A conceptual review of the comorbidity of attention-deficit/hyperactivity disorder and anxiety: Implications for future research and practice

Reciprocal relations between dimensions of attention-deficit/hyperactivity and anxiety disorders from preschool age to adolescence: sex differences in a birth cohort sample

BACKGROUND

Symptoms of anxiety and attention-deficit/hyperactivity disorder (ADHD) are prospectively related from childhood to adolescence. However, whether the two dimensions of ADHD-inattention and hyperactivity-impulsivity-are differentially related to anxiety and whether there are developmental and sex/gender differences in these relations are unknown.

METHODS

Two birth cohorts of Norwegian children were assessed biennially from ages 4 to 16 (N = 1,077; 49% girls) with diagnostic parent interviews used to assess symptoms of anxiety and ADHD. Data were analyzed using a random intercept cross-lagged panel model, adjusting for all unobserved time-invariant confounding effects.

RESULTS

In girls, increased inattention, but not hyperactivity-impulsivity, predicted increased anxiety 2 years later across all time-points and increased anxiety at ages 12 and 14 predicted increased inattention but not hyperactivity-impulsivity. In boys, increased hyperactivity-impulsivity at ages 6 and 8, but not increased inattention, predicted increased anxiety 2 years later, whereas increased anxiety did not predict increased inattention or hyperactivity-impulsivity.

CONCLUSIONS

The two ADHD dimensions were differentially related to anxiety, and the relations were sex-specific. In girls, inattention may be involved in the development of anxiety throughout childhood and adolescence and anxiety may contribute to girls developing more inattention beginning in early adolescence. In boys, hyperactivity-impulsivity may be involved in the development of anxiety during the early school years. Effective treatment of inattention symptoms in girls may reduce anxiety risk at all time-points, while addressing anxiety may decrease inattention during adolescence. Similarly, treating hyperactivity-impulsivity may reduce anxiety risk in boys during late childhood (at ages 8-10).

The Relationship Between Social Anxiety Disorder and ADHD in Adolescents and Adults: A Systematic Review

OBJECTIVE

This review aimed to systematically gather empirical data on the link between social anxiety disorder and ADHD in both clinical and non-clinical populations among adolescents and adults.

METHOD

Literature searches were conducted in PsycInfo, PubMed, Scopus, and Web of Science, resulting in 1,739 articles. After screening, 41 articles were included. Results were summarized using a narrative approach.

RESULTS

The prevalence of ADHD in adolescents and adults with SAD ranged from 1.1% to 72.3%, while the prevalence of SAD in those with ADHD ranged from 0.04% to 49.5%. Studies indicate that individuals with both SAD and ADHD exhibit greater impairments. All studies were judged to be of weak quality, except for two studies which were rated moderate quality.

DISCUSSION

Individuals with SAD should be screened for ADHD and vice versa, to identify this common comorbidity earlier. Further research is needed to better understand the prevalence of comorbid ADHD and SAD in adolescents.

Consequences of vestibular hypofunction in children with ADHD/DCD

BACKGROUND

Children with Attention Deficit Hyperactivity Disorder (ADHD) demonstrate a heterogeneous sensorimotor, emotional, and cognitive profile. Comorbid sensorimotor imbalance, anxiety, and spatial disorientation are particularly prevalent among their non-core symptoms. Studies in other populations presented these three comorbid dysfunctions in the context of vestibular hypofunction.

OBJECTIVE

To test whether there is a subgroup of children with ADHD who have vestibular hypofunction presenting with concomitant imbalance, anxiety, and spatial disorientation.

METHODS

Children with ADHD-only (n = 28), ADHD + Developmental Coordination Disorder (ADHD + DCD; n = 38), and Typical Development (TD; n = 19) were evaluated for vestibular function by the Dynamic Visual Acuity test (DVA-t), balance by the Bruininks-Oseretsky Test of motor proficiency (BOT-2), panic anxiety by the Screen for Child Anxiety Related Emotional Disorders questionnaire-Child version (SCARED-C), and spatial navigation by the Triangular Completion test (TC-t).

RESULTS

Children with ADHD vs. TD presented with a high rate of vestibular hypofunction (65 vs. 0 %), imbalance (42 vs. 0 %), panic anxiety (27 vs. 11 %), and spatial disorientation (30 vs. 5 %). Children with ADHD + DCD contributed more frequent and severe vestibular hypofunction and imbalance than children with ADHD-only (74 vs. 54 %; 58 vs. 21 %, respectively). A concomitant presence of imbalance, anxiety, and spatial disorientation was observed in 33 % of children with ADHD, all sharing vestibular hypofunction.

