tested model. These findings were robust to control for child IQ, age, sex, SES, anxiety, and depression.

CONCLUSION

Parental involvement may not serve as a protective factor against academic underachievement for children with clinically elevated ADHD symptoms, and may predict lower rather than higher academic achievement for clinically evaluated children in general.

Are There Resilient Children with ADHD?

OBJECTIVE

The adverse outcomes associated with ADHD are well known, but less is known about the minority of children with ADHD who may be flourishing despite this neurodevelopmental risk. The present multi-informant study is an initial step in this direction with the basic but unanswered question: Are there resilient children with ADHD?

METHOD

Reliable change analysis of the BASC-3 Resiliency subscale for a clinically evaluated sample of 206 children with and without ADHD (ages 8-13; 81 girls; 66.5% White/Non-Hispanic).

RESULTS

Most children with ADHD are perceived by their parents and teachers as resilient (52.8%-59.2%), with rates that did not differ from the comorbidity-matched Non-ADHD sample.

CONCLUSION

Exploratory analyses highlighted the importance of identifying factors that promote resilience for children with ADHD specifically, such that some child characteristics were promotive (associated with resilience for both groups), some were protective (associated with resilience only for children with ADHD), and some were beneficial only for children without ADHD.

Experiences of adolescents and parents on the mental health management of depression in adolescents, North West province, South Africa

Background

Living with or managing an adolescent suffering from depression predisposes the adolescent and parents to various experiences, considering the multifactorial nature of depression and associated symptoms.

Objective

This study explored and described the experiences of adolescents and their parents on the mental health management of depression in the North West province (NWP), South Africa.

Method

A qualitative, exploratory, descriptive, contextual research design was adopted. Data was collect from two mental health care institutions and two mental health care units attached to two general hospitals in the NWP, SA. Thirty-two participants (18 adolescents and 14 parents) were purposefully selected for the study. Data were collected through individual interviews and analysed using Tesch’s open-coding method to generate themes and categories which were presented with the concurrent support of participants direct quotations.

Results

The study revealed that the experiences of adolescents with depression and their parents taking care of them at homes include the following: emotional distress, poor coping mechanisms, financial burden, repeated suicidal attempts, negative attitudes from support systems and withdrawal behaviours. Appropriate therapeutic environments, ongoing monitoring by mental healthcare practitioners and adequate support systems were suggested by participants as management approaches that could enhance the recovery of adolescents from depression.

Conclusion

The findings revealed the devastating experiences of adolescents with depression and their parents taking care of them in their various homes which confirms the dire need for attention on the plights of these groups in order to facilitate adolescents’ recovery and strengthen the adolescents’ and parents’ coping mechanisms for a healthier family.

The usefulness of virtual, augmented, and mixed reality technologies in the diagnosis and treatment of attention deficit hyperactivity disorder in children: an overview of relevant studies

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition characterized by attention problems, excessive physical activity, and impulsivity. ADHD affects not only the patients but also their families. The development and use of technologies such as virtual reality (VR), augmented reality (AR), and mixed reality (MR) for ADHD has increased over recent years. However, little is known about their potential usefulness. This overview aimed to clarify the current knowledge about the use of these three innovative technologies for the diagnosis and treatment of children with ADHD.

METHODS

This overview was conducted using the PubMed, Web of Science, and Scopus databases until January 24th, 2021. The following descriptive information was compiled from the identified studies: country, year of publication, sample size, study design, ADHD diagnosis methods, applied technology, hardware equipment, clinical target, and main findings.

RESULTS

The initial database searches yielded 409 articles, but 103 were removed as duplicates. Eventually, 30 eligible studies remained for analysis, the majority of which were case-control (n = 22, 73%). Regarding the applied technology/hardware equipment, VR (n = 27; 90%), head-mounted displays (n = 19, 63%), VR-based continuous performance tests (VR-CPT) (n = 21, 70%) were most frequently used. Most studies (n = 21, 70%) used the DSM criteria for the diagnosis of childhood ADHD. They primarily evaluated the utility of these technologies in assessing ADHD symptoms (n = 10, 33%) and improving the ADHD diagnostic process (n = 7, 23%).

CONCLUSION

This comprehensive overview evaluated the studies on the use of VR, AR, and MR technologies for children with ADHD. These technologies seem to be promising tools for improving the diagnosis and management of ADHD in this population.

Does central executive training and/or inhibitory control training improve emotion regulation for children with attention-deficit/hyperactivity disorder? A randomized controlled trial

INTRODUCTION

Approximately 48-54% of children with attention-deficit/hyperactivity disorder (ADHD) have impairing difficulties with emotion regulation, and these difficulties are not ameliorated by first-line ADHD treatments. Working memory and inhibitory control represent promising intervention targets given their functional, if not causal, links with ADHD-related emotion dysregulation.

METHODS

This preregistered randomized controlled trial tested whether two digital therapeutic training protocols that have been previously shown to improve working memory (Central Executive Training [CET]) and inhibitory control (Inhibitory Control Training [ICT]) can improve emotion regulation in a sample of 94 children with ADHD aged 8-13 years (M = 10.22, SD = 1.43; 76% White/non-Hispanic; 29 girls).

RESULTS

Results of Bayesian mixed model ANOVAs indicated both treatment groups demonstrated significant decreases in emotion dysregulation relative to pre-treatment at immediate post-treatment (parent report; d = 1.25, BF₁₀ = 8.04 × 10¹³, p < 0.001), at 1-2 months after completing treatment (teacher report; d = 0.99, BF₁₀ = 1.22 × 10⁶, p < 0.001), and at 2-4-months follow-up (parent report; d = 1.22, BF₁₀ = 1.15 × 10¹⁴, p < 0.001). Contrary to our hypotheses, the CET and ICT groups demonstrated equivalent reductions in emotion dysregulation and maintenance of effects. Exploratory analyses revealed that results were robust to control for informant expectancies, ADHD medication status/changes, in-person vs. at-home treatment, child age, and time from treatment completion to post-treatment ratings.

DISCUSSION

To determine whether working memory and inhibitory control are causally linked with ADHD-related emotion dysregulation, future studies should include active control conditions that do not train executive functions prior to making decisions about the clinical utility of CET/ICT for the treatment of emotion dysregulation in ADHD.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/], identifier [NCT03324464].

Childhood ADHD, Going Beyond the Brain: A Meta-Analysis on Peripheral Physiological Markers of the Heart and the Gut

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common neurodevelopmental disorder diagnosed in children. Questions regarding its increased diagnostic rates and pharmacological treatments in developing children have led to a more holistic review of the multi-system pathophysiology observed in ADHD. The dopaminergic neurotransmitter system, known for its influence on reward-motivated behaviors and motor control, and the frontostriatal systems, that mediate motor, cognition, and behavior, are associated with ADHD's development. However, studies have shown that these neural systems do not wholly account for ADHD's multilayered and heterogeneous symptom presentation. For instance, the literature suggests that emotional dysregulation, the inability to regulate one's emotional responses to provoking stimuli, is associated with increased risk for social impairment in ADHD. A broader examination of physiological systems in children with ADHD has found potential markers in the heart-brain and gut-brain axes that correspond with certain behaviors associated with emotional dysregulation in recent studies. Hence, the purpose of this meta-analysis is to aggregate ten applicable published case studies and analyze task-related heart rate reactivity (HRR; n = 5 studies) and gut microbiota (n = 5 studies) data in children with and without ADHD. Data from a total of 531 youth with ADHD and 603 youth without ADHD revealed significant small and medium effect sizes for higher Chao1 levels and Actinobacteria levels in the ADHD group, respectively, but no evidence of altered task-related HRR. Thus, further research into multi-system psychophysiological measures of emotional dysregulation and ADHD is warranted. The clinical, empirical, and educational implications of these findings are discussed.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier PROSPERO (CRD42021236819).

Economic burden of attention-deficit/hyperactivity disorder among children and adolescents in the United States: a societal perspective

OBJECTIVE

To provide a comprehensive evaluation of the economic burden associated with attention-deficit/hyperactivity disorder (ADHD) among children and adolescents from a US societal perspective.

MATERIALS AND METHODS

Direct healthcare costs of children (5-11 years) and adolescents (12-17 years) with ADHD were obtained using claims data from the IBM MarketScan Research Databases (01/01/2017-12/31/2018). Direct non-healthcare and indirect costs were estimated based on literature and government publications. Each cost component was estimated using a prevalence-based approach, with per-patient costs extrapolated to the national level.

RESULTS

The total annual societal excess costs associated with ADHD were estimated at $19.4 billion among children ($6,799 per child) and $13.8 billion among adolescents ($8,349 per adolescent). Education costs contributed to approximately half of the total excess costs in both populations ($11.6 billion [59.9%] in children; $6.7 billion [48.8%] in adolescents). Other major contributors to the overall burden were direct healthcare costs ($5.0 billion [25.9%] in children; $4.0 billion [29.0%] in adolescents) and caregiving costs ($2.7 billion [14.1%] in children; $1.6 billion [11.5%] in adolescents).

LIMITATIONS

Cost estimates were calculated based on available literature and/or governmental publications due to the absence of a single data source for all costs associated with ADHD. Thus, the quality of cost estimates is limited by the accuracy of available data as well as the study populations and methodologies used by different studies.

CONCLUSION

ADHD in children and adolescents is associated with a substantial economic burden that is largely driven by education costs, followed by direct healthcare costs and caregiver costs. Improved intervention strategies and policies may reduce the clinical and economic burden of ADHD in these populations.