Current Australian pediatric practice in the assessment and treatment of ADHD

Mental health-related service and medicine use among a cohort of urban Aboriginal children and young people: Data linkage study

OBJECTIVE

The objective was to describe mental health service and psychotropic medicine use among a cohort of Aboriginal young people and quantify their relation to sociodemographic, family and health factors.

METHODS

In a prospective cohort study with data linkage, 892 Aboriginal children aged 0-17 years living in urban and regional areas of New South Wales, Australia, were included. We assessed mental health-related service use, paediatric service use and psychotropic medicine dispensing claims covered by the Australian Government Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme from July 2012 to June 2017.

RESULTS

Most children (71%) did not have a record of mental health service or psychotropic medication use. 18.7% had ⩾1 mental health-related service claim; 26.7% had ⩾1 paediatric service claim; and 20.3% had ⩾1 psychotropic medicine dispensing claim. General practitioner services were the most accessed mental health-related service (17.4%) and 12.7% had been dispensed attention-deficit hyperactivity disorder medicines. Child characteristics associated with treatment included emotional and behavioural problems (prevalence ratio: 1.97, 95% confidence interval = [1.46, 2.64] for mental health services; prevalence ratio: 2.87, 95% confidence interval = [2.07, 3.96] for medicines) and risky behaviour (prevalence ratio: 1.56, 95% confidence interval = [1.12, 2.16] for mental health services; prevalence ratio: 2.28, 95% confidence interval = [1.54, 3.37] for medicines). Parent-related factors included chronic illness (prevalence ratio: 1.42, 95% confidence interval = [1.03, 1.95] for mental health services; prevalence ratio: 2.00, 95% confidence interval = [1.49, 2.69] for medicines) and functional limitations (prevalence ratio: 1.61, 95% confidence interval = [1.16, 2.24] for mental health services; prevalence ratio: 1.86, 95% confidence interval = [1.34, 2.59] for medicines).

CONCLUSIONS

Most Aboriginal children and young people did not have claims for mental health services or medicines. Aboriginal children with emotional and behavioural problems, or parents with health problems were more likely to have mental health service or medicine claims.

Investigating Variations in Medicine Approvals for Attention-Deficit/Hyperactivity Disorder: A Cross-Country Document Analysis Comparing Drug Labeling

OBJECTIVE

This study aimed to compare the approval of medicines for attention deficit/hyperactivity disorder (ADHD) for pediatric patients across five countries.

METHOD

A document analysis was completed, using the drug labeling for ADHD medicines from five countries; United Kingdom, Australia, New Zealand, Canada and United States (US). Comparisons of available formulations and approval information for ADHD medicine use in pediatric patients were made.

RESULTS

The US had the highest number of approved medicines and medicine forms across the studied countries (29 medicine forms for 10 approved medicines). Approved age and dosage variations across countries and missing dosage information were identified in several drug labeling.

CONCLUSIONS

The discrepancies in approval information in ADHD medicine drug labeling and differing availability of medicine formulations across countries suggest variations in the management of ADHD across countries. The update of drug labeling and further research into reasons for variability and impact on practice are needed.

Age at diagnosis and diagnostic delay across attention-deficit hyperactivity and autism spectrums

BACKGROUND

Despite the known benefits of accurate and timely diagnosis for children with attention-deficit hyperactivity disorder and autism spectrum disorders (autism), for some children this goal is not always achieved. Existing research has explored diagnostic delay for autism and attention-deficit hyperactivity disorder only, and when attention-deficit hyperactivity disorder and autism co-occur, autism has been the focus. No study has directly compared age at diagnosis and diagnostic delay for males and females across attention-deficit hyperactivity disorder, autism and specifically, attention-deficit hyperactivity disorder + autism.

METHODS

Australian caregivers (N = 677) of children with attention-deficit hyperactivity disorder, autism or attention-deficit hyperactivity disorder + autism were recruited via social media (n = 594) and the Monash Autism and ADHD Genetics and Neurodevelopment Project (n = 83). Caregivers reported on their child's diagnostic process. Diagnostic delay was the mean difference between general initial developmental concerns and the child's attention-deficit hyperactivity disorder and autism diagnosis.

RESULTS

Children with autism were significantly younger at autism diagnosis than the attention-deficit hyperactivity disorder + autism group (ηp2 = 0.06), whereas children with attention-deficit hyperactivity disorder were significantly older at attention-deficit hyperactivity disorder diagnosis than the attention-deficit hyperactivity disorder + autism group (ηp2 = 0.01). Delay to attention-deficit hyperactivity disorder and autism diagnosis was significantly longer in the attention-deficit hyperactivity disorder + autism group compared to attention-deficit hyperactivity disorder (ηp2 = 0.02) and autism (η2 = 0.04) only. Delay to autism diagnosis for females with autism (η2 = 0.06) and attention-deficit hyperactivity disorder + autism (η2 = 0.04) was longer compared to males.

CONCLUSIONS

Having attention-deficit hyperactivity disorder + autism and being female were associated with longer delays to diagnosis. The reasons for these delays and possible adverse effects on outcomes require further study.

Associations Between Anxiety and Home Learning Difficulties in Children and Adolescents with ADHD During the COVID-19 Pandemic

The COVID-19 pandemic has markedly impacted functioning for children and adolescents including those with attention-deficit/hyperactivity disorder (ADHD). We explored home learning difficulties (HLD) during COVID-19 restrictions in Australian children (aged 5-17) with ADHD, aiming to: (1) describe home learning experiences, and (2) examine associations between child anxiety (i.e., concurrent anxiety symptoms and pre-existing anxiety disorder status) and HLD. Baseline data from the longitudinal ADHD COVID-19 Survey were used (n = 122). Parents reported on school factors and HLD; pre-existing anxiety and co-occurring difficulties; anxiety, ADHD, and oppositional symptoms; demographics; and medications. Parents retrospectively reported more children often looked forward to school pre-pandemic, than during the pandemic. Anxiety symptoms, but not pre-existing anxiety disorder status, were associated with HLD after accounting for covariates. ADHD inattention symptoms were also associated with HLD. Results support recommendations to continue pre-pandemic supports to assist with ADHD symptoms during home learning, and strategies/supports for families are discussed.

Medicinal Cannabis for Paediatric Developmental, Behavioural and Mental Health Disorders

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

Características das prescrições de metilfenidato em ambulatório de neuropediatria

RESUMO O metilfenidato não é disponibilizado pelo Sistema Único de Saúde (SUS), pois não faz parte da Relação Nacional de Medicamentos Essenciais. Todavia, o metilfenidato 10 mg é disponibilizado pela rede pública em Maringá-PR de acordo com a Política da Assistência Farmacêutica do município. Objetivou-se analisar as características das prescrições médicas de metilfenidato para crianças em ambulatório de neuropediatria vinculado ao SUS no município. Estudo transversal observacional retrospectivo de caráter quantitativo, realizado por meio da coleta de dados dos prontuários cadastrados no Sistema Gestor da rede pública de saúde do município, pelo ambulatório de neuropediatria na Unidade Básica de Saúde, Zona 7, entre janeiro de 2017 e novembro de 2019. Analisaram-se os dados por frequência relativa e absoluta. Emitiram-se 339 prescrições pelo neuropediatra responsável do ambulatório para 107 pacientes de 6 a 11 anos. Notou-se distribuição geográfica desigual das crianças atendidas conforme bairro da cidade, o que denota influência socioeconômica na prescrição de medicamentos. Ressaltam-se picos de prescrições coincidindo com o período do ano letivo escolar. Concluiu-se que o acompanhamento especializado adequado é premissa para o tratamento, não dispensando a rede longitudinal de assistência. Ademais, evidencia-se o impacto das condições socioeconômicas, tanto na prescrição como na aquisição do medicamento.

Examining the pharmacological and psychological treatment of child and adolescent ADHD in Australia: Protocol for a retrospective cohort study using linked national registry data

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder which affects 5% of children globally. In Australia, it is estimated that 4.1% of children and adolescents have ADHD. While research has examined the treatment and outcomes of children with ADHD attending public mental health services during their time in the public system in Australia, it is not known what treatment they received before and after these treatment episodes, which will provide a more complete understanding of these children's treatment journey.

METHODS AND ANALYSIS

We will link clinical data from cohorts of children and adolescents treated in the public child and youth mental health and/or child development services in Brisbane, Melbourne and Sydney to the Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (PBS) and National Death Index. MBS data will demonstrate the treatment journey with respect to clinicians seen, and treatment episodes from the public health service data sets will be examined to assess if the type and intensity of treatment are related to treatment outcomes. PBS data will reveal all psychotropic medications prescribed, allowing an examination of not just ADHD medications, but also other psychotropics which may indicate co-occurring conditions (eg, anxiety and mood disorders). Statistical analyses will include descriptive statistics to describe the rates of specific medications and clinician specialties seen. Linear and logistic regression will be used to model how treatment and sociodemographic variables relate to routinely collected outcome measures in the public health system while controlling for covarying factors.

ETHICS AND DISSEMINATION

This study has been approved by the following institutional ethics committees: (1) Children's Health Queensland Hospital and Health Service (HREC/21/QCHQ/76260), (2) The University of Queensland (2021/HE002143) and (3) The Australian Institute of Health and Welfare (EO2021/4/1300). Findings will be disseminated through peer-reviewed journals, conferences, professional associations and to public mental health services that treat ADHD.

Physical Health, Media Use, and Mental Health in Children and Adolescents With ADHD During the COVID-19 Pandemic in Australia

OBJECTIVE

To examine the impact of COVID-19 restrictions among children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Parents of 213 Australian children (5-17 years) with ADHD completed a survey in May 2020 when COVID-19 restrictions were in place (i.e., requiring citizens to stay at home except for essential reasons).

RESULTS

Compared to pre-pandemic, children had less exercise (Odds Ratio (OR) = 0.4; 95% CI 0.3-0.6), less outdoor time (OR = 0.4; 95% 0.3-0.6), and less enjoyment in activities (OR = 6.5; 95% CI 4.0-10.4), while television (OR = 4.0; 95% CI 2.5-6.5), social media (OR = 2.4; 95% CI 1.3-4.5), gaming (OR = 2.0; 95% CI 1.3-3.0), sad/depressed mood (OR = 1.8; 95% CI 1.2-2.8), and loneliness (OR = 3.6; 95% CI 2.3-5.5) were increased. Child stress about COVID-19 restrictions was associated with poorer functioning across most domains. Most parents (64%) reported positive changes for their child including more family time.

CONCLUSIONS

COVID-19 restrictions were associated with both negative and positive impacts among children with ADHD.

Does the treatment of anxiety in children with Attention-Deficit/Hyperactivity Disorder (ADHD) using cognitive behavioral therapy improve child and family outcomes? Protocol for a randomized controlled trial

BACKGROUND

Up to 60% of children with Attention-Deficit/Hyperactivity Disorder (ADHD) meet diagnostic criteria for at least one anxiety disorder, including Social, Generalized and/or Separation Disorder. Anxiety in children with ADHD has been shown to be associated with poorer child and family functioning. Small pilot studies suggest that treating anxiety in children with ADHD using cognitive-behavioral therapy (CBT) has promising benefits. In a fully powered randomized controlled trial (RCT), we aim to investigate the efficacy of an existing CBT intervention adapted for children with ADHD and comorbid anxiety compared with usual care.

METHODS

This RCT is recruiting children aged 8-12 years (N = 228) from pediatrician practices in Victoria, Australia. Eligibility criteria include meeting full diagnostic criteria for ADHD and at least one anxiety disorder (Generalized, Separation or Social). Eligible children are randomized to receive a 10 session CBT intervention (Cool Kids) versus usual clinical care from their pediatrician. The intervention focuses on building child and parent skills and strategies to manage anxiety and associated impairments including cognitive restructuring and graded exposure. Minor adaptations have been made to the delivery of the intervention to meet the needs of children with ADHD including increased use of visual materials and breaks between activities. The primary outcome is change in the proportion of children meeting diagnostic criteria for an anxiety disorder at 5 months randomization. This will be assessed via diagnostic interview with the child's parent (Anxiety Disorders Interview Schedule for Children V) conducted by a researcher blinded to intervention condition. Secondary outcomes include a range of child (e.g., anxiety symptoms, ADHD severity, behavior, quality of life, sleep, cognitive functioning, school attendance) and parent (e.g., mental health, parenting behaviors, work attendance) domains of functioning assessed at 5 and 12 months post-randomization. Outcomes will be analyzed using logistic and mixed effects regression.

DISCUSSION

The results from this study will provide evidence on whether treating comorbid anxiety in children with ADHD using a CBT approach leads to improvements in anxiety and/or broader functional outcomes.

TRIAL REGISTRATION

This trial was prospectively registered: Current Controlled Trials ISRCTN59518816 (https://doi.org/10.1186/ISRCTN59518816). The trial was first registered 29/9/15 and last updated 15/1/19.

Impact of a behavioral intervention, delivered by pediatricians or psychologists, on sleep problems in children with ADHD: a cluster-randomized, translational trial

BACKGROUND

We have demonstrated the efficacy of a brief behavioral intervention for sleep in children with ADHD in a previous randomized controlled trial and now aim to examine whether this intervention is effective and cost-effective when delivered by pediatricians or psychologists in community settings.

METHODS

Translational, cluster-randomized trial of a behavioral intervention versus usual care from 19th January, 2015 to 30th June, 2017. Participants (n = 361) were children aged 5-13 years with ADHD and parent report of a moderate/severe sleep problem who met criteria for American Academy of Sleep Medicine criteria for chronic insomnia disorder, delayed sleep-wake phase disorder, or were experiencing sleep-related anxiety. Participants were randomized at the level of the pediatrician (n = 61) to intervention (n = 183) or usual care (n = 178). Families in the intervention group received two consultations with a pediatrician or a psychologist covering sleep hygiene and tailored behavioral strategies.

RESULTS

In an intention-to-treat analysis, at 3 and 6 months respectively, the proportion of children with moderate to severe sleep problems was lower in the intervention (28.0%, 35.8%) compared with usual care group (55.4%, 60.1%; 3 month: risk ratio (RR): 0.51, 95% CI 0.37, 0.70, p < .001; 6 month: RR: 0.58; 95% CI 0.45, 0.76, p < .001). Intervention children had improvements across multiple Children's Sleep Habits Questionnaire subscales at 3 and 6 months. No benefits of the intervention were observed in other domains. Cost-effectiveness of the intervention was AUD 13 per percentage point reduction in child sleep problem at 3 months.

CONCLUSIONS

A low-cost brief behavioral sleep intervention is effective in improving sleep problems when delivered by community clinicians. Greater sample comorbidity, lower intervention dose or insufficient clinician supervisions may have contributed to the lack benefits seen in our previous trial.

Prevalence and Predictors of Medication Use in Children with Attention-Deficit/Hyperactivity Disorder: Evidence from a Community-Based Longitudinal Study

OBJECTIVES

To determine, in a community-based sample of primary school-aged children meeting diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD), (1) the proportion of children with ADHD treated with medication; (2) predictors of medication use; and (3) the association between medication use and psychological service utilization.

METHODS

Grade 1 children with ADHD were recruited through 43 schools in Melbourne, Australia, using a two-stage screening and case confirmation procedure. Parent report of medication treatment, clinician diagnosis, and psychological service use were collected at ages 7 and 10 years. Medication use was analyzed by ADHD subtype. Predictors of medication treatment examined included ADHD symptom severity and persistence, externalizing comorbidities, poor academic performance, and social disadvantage. Unadjusted and adjusted logistic regression were used to identify the predictors of medication status.

RESULTS

One hundred seventy-nine children with ADHD were recruited. At baseline, 17.3% had been clinically diagnosed with ADHD, increasing to 37.7% at age 10 years. At baseline, 13.6% were taking ADHD medications, increasing to 25.6% at age 10. Children with the combined and hyperactive-impulsive subtypes were more likely to be taking medication than those with inattentive subtype (age 7: p = 0.002; age 10: p = 0.03). ADHD symptom severity (Conners 3 ADHD Index) at baseline was concurrently and prospectively associated with medication use at both ages (both p = 0.01), and ADHD symptom severity at age 10 was also associated with medication use at age 10 (p = 0.01). Baseline area-level disadvantage was associated with medication use at age 7 (p = 0.04). At 10 years, children receiving medication were more likely, compared with those who were not, to be receiving psychological services (p = 0.001).

CONCLUSIONS

In this study, only a minority of children meeting diagnostic criteria for ADHD were diagnosed clinically or treated with ADHD medication by age 10. The strongest predictors of medication treatment were ADHD symptom severity and area disadvantage.

Attention deficit hyperactivity disorder: Some challenging clinical scenarios

Paediatricians generally have good skills in the assessment and management of attention deficit hyperactivity disorder. In most cases this is not difficult - the paediatrician's role is clear, and evidence-based treatment can be delivered. There are however some clinical situations which present diagnostic, ethical and/or management dilemmas for paediatricians in relation to possible attention deficit hyperactivity disorder. This Viewpoint article addresses some of these scenarios.

Hallucinations and other psychotic symptoms in response to methylphenidate in children and adolescents with attention-deficit/hyperactivity disorder: a Cochrane systematic review with meta-analysis and trial sequential analysis. Scand J Child Adolesc Psychiatr Psychol 2018;6:52-71. [PMID: 33520751 PMCID: PMC7750702 DOI: 10.21307/sjcapp-2018-003]

BACKGROUND

There is little evidence in the literature on the association between methylphenidate treatment and psychotic symptoms in children and adolescents with attention-deficit/hyperactivity disorder (ADHD).

OBJECTIVE

We examine the occurrence of psychotic symptoms during methylphenidate treatment of children and adolescents with ADHD. The data arise from our two Cochrane systematic reviews on methylphenidate, reported elsewhere.

METHODS

Electronic databases were searched up to January 2016 (for observational studies) and March 2017 (for randomized trials). We summarized data as risk ratios and pooled prevalences. Trial Sequential Analysis was used to control for random errors. We assessed the risk of bias and the quality of evidence according to Cochrane guidelines.

RESULTS

Ten randomized trials (1103 participants), 17 non-randomized studies (76,237 participants) and 12 patient reports or series (18 patients) were identified. In the randomized trials, there was no significant difference in the risk of developing psychotic symptoms [10 of 654 (pooled prevalence, 2.5%) methylphenidate versus 1 of 508 (pooled prevalence, 1.7%) placebo patients; risk ratio, 2.07; 95% confidence interval, 0.58 to 7.35]. Nine of 10 trials had a high risk of bias, and according to the Trial Sequential Analysis, the required information size was not achieved, that is, the meta-analysis was considerably underpowered. There were 873 instances of psychotic symptoms in the non-randomized studies among 55,603 participants (pooled prevalence, 1.2%; 95% confidence interval, 0.7 to 2.4). In the comparative cohort study, methylphenidate significantly increased the risk for any psychotic disorder by 36% (risk ratio, 1.36; 95% confidence interval, 1.17 to 1.57). The overall risk of bias was rated as critical for this study.

CONCLUSIONS

Because of sparse data and low quality of evidence, we cannot confirm or refute whether methylphenidate increases the risk of psychotic symptoms in children and adolescents with ADHD. This possible adverse event may affect 1.1% to 2.5%, and physicians, patients and caregivers should be aware of this to ensure proper treatment in case of occurrence during methylphenidate treatment.

Managing Anxiety in Children With ADHD Using Cognitive-Behavioral Therapy: A Pilot Randomized Controlled Trial

OBJECTIVE

This pilot randomized controlled trial examined the acceptability and feasibility of a cognitive-behavioral therapy (CBT) intervention for children with ADHD and anxiety, and provided preliminary information on child and family outcomes.

METHOD

Children with ADHD and anxiety (8-12 years) were randomized to receive an adapted version of the Cool Kids CBT program or usual clinical care. Key outcomes included feasibility and acceptability of the intervention (participant enrollment, drop-out, intervention session attendance), remission of anxiety assessed via diagnostic interview, ADHD symptom severity, quality of life (QoL), and parent mental health.

RESULTS

Twelve children participated (67% uptake). Most families attended all 10 intervention sessions, with no drop-outs. Intervention participants had marked improvements in both child and family well-being by parent and teacher report, including anxiety, ADHD symptom severity, QoL, and parent mental health.

CONCLUSION

Non-pharmacological interventions may improve important domains of functioning for children with ADHD and anxiety, including ADHD symptom severity.

Systematic review of meditation-based interventions for children with ADHD

Meditation-based interventions such as mindfulness and yoga are commonly practiced in the general community to improve mental and physical health. Parents, teachers and healthcare providers are also increasingly using such interventions with children. This review examines the use of meditation-based interventions in the treatment of children with Attention-Deficit Hyperactivity Disorder (ADHD). Electronic databases searched included PsycINFO, Medline, CINAHL, and AMED. Inclusion criteria involved children (aged to 18 years) diagnosed with ADHD, delivery of a meditation-based intervention to children and/or parents, and publication in a peer-reviewed journal. Studies were identified and coded using standard criteria, risk of bias was assessed using Risk of Bias in Non-randomised Studies- of interventions (ROBINS-I), and effect sizes were calculated. A total of 16 studies were identified (8 that included children in treatment, and 8 that included combined parent-child treatment). Results indicated that risk of bias was high across studies. At this stage, no definitive conclusions can be offered regarding the utility of meditation-based interventions for children with ADHD and/or their parents, since the methodological quality of the studies reviewed is low. Future well designed research is needed to establish the efficacy of meditation-based interventions, including commonly used practices such as mindfulness, before recommendations can be made for children with ADHD and their families.

Heroic struggles, criminals and scientific breakthroughs: ADHD and the medicalization of child behaviour in Australian newsprint media 1999-2009

There is a dearth of scholarly analysis and critique of the Australian newsprint media’s role in the medicalization of child behaviour. To begin to redress this lack this paper analyses newsprint media’s use of metaphors that re/describe and construct realities of ADHD with a medicalizing effect. The interdisciplinary team used the Factiva^TM database to locate and review 453 articles published in Australian national and metropolitan newspapers during the decade 1999–2009. Data analysis involved generating statistical descriptions of the dataset according to attributes such as: date, state, newspaper titles and author names. This was followed by inductive analysis of article content. Content analysis revealed pervasive and striking use of metaphor in newsprint media reporting of ADHD content, especially when describing health professionals, educators, parents and children. This collection of metaphors was striking, and while the metaphors deployed were varied, this diversity seemed underscored by a common functionality that increased the risk that child behaviour was explained using medicalized knowledge. We contend that these metaphors collectively and coherently functioned to simplify and delimit meanings of children’s health and behaviour to favour depictions that medicalize problems of children and childhood.

Transition in ADHD: attention to the lifespan

OBJECTIVES

This paper reviews the importance of transition to adult services for young people with ADHD.

METHOD

Different models are described and evidence sought for their effectiveness in clinical practice.

RESULTS

Models of care for children with ADHD include specialised mental health services, individual paediatricians and child and adolescent psychiatrists. Although it might be expected that transition would be to equivalent adult teams or specialists, studies have shown that transition may not run smoothly, and the adult services are frequently inadequate. This may result in attrition from treatment or discharge to the general practitioner.

CONCLUSIONS

Adult mental health services for transitioning young people with ADHD are under-resourced. The way forward may be a generic ADHD specialist or service, treating ADHD across the lifespan and avoiding the need for transition.

Congruent Validity of the Strengths and Difficulties Questionnaire to Screen for Comorbidities in Children With ADHD

OBJECTIVE

This study aimed to determine whether the Strengths and Difficulties Questionnaire (SDQ) is an effective screening tool for identifying comorbid mental health difficulties in children with ADHD.

METHOD

Parents of children with ADHD (5-13 years) completed the SDQ and the Anxiety Disorders Interview Schedule for DSM-IV-Parent Version (ADIS-C/P-IV). Data from both the measures were compared to determine congruent validity.

RESULTS

Analyses revealed that significant relationships exist between the SDQ total score and the total number of comorbidities on the ADIS-C/P-IV. The SDQ emotional problem and conduct problem scales were significantly related to internalizing and externalizing comorbidities on the ADIS-C/P-IV, respectively.

CONCLUSION

While significant relationships were found between the SDQ and ADIS-C/P-IV across various domains, this relationship was stronger for externalizing comorbidities. Additional screening questions are required to effectively screen for less common internalizing comorbidities in children with ADHD, for example, major depression and panic disorder.

Children referred for evaluation for ADHD: comorbidity profiles and characteristics associated with a positive diagnosis

BACKGROUND

The symptoms of attention-deficit/hyperactivity disorder (ADHD) are non-specific, and a range of possible causes and comorbidities need to be considered in children referred for assessment.

OBJECTIVE

To examine the factors associated with ADHD diagnosis following multidisciplinary assessment.

METHODS

Children underwent multidisciplinary evaluation including parent and teacher questionnaires; semi-structured interview to screen for internalizing and externalizing diagnoses; paediatric, psychology and special education assessments; and case conference. Predictors of ADHD diagnosis were examined in univariable and multivariable logistic regression models.

RESULTS

Data from 190 assessments (82% male, mean age 6.8 years) were included. ADHD was diagnosed in 132 (70%) cases, of which 77% had one or more comorbidities. In children not diagnosed with ADHD, 60% had one or more alternate diagnosis made. Teacher-reported ADHD symptom severity and learning difficulties were the strongest predictors of ADHD diagnosis. The pattern of comorbid/alternative diagnoses was similar between those diagnosed with ADHD and those not diagnosed with ADHD.

CONCLUSIONS

Direct report from teachers is the most critical element of the clinical dataset for the evaluation for ADHD. These findings emphasize the importance of cross-situational impairment to ADHD diagnosis. The frequency and similarity of diagnoses in both groups highlight the overlapping nature of childhood developmental disorders, and the importance of evaluating for comorbid disorders regardless of the primary diagnosis.

Management of ADHD in children and adolescents: clinical audit in a South African setting

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD) is common, yet under-recognised and undertreated, particularly in low socio-economic settings. Little is known about compliance to evidence- based guidelines in low- and middle-income countries, and no clinical audits have been published in Africa. We undertook to measure compliance in a South African setting using the National Institute for Clinical Excellence (NICE) guidelines for ADHD as the gold standard to compare compliance and socio-demographic characteristics between two treatment locations in Cape Town and to generate an audit checklist for standardising care.

METHODS

The study used a sample of 100 randomly selected cases of school-age patients diagnosed with ADHD, at the Division of Child & Adolescent Psychiatry, Red Cross War Memorial Children's Hospital and University of Cape Town, South Africa. Fifty cases each from a central and a peripheral clinic location were reviewed retrospectively using audit tools, including 17 audit standards derived from NICE guidelines. We defined compliance as "good" with ≥80%, "fair" with 50-79%, and "poor" with <50% adherence.

RESULTS

Compliance was low, with only four audit standards rated as "good". Physical monitoring was especially poor. The central group received more treatment options and relatively safer monitoring.

CONCLUSIONS

We recommend introducing structured protocols followed by re-auditing to improve service delivery, and present a checklist for use in future audit cycles.

The diagnosis of attention-deficit/hyperactivity disorder in Australian children: Current paediatric practice and parent perspective

AIMS

In a sample of newly diagnosed children with attention-deficit/hyperactivity disorder (ADHD), the aims were to examine (1) paediatrician assessment and management practices; (2) previous assessments and interventions; (3) correspondence between parent-report and paediatrician identification of comorbidities; and (4) parent agreement with diagnosis of ADHD.

DESIGN

cross-sectional, multi-site practice audit with questionnaires completed by paediatricians and parents at the point of ADHD diagnosis.

SETTING

private/public paediatric practices in Western Australia and Victoria, Australia.

MAIN OUTCOME MEASURES

paediatricians: elements of assessment and management were indicated on a study-designed data form. Parents: ADHD symptoms and comorbidities were measured using the Conners 3 ADHD Index and Strengths and Difficulties Questionnaire, respectively. Sleep problems, previous assessments and interventions, and agreement with ADHD diagnosis were measured by questionnaire.

RESULTS

Twenty-four paediatricians participated, providing data on 137 patients (77% men, mean age 8.1 years). Parent and teacher questionnaires were used in 88% and 85% of assessments, respectively. Medication was prescribed in 75% of cases. Comorbidities were commonly diagnosed (70%); however, the proportion of patients identified by paediatricians with internalising problems (18%), externalising problems (15%) and sleep problems (4%) was less than by parent report (51%, 66% and 39%). One in seven parents did not agree with the diagnosis of ADHD.

CONCLUSIONS

Australian paediatric practice in relation to ADHD assessment is generally consistent with best practice guidelines; however, improvements are needed in relation to the routine use of questionnaires and the identification of comorbidities. A proportion of parents do not agree with the diagnosis of ADHD made by their paediatrician.

Child attention deficit hyperactive disorder co morbidities on family stress: effect of medication

We examined the degree of parental and child mental health in a community sample of children diagnosed with Attention Deficit Hyperactive Disorder and the effect on family stress prior to and during treatment using a community retrospective questionnaire study. In total 358 questionnaires were returned for analysis where 92 % of children had at least one co-morbid condition and mental health conditions in parents was common. Overall, the Family Strain Index was significantly reduced after commencement of medication (p < 0.0001), but remained higher in families where the children had either externalizing disorders or autism spectrum disorder.

Attention-deficit/hyperactivity disorder: the past 50 years

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder and one of the main diagnoses seen by general paediatricians today. Despite the impression often portrayed in the media, it is not a new condition; in fact it has been described for over 200 years. The past 50 years has seen a progressive increase in our understanding of the underlying neurocognitive deficits in ADHD, and over the past 20 years behavioural genetics and neuroimaging studies have shed light on the complex causal factors and neurobiological processes operating. The plethora of ADHD research has advanced our knowledge of the condition, but so far has had little impact on improving clinical practice. Stimulant medication has been the mainstay of symptomatic treatment for over 30 years; however, it is still unclear how developmental trajectories can be modified to achieve best outcomes. It is hoped that novel therapies and more individualised management will evolve over the coming decades.

Functional status in children with ADHD at age 6-8: a controlled community study

OBJECTIVES

To examine the functional status (mental health, academic performance, peer problems) of a community-based sample of children who have attention-deficit/hyperactivity disorder (ADHD) and non-ADHD controls, and to investigate gender and subtype differences.

METHODS

Children aged 6 to 8 years were recruited through 43 Melbourne schools, using a 2-stage screening (parent and teacher Conners 3 ADHD index) and case confirmation (Diagnostic Interview Schedule for Children, Version IV; [DISC-IV]) procedure. Outcome measures were mental health disorders (DISC-IV), academic performance (Wide Range Achievement Test 4), and peer problems (Strength and Difficulties Questionnaire). Unadjusted and adjusted linear and logistic regression were used to compare ADHD and non-ADHD controls.

RESULTS

A total of 179 children who have ADHD and 212 non-ADHD controls were recruited. Compared with controls, children who had ADHD had higher odds of externalizing (odds ratio [OR], 11.0; 95% confidence interval [CI], 5.6-21.6; P < .001) and internalizing (OR, 2.9; 95% CI, 1.2-7.2; P = .02) disorders; poorer reading (effect size, -0.66) and mathematics (effect size, -0.69) performance; and more peer problems (P < .001). Boys and girls who had ADHD were equally impaired. Only 17% of children in our ADHD group had been previously diagnosed. Previous diagnosis was higher in the Combined group and for boys.

CONCLUSIONS

In their second year of school, children who had ADHD performed worse than controls across all functional domains, yet only a minority had been formally diagnosed with ADHD. Findings highlight the need for earlier diagnosis and intervention.

Contact with the juvenile justice system in children treated with stimulant medication for attention deficit hyperactivity disorder: a population study

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is the most frequent neurodevelopmental disorder in children and is sometimes noted retrospectively in young people and adults who are incarcerated. We aimed to investigate juvenile justice encounters in children with and without ADHD.

METHODS

Between January, 1995, and December, 2010, we did a population-based cohort study in Western Australia. Anonymised linked population data were obtained from the Western Australia Midwives Notification System. 12 831 non-Indigenous Australian children and young people aged 10-21 years, who were diagnosed and treated with stimulant drugs for ADHD and had a record in the Monitoring Drugs of Dependence System (ADHD cohort), were identified and frequency-matched by age, sex, and socioeconomic status to 29 722 non-Indigenous Australian children and young people who had no record in the Monitoring Drugs of Dependence System (controls). Community correction records and incarceration records were retrieved for all participants from Total Offending Management Solutions. Our primary outcome was to compare justice outcomes between children with ADHD and those without this disorder. We compared cohorts by conditional logistic regression analysis.

FINDINGS

9939 boys and 2892 girls were diagnosed and treated for ADHD; 22 875 boys and 6847 girls were frequency-matched controls. 792 (8%) boys and 75 (3%) girls with ADHD had a community correction record, compared with 822 (4%) boys and 75 (1%) girls without ADHD. 132 (1%) boys and 11 (<1%) girls with ADHD had an incarceration record, compared with 108 (<1%) boys and five (<1%) girls without ADHD. Compared with controls, boys with ADHD were two and half times more likely to have a community correction record (odds ratio 2·48, 95% CI 2·22-2·76) or an incarceration record (2·63, 2·01-3·44). Compared with their non-ADHD counterparts, girls with ADHD were nearly three times more likely to have a community correction record (odds ratio 2·86, 95% CI 2·03-4·03) and seven times more likely to have an incarceration record (7·27, 2·29-23·08). Boys with ADHD received their first community correction record at a younger age compared with controls (15·9 vs 16·3 years; p=0·0005), but age at first community correction record was similar for girls (16·5 vs 16·4 years; p=0·87). Burglaries and breaking and entering were the most common reason for a first justice record (total 659 [37%]), and this offence was twice as likely in children with ADHD (for boys, odds ratio 2·24, 95% CI 1·90-2·64; for girls, 2·19, 1·40-3·42).

INTERPRETATION

Justice outcomes for boys and girls were more frequent among children and young people treated for ADHD compared with their non-ADHD counterparts. Unlike girls, boys were more likely to offend at a younger age. Early diagnosis and management of children and young people with ADHD might reduce the over-representation of children with this disorder within the juvenile justice system.

FUNDING

National Health and Medical Research Council (Australia), Australian Research Council.