CONCLUSIONS

Vestibular hypofunction may be the common pathophysiology of imbalance, anxiety, and spatial disorientation in children. These comorbidities are preferentially present in children with ADHD + DCD rather than ADHD-only, thus likely related to DCD rather than to ADHD disorder. Children with this profile may benefit from a vestibular rehabilitation intervention.

Cognitive Functioning in Youth with Anxiety Disorders: A Systematic Review

Anxiety disorders are disorders involving cognition. Research on cognition in youth with anxiety can focus on cognitive content (e.g., self-talk) as well cognitive functioning. The present review examines domains of cognitive functioning (i.e., episodic memory, language, attention, executive functioning, motor skills, and visual functioning) in youth diagnosed with an anxiety disorder. A database search of Embase, PsycINFO, and PubMed yielded 28 studies that met inclusion criteria of youth aged 17 years or younger, a sample diagnosed with a principal anxiety disorder and a comparison sample of controls, a comparison between those samples, and use of a behavioral measure of neuropsychological performance. Findings did not identify any cognitive functioning strengths for anxious youth. Deficits were found in two domains (i.e., receptive language and motor skills) whereas no deficits were found in attention, visuospatial skills and one domain of executive functioning (i.e., inhibition). Most domains had mixed findings. Additional analysis indicated that anxiety disorders in youth are not associated with diminished IQ. Directions for future research are identified including (a) the prioritization of studies with larger, representative samples (b) the role of cognitive functioning as a predictor of anxiety treatment outcome (c) the examination of the effect of treatment on cognitive performance, and (d) the course of anxiety and potential impairment in cognitive functioning.

Probiotics as a Promising Therapy in Improvement of Symptoms in Children With ADHD: A Systematic Review

BACKGROUND

ADHD is widely recognized as the most prevalent neurodevelopmental disorder in children. Recently, the potential role of gut microbiota as an etiological factor in ADHD has gained attention. This systematic review aims to investigate the potential impact of probiotic supplements on alleviating ADHD symptoms and influencing behavior.

METHODS

PubMed, Web of Science, Cochrane Library, and SCOPUS were searched from inception to May 2023. Only randomized controlled trials that have suitable data of the effects of probiotics/synbiotics on children with ADHD were enrolled. The risk of bias of the included studies was assessed by Cochrane Collaboration risk of bias tool.

RESULTS

Five related randomized controlled trial were evaluated in the current review. Types of interventions ranged from single/multi strain probiotics to synbiotic. The duration of intervention in all of the studies were 2 to 3 months. The assessed outcomes were very diverse and different tools were used to report the symptoms in children. Among those which used Conners' Parent Rating Scale, a decrease in the total score occurred in the probiotic group, compared to the placebo group. An improvement in both intervention and control groups was seen in one study which used ADHD-Rating Scale.

CONCLUSION

In summary, the combined findings from the reviewed studies suggest that probiotic supplements might potentially serve as a complementary intervention for ADHD. However, given the small number of studies, limited sample sizes, and the diversity of probiotic strains, further research is needed to clarify the effects of probiotics in children with ADHD. The observed tolerability of probiotics is noteworthy as none of the studies report adverse effects.

Loneliness in Young People with ADHD: A Systematic Review and Meta-Analysis

Many studies focus on problematic peer functioning in attention deficit/hyperactivity disorder (ADHD) but loneliness has been studied less. This paper examined (1) The loneliness level differences between young people (below 25 years old) with ADHD and those without ADHD, and (2) The association between loneliness and mental health difficulties in young people with ADHD. Six electronic databases were searched and 20 studies were included. A random effects meta-analysis was carried out in RStudio using the metafor package for the first question, while a narrative synthesis summarized the findings for the second question. The meta-analysis (n = 15) found that young people with ADHD reported significantly higher loneliness than those without ADHD, with a small-to-medium weighted pool effect (Hedges' g = 0.41) and high heterogeneity (I2 = 75.1%). For the second question (n = 8), associations between loneliness and mental health difficulties in ADHD was found (r = 0.05-0.68). Targeted research and interventions on loneliness in young people with ADHD is needed.

Attention-deficit/hyperactivity disorder (ADHD) and anxiety during the COVID-19 pandemic: Implications for internalizing behaviors in college students

Objective: The purpose of this study was to delineate the moderating roles of negative experiences related to the coronavirus disease 2019 (COVID-19) on the association between Attention-Deficit/Hyperactivity Disorder symptoms and anxiety symptoms and internalizing behaviors during Fall 2020. Method: Participants were 200 college students. Using a moderated moderation model, researchers found that attention-deficit/hyperactivity disorder symptoms predicted anxiety symptoms for those who internalized behaviors and experienced COVID-19 more negatively. Results: Results suggested that ADHD symptoms were playing a role in the manifestation of anxiety symptoms during the COVID-19 pandemic and that college students who internalize behaviors experienced worsened ADHD symptoms. Conclusion: Clinical implications underscore the importance of providing mental health resources for students on campus, particularly during the COVID-19 pandemic. Specialized treatment may include help with developing time management skills and teaching interventions such as mindfulness exercises that may help alleviate anxiety and improve attention and concentration.

Does Anxiety Systematically Bias Estimates of Executive Functioning Deficits in Pediatric Attention-Deficit/Hyperactivity Disorder?

Growing evidence suggests that childhood ADHD is associated with larger impairments in working memory relative to inhibition. However, most studies have not considered the role of co-occurring anxiety on these estimates - a potentially significant confound given prior evidence that anxiety may increase working memory difficulties but decrease inhibition difficulties for these children. The current study extends prior work to examine the extent to which co-occurring anxiety may be systematically affecting recent estimates of the magnitude of working memory/inhibitory control deficits in ADHD. The carefully-phenotyped sample included 197 children with ADHD and 142 children without ADHD between the ages of 8 and 13 years (N = 339; Mage = 10.31, SD = 1.39; 144 female participants). Results demonstrated that ADHD diagnosis predicted small impairments in inhibitory control (d = 0.31) and large impairments in working memory (d = 0.99). However, child trait anxiety assessed dimensionally across multiple informants (child, parent, teacher) did not uniquely predict either executive function, nor did it moderate estimates of ADHD-related working memory/inhibition deficits. When evaluating anxiety categorically and controlling for ADHD, anxiety diagnosis predicted slightly better working memory (d = 0.19) but not inhibitory control for clinically evaluated children generally. Findings from the current study indicate that trait anxiety, measured dimensionally or categorically, does not differentially affect estimates of executive dysfunction in pediatric ADHD. Further, results suggest that trait anxiety is generally not associated with executive dysfunction above and beyond the impact of co-occurring ADHD. Future research is needed to further assess the role of anxiety in ADHD behavioral symptomatology, neurocognitive functioning, and mechanisms underlying these relations.

Assessment of anxiety in children with neurodevelopment disorders: Rasch analysis of the Spence Children's Anxiety Scale

Anxiety is common in neurodevelopmental disorders (NDD). The parent version of the Spence Children's Anxiety Scale (SCAS-P) is a widely used measure to assess anxiety across a broad range of childhood populations. However, assessment of the measurement properties of the SCAS-P in NDDs have been limited. The present study aimed to assess the psychometric properties of the SCAS-P in children with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) using Rasch Measurement Theory. Data from the Province of Ontario Neurodevelopmental Disorders Network Registry were used in the analysis. Children (ages 6-13 years old) with a primary diagnosis of ADHD (n=146) or ASD (n=104) were administered the SCAS-P. Rasch Measurement Theory was used to assess measurement properties of the SCAS-P, including unidimensionality and item-level fit, category ordering, item targeting, person separation index and reliability and differential item functioning. The SCAS-P fit well to the Rasch model in both ADHD and ASD, including unidimensionality, satisfactory category ordering and goodness-of-fit. However, item-person measures showed poor precision at lower levels of anxiety. Some items showed differential item functioning, including items within the obsessive-compulsive, panic/agoraphobia and physical injury fears domains, suggesting that the presentation of anxiety may differ between ADHD and ASD. Overall, the results generally support the use of the SCAS-P to screen and monitor anxiety symptoms in children with ADHD and ASD. Future studies would benefit from examination of more severely anxious NDD cohort, including those with clinically diagnosed anxiety.

Sleep and internalizing problems in primary school children with attention-deficit hyperactivity disorder

BACKGROUND

Internalizing and externalizing problems have received great attention, and children with ADHD exhibit high rates of comorbid internalizing and externalizing disorders. This study aimed to explore the relationship between sleep and internalizing problems in children with attention-deficit hyperactivity disorder (ADHD) and the probable mediating role of externalizing problems.

METHODS

A total of 203 primary school children diagnosed with ADHD for the first time were recruited for this study. Children with ADHD were evaluated by Children's Sleep Habits Questionnaire (CSHQ), Strengths and Difficulties Questionnaire (SDQ). Internalizing problems were represented by emotional symptoms and peer problems of SDQ, and externalizing problems were represented by conduct problems and hyperactivity-inattention problems of SDQ. Multi-step linear regression analysis was used to investigate the mediating effect of externalizing problems on the relationship between sleep and internalizing problems.

RESULTS

Sleep in children with ADHD was associated with emotional problems in internalizing problems, and conduct problems in externalizing problems mediated the association between sleep and emotional problems.

CONCLUSION

For children with ADHD, when it is difficult to identify internalizing problems, especially emotional problems, we can take sleep and externalizing problems as clues to improve our clinical ability to recognize and deal with emotional problems.

IMPACT

1. We first explored the possible mediating role of conduct problems between sleep and emotional problems in primary school children with ADHD. 2. When it is difficult to identify internalizing problems, especially emotional problems, we can take sleep and externalizing problems as clues to improve our clinical ability to recognize emotional problems for children with ADHD. 3. For children with ADHD with potential internalizing problems, especially emotional problems, interventions for their sleep and externalizing problems may be the possible methods to deal with.

Identifying subgroups of attention-deficit/hyperactivity disorder from the psychopathological and neuropsychological profiles

The Research Domain Criteria (RDoC) advocates the dimensional approach in characterizing mental disorders. We followed RDoC to characterize children with ADHD using profiling based on the cognitive and psychopathological domains. We aimed to identify and validate ADHD subtypes with different clinical characteristics and functional impairments. We recruited 362 drug-naïve children with ADHD and 103 typically developing controls. The cluster analysis was used to identify subgroups based on the Child Behaviour Checklist (CBCL) and the Behaviour Rating Inventory of Executive Function (BRIEF). The subgroups' clinical characteristics and functional impairments were assessed using the WEISS Functional Impairment Rating Scale-Parent Report (WFIRS-P) and the Conners Parent Symptom Questionnaire (PSQ). The cluster analysis yielded four subgroups: (1) ADHD with severe impairment in psychopathology and executive functions (EF), (2) ADHD with mild executive dysfunctions and normal-level psychopathology, (3) ADHD with severe externalizing problems and (4) ADHD with severe executive dysfunctions. These subgroups showed different clinical characteristics and degrees of functional impairment. The EF impairment group displayed more serious learning problems and worse life skills than the externalizing group. The two groups with externalizing problems (i.e. the severe impairment group and the externalizing group) both exhibited higher rates of the combined subtype of ADHD and higher rates of comorbid ODD. Different subtypes of ADHD displayed different profiles of internalizing and externalizing problems and levels of executive dysfunctions. In particular, the subtype with severe impairment in EF exhibited more learning problems and worse life skills, suggesting EF is a critical target for intervention in children with ADHD.

Attachment and comorbid anxiety in ADHD

Anxiety comorbidity is quite common in children with attention-deficit hyperactivity disorder (ADHD). What is known about the relationship between anxiety, attachment and emotion regulation in such children is still limited. We aimed to investigate the associations between attachment, emotion regulation and comorbid anxiety in children with ADHD. 100 children with ADHD and 100 children without any diagnosis aged 8-13 years were included. After the participants were clinically evaluated, Turgay ADHD Scale, Emotion Regulation Checklist, Revised Child Anxiety and Depression Scale-Child Version (RCADS-CV) and Kerns' Security Scale were completed. According to the RCADS-CV scores, ADHD/ANX(+), ADHD/ANX(-), and control groups were formed. The emotional lability/negativity levels were higher in the ADHD groups compared to the non-ADHD controls. Paternal and maternal attachment security levels were lower in the ADHD/ANX(+) group compared to the controls. The regression analysis indicated that higher hyperactivity/impulsivity symptom levels and lower maternal attachment quality were associated with higher anxiety in children with ADHD. These results suggest that focusing on attachment quality and emotion regulation problems may be significant in management of core symptoms and comorbid anxiety problems in children with ADHD.

Pre-pandemic Executive Function Protects Against Pandemic Anxiety in Children with and Without Autism Spectrum Disorder

The COVID-19 pandemic may have exacerbated depression, anxiety, and executive function (EF) difficulties in children with autism spectrum disorder (ASD). EF skills have been positively associated with mental health outcomes. Here, we probed the psychosocial impacts of pandemic responses in children with and without ASD by relating pre-pandemic EF assessments with anxiety and depression symptoms several months into the pandemic. We found that pre-pandemic inhibition and shifting difficulties, measured by the Behavior Rating Inventory of Executive Function, predicted higher risk of anxiety symptoms. These findings are critical for promoting community recovery and maximizing clinical preparedness to support children at increased risk for adverse psychosocial outcomes.

Adolescent Cannabis Use, Comorbid Attention-Deficit/Hyperactivity Disorder, and Other Internalizing and Externalizing Disorders

Cannabis use often co-occurs with attention-deficit/hyperactivity disorder and other internalizing and externalizing disorders. Treatment planning, including pharmacologic and psychosocial interventions, for these comorbid disorders require thorough diagnostic evaluation to determine the extent of social, emotional, and behavioral impairments, severity of substance use, and motivation for change. Improved understanding of these comorbid disorders will inform treatment planning that address current symptoms and behaviors and may also prevent the development of mental health and substance use disorders in early adulthood.

Changes in Anxiety following Taste Education Intervention: Fussy Eating Children with and without Neurodevelopmental Disorders

Despite the surge in studies on fussy eating in recent years, anxiety as an associated factor is generally not considered, even though children with fussy eating and those with neurodevelopmental disorders, including Autism Spectrum Disorder or Attention Deficit/Hyperactivity Disorder (ADHD) often have higher levels of anxiety than typically developing children. The current study investigated changes in anxiety scores during a Taste Education intervention, a seven-week school-based intervention for 71 children with fussy eating. Comparisons were made based on neurodevelopmental status (between children with (n = 30) and without (n = 41) neurodevelopmental disorders). Participants were paired based on age, sex, and neurodevelopmental disorder. The Multidimensional Anxiety Scale for Children (MASC) was administered at delayed intervention (for those waiting 7 weeks before starting the intervention), pre-intervention, post-intervention, and at six-month follow-up. Results did not indicate elevated anxiety based on mean MASC T-scores. MASC Total T-scores ranged from slightly elevated to average, decreasing significantly between pre-intervention and post-intervention, plateauing at six-month follow-up. Significant reductions between measurement points were seen for the physical symptoms, social anxiety, and separation anxiety subscales, but not for harm avoidance. Repeated measures analysis of variance with neurodevelopmental disorders as between-subjects factors did not reveal a significant interaction effect between neurodevelopmental disorders and changes in MASC Total score or subscales. The results indicated that our food-based intervention did not elevate MASC scores in fussy eating children, with or without neurodevelopmental disorders.

Anxiety and depression from age 3 to 8 years in children with and without ADHD symptoms

Childhood anxiety and depressive symptoms may be influenced by symptoms of attention deficit/hyperactivity disorder (ADHD). We investigated whether parent- and teacher-reported anxiety, depressive and ADHD symptoms at age 3 years predicted anxiety disorders and/or depression in children with and without ADHD at age 8 years. This study is part of the longitudinal, population-based Norwegian Mother, Father and Child Cohort Study. Parents of 3-year-olds were interviewed, and preschool teachers rated symptoms of anxiety disorders, depression and ADHD. At age 8 years (n = 783), Child Symptom Inventory-4 was used to identify children who fulfilled the diagnostic criteria for anxiety disorders and/or depression (hereinafter: Anx/Dep), and ADHD. Univariable and multivariable logistic regression analyses were used. In the univariable analyses, parent-reported anxiety, depressive and ADHD symptoms, and teacher-reported anxiety symptoms at age 3 years all significantly predicted subsequent Anx/Dep. In the multivariable analyses, including co-occurring symptoms at age 3 years and ADHD at 8 years, parent-reported anxiety and depressive symptoms remained significant predictors of subsequent Anx/Dep. At age 3 years, regardless of ADHD symptoms being present, asking parents about anxiety and depressive symptoms, and teachers about anxiety symptoms, may be important to identify children at risk for school-age anxiety disorders and/or depression.

Compounding Effects of Domain-General Cognitive Weaknesses and Word Reading Difficulties on Anxiety Symptoms in Youth

This study examined whether domain-general cognitive weaknesses in processing speed (PS) or executive functioning (EF) moderate the relation between word reading scores and anxiety such that lower word reading scores in combination with lower cognitive scores are associated with higher anxiety symptoms. The sample consisted of 755 youth ages 8-16 who were recruited as part of the Colorado Learning Disabilities Research Center twins study. Lower scores on PS (R2 = .007, p = .014), EF (R2 = .009, p = .006), and word reading (R2 = .006-.008, p = .010-.032) were associated with higher anxiety scores. In addition, the word reading × cognitive interactions were significant such that lower scores on PS (R2 = .010, p = .005) or EF (R2 = .013, p = .010) combined with lower word reading were associated with higher-than-expected anxiety symptoms. Results suggest that weaknesses in PS, EF, and word reading are modestly associated with higher anxiety symptoms, and these anxiety symptoms may be compounded in youth with both PS or EF weaknesses and word reading difficulties. These findings can guide assessment approaches for identifying youth with word reading challenges who may be at increased risk for anxiety.

Perceived Social Support on the Relationship Between ADD/ADHD and Both Anxious and Depressive Symptoms Among Canadian Adults

OBJECTIVE

The primary goal of the present research was to examine whether the relationships that social support demonstrates with both anxiety and depression varied between adults with and without ADD/ADHD in a Canadian sample.

METHOD

Data were obtained from the 2012 Canadian Community Health Survey-Mental Health (N ≥ 16,354). Presence of social support, diagnosis of generalized anxiety disorder (GAD), and experience of major depressive episodes (MDEs) were estimated in the self-report ADD/ADHD and non-ADD/ADHD groups.

RESULTS

Although social support was negatively associated with having GAD or experiencing an MDE, and self-report ADD/ADHD was positively associated with these outcomes. Presence of self-report ADD/ADHD did not significantly modify the relationships between social support and GAD or MDE.

CONCLUSION

Social support may be a protective factor against symptoms of anxiety and depression in the general Canadian population, for adults with and without ADHD.

Treating ADHD and Comorbid Anxiety in Children: A Guide for Clinical Practice

Attention-deficit hyperactivity disorder (ADHD) is frequently comorbid with anxiety disorders with rates as high as 25% to 50% in children and adolescents. Despite various treatment options for ADHD symptoms, limited research addresses treatment in the context of comorbidity. This article seeks to provide a review of the evidence regarding treatment of this comorbid population. Distinct emotional, cognitive, and behavioral symptoms have been observed in this population, suggesting a need for tailored treatment. Despite common concerns about anxiety exacerbation, stimulant medications demonstrate good tolerability and good response in addressing symptoms. Atomoxetine has also demonstrated some benefit and good tolerability for treating this comorbid population. Selective serotonin reuptake inhibitors can be used as adjunctive treatment for anxiety but require careful monitoring of side effects. Cognitive behavioral therapy (CBT) is an important treatment to improve anxiety symptoms in the absence of significant ADHD symptoms. Psychosocial interventions are also essential to improve outcomes.

Adolescent Cannabis Use, Comorbid Attention-Deficit/Hyperactivity Disorder, and Other Internalizing and Externalizing Disorders

Cannabis use often co-occurs with attention-deficit/hyperactivity disorder and other internalizing and externalizing disorders. Treatment planning, including pharmacologic and psychosocial interventions, for these comorbid disorders require thorough diagnostic evaluation to determine the extent of social, emotional, and behavioral impairments, severity of substance use, and motivation for change. Improved understanding of these comorbid disorders will inform treatment planning that address current symptoms and behaviors and may also prevent the development of mental health and substance use disorders in early adulthood.

Assessing Peer-Related Impairments Linked to Adolescent Social Anxiety: Strategic Selection of Informants Optimizes Prediction of Clinically Relevant Domains

Socially anxious adolescents commonly experience impaired interpersonal functioning with unfamiliar, same-age peers. Yet, we lack short screening tools for assessing peer-related impairments. Recent work revealed that a parent-reported, three-item screening tool produced scores that uniquely related to social anxiety concerns. However, this tool ought to go beyond linking impairments to service needs (i.e., social anxiety symptoms). This tool should also inform the goals of services, in particular by linking impairments to key domains relevant to therapeutically addressing adolescents' anxiety-related needs, such as social skills when interacting with unfamiliar peers. This requires an assessment approach that involves strategic selection of informants who vary in their expertise for observing anxiety-related needs, as well as the therapeutic goals for addressing anxiety-related impairments (e.g., social skills within peer interactions). We leveraged parents' reports to link impairments to social anxiety-related needs. To link impairments to social skills, we leveraged informants (i.e., unfamiliar untrained observers [UUOs]) who observed adolescents within tasks designed to simulate interactions with same-age, unfamiliar peers. We tested this approach using a mixed-clinical/community sample of 134 adolescents, ages 14- to 15 years old. We leveraged multi-informant survey reports to assess adolescent social anxiety, and trained independent observers rated adolescents' social skills within unfamiliar peer interactions. Parents' reports performed best when distinguishing adolescents on referral status and predicting survey-reported social anxiety, whereas only UUOs' reports predicted independent observers' social skills ratings. These findings inform the strategic selection of informants for assessing impairments that commonly prompt the need for adolescents to access mental health services for social anxiety.

Does emotion dysregulation mediate the association between ADHD symptoms and internalizing problems? A longitudinal within-person analysis in a large population-representative study

BACKGROUND

Previous research has suggested that children with attention-deficit/hyperactivity disorder (ADHD) symptoms commonly show emotion dysregulation difficulties. These difficulties may partly explain the strong tendency for internalizing problems such as anxiety and depression to co-occur with ADHD symptoms. However, no study has yet provided a longitudinal analysis of the within-person links between ADHD symptoms, emotion dysregulation, and internalizing problems necessary to examine this hypothesis from a developmental perspective.

METHODS

We used data from the age 3, 5, and 7 waves of the large UK population-representative Millennium Cohort Study (n = 9,619, 4,885 males) and fit gender-stratified autoregressive latent trajectory models with structured residuals (ALT-SR) to disaggregate within- and between-person relations between ADHD symptom, emotion dysregulation, and internalizing problem symptoms.

RESULTS

We found that emotion dysregulation significantly mediated the longitudinal within-person association between ADHD symptoms and internalizing problems.

CONCLUSIONS

Results underline the promise of targeting emotion dysregulation as a means of preventing internalizing problems co-occurring with ADHD symptoms.

Adolescent chronic unpredictable stress leads to increased anxiety and attention deficit/hyperactivity-like symptoms in adulthood

BACKGROUND

Early-life adversities during development (e.g., child abuse and neglect) are linked to multiple behavioral and cognitive dysfunctions, such as attention deficit/hyperactivity disorder (ADHD) and anxiety disorders, which have high comorbidity. However, the impact of adversities during adolescence, a crucial period in early life for these disorders, is understudied. Using a chronic unpredictable stress (CUS) model in rats, we investigated whether adversities in adolescence could lead to increased anxiety and ADHD-like symptoms in adulthood.

METHODS

Mid- to late-adolescent (5-7-week-old) male and female Sprague-Dawley rats underwent a mild CUS procedure for 2 weeks. Various stressors were applied in an unpredictable way. Rats of both sexes were then trained with a 2-choice reaction time (2-CRT) task during adulthood, which are designed to detect ADHD-like symptoms, including increased impulsivity and lapse of attention. In addition, an open field test was conducted to examine if CUS resulted in a persistent increase in anxiety-like behavior during adulthood.

RESULTS

Both male and female rats with CUS exposure travelled shorter distances in the open field and spent less time in the center zone, indicating increased anxiety. In the 2-CRT task, rats of both sexes with CUS exposure showed increased impulsivity. Augmented lapses of attention were observed in female but not male rats.

CONCLUSION

Chronic unpredictable stress during adolescence increases anxiety and leads to ADHD-like symptoms in both male and female rats in adulthood. The deficits are more severe in females than in males. These observations support that adversities during adolescence persistently increase anxiety, which is comorbid with attention deficits.

When Adolescents Experience Co-Occurring Social Anxiety and ADHD Symptoms: Links With Social Skills When Interacting With Unfamiliar Peer Confederates

Adolescents with elevated social anxiety commonly experience peer-related impairments - particularly with same-age, unfamiliar peers - stemming from their avoidant behaviors. Yet, peer-related impairments are not unique to social anxiety. For example, adolescents who experience social anxiety may also experience symptoms of attention deficit/hyperactivity disorder (ADHD), which also increase risk for peer-related impairments. Relative to social anxiety, peer-related impairments linked to ADHD symptoms more likely stem from hyperactivity (i.e., approach behaviors). These distinct pathways point to adolescents with elevated social anxiety and ADHD symptoms (i.e., social anxiety + ADHD) experiencing particularly high peer-related impairments, which commonly manifest as behavioral displays of low social skills when interacting with unfamiliar peers. We tested this notion in a mixed-clinical/community sample of 134 14- to 15-year-old adolescents and their parents. Adolescents participated in a series of social interaction tasks designed to simulate how adolescents interact with same-age, unfamiliar peers. Trained observers independently rated adolescents on observed social skills within these interactions. Both parents and adolescents completed parallel surveys of social anxiety and ADHD symptoms, which we used to identify social anxiety + ADHD adolescents as well as other combinations of social anxiety and ADHD symptoms (i.e., neither, elevated on one but not the other). Adolescents with social anxiety + ADHD displayed significantly lower social skills, relative to all other groups. Among adolescents, social anxiety + ADHD may have a compounding effect on social skills. As such, therapists working with social anxiety + ADHD adolescents should probe for peer-related impairments and factors implicated in the development and maintenance of these impairments.

Reduced basal ganglia tissue-iron concentration in school-age children with attention-deficit/hyperactivity disorder is localized to limbic circuitry

Dopamine-related abnormalities in the basal ganglia have been implicated in attention-deficit/hyperactivity disorder (ADHD). Iron plays a critical role in supporting dopaminergic function, and reduced brain iron and serum ferritin levels have been linked to ADHD symptom severity in children. Furthermore, the basal ganglia is a central brain region implicated in ADHD psychopathology and involved in motor and reward functions as well as emotional responding. The present study repurposed diffusion tensor imaging (DTI) to examine effects of an ADHD diagnosis and sex on iron deposition within the basal ganglia in children ages 8-12 years. We further explored associations between brain iron levels and ADHD symptom severity and affective symptoms. We observed reduced iron levels in children with ADHD in the bilateral limbic region of the striatum, as well as reduced levels of iron-deposition in males in the sensorimotor striatal subregion, regardless of diagnosis. Across the whole sample, iron-deposition increased with age in all regions. Brain-behavior analyses revealed that, across diagnostic groups, lower tissue-iron levels in bilateral limbic striatum correlated with greater ADHD symptom severity, whereas lower tissue-iron levels in the left limbic striatum only correlated with anxious, depressive and affective symptom severity. This study sheds light on the neurobiological underpinnings of ADHD, specifically highlighting the localization of tissue-iron deficiency in limbic regions, and providing support for repurposing DTI for brain iron analyses. Our findings highlight the need for further investigation of iron as a biomarker in the diagnosis and treatment of ADHD and sex differences.

Young Adulthood Outcomes of Joint Mental Health Trajectories: A Group-Based Trajectory Model Analysis of a 13-Year Longitudinal Cohort Study

Developmental trajectories of common mental health issues such as ADHD symptoms, internalising problems, and externalising problems can often be usefully summarised in terms of a small number of 'developmental subtypes' (e.g., 'childhood onset', 'adolescent onset') that may differ in their profiles or levels of clinically meaningful variables such as etiological risk factors. However, given the strong tendency for symptoms in these domains to co-occur, it is important to consider not only developmental subtypes in each domain individually, but also the joint developmental subtypes defined by symptoms trajectories in all three domains together (e.g., 'late onset multimorbid', 'pure internalising', 'early onset multimorbid'). Previous research has illuminated the joint developmental subtypes of ADHD symptoms, internalising problems, and externalising problems that emerge from normative longitudinal data using methods such as group-based trajectory modelling, as well as predictors of membership in these developmental subtypes. However, information on the long-term outcomes of developmental subtype membership is critical to illuminate the likely nature and intensity of support needs required for individuals whose trajectories fit different developmental subtypes. We, therefore, evaluated the relations between developmental subtypes previously derived using group-based trajectory modelling in the z-proso study (n = 1620 with trajectory data at ages 7, 8, 9, 10, 11, 12, 13, 15) and early adulthood outcomes. Individuals with multimorbid trajectories but not 'pure' internalising problem elevations showed higher levels of social exclusion and delinquency at age 20. These associations held irrespective of the specific developmental course of symptoms (e.g., early versus late onset versus remitting). There was also some evidence that intimate partner violence acts as a form of heterotypic continuity for earlier externalising problems. Results underline the need for early intervention to address the pathways that lead to social exclusion and delinquency among young people with multiple co-occurring mental health issues.

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.

Do comorbid symptoms discriminate between autism spectrum disorder, ADHD and nonverbal learning disability?

Characterizing the functioning of individuals with neurodevelopmental disorders is crucial to their diagnosis. Research has found that children with different neurodevelopmental disorders, including autism spectrum disorders (ASD), attention deficit and hyperactivity disorder (ADHD), and nonverbal learning disability (NLD), may have comorbid symptoms of anxiety and depression, and problems with pragmatic language. The main aim of the present study was to identify any differences in the above-mentioned comorbid symptoms associated with these clinical profiles. A second aim was to establish how well signs of pragmatic language difficulties could discriminate between the three clinical profiles, in terms of their diagnostic power. For this purpose, 107 participants from 8 to 16 years old with a diagnosis of ASD, ADHD or NLD were compared with a group of typically-developing children. Self-reports on symptoms of anxiety and depression, and parents' reports on social and communication problems were analyzed. Our findings confirmed that symptoms of anxiety and depression, and problems with pragmatic language are associated with different neurodevelopmental disorders, but not in the same way. In terms of diagnostic power, we found that pragmatic language difficulties clearly discriminated children with ASD, ADHD or NLD from typically-developing children. Importantly, pragmatic language difficulties also discriminated adequately between ASD and NLD. Our findings are discussed in terms of the value of considering comorbid symptoms to obtain a more accurate diagnosis of neurodevelopmental disorders.

The Effects of Emotion Regulation Treatment on Disruptive Behavior Problems in Children: A Randomized Controlled Trial

Disruptive behavior problems are a frequent reason for children’s referrals to psychological services and can have negative effects on social and academic functioning. Most treatment programs involve parents as recipients and implementation of intervention programs in school is low. Deficits in emotion regulation have recently been implicated in the development of disruptive behavior disorders, making child directed early intervention programs focusing on increasing emotion regulation skills feasible. The purpose of this study was to assess the effects of Tuning Your Temper, a brief cognitive behavioral program for children with disruptive behavior problems, in a randomized controlled trial. A total of 125 children with disruptive behavior problems at school, aged 6–11 years old were randomized to either intervention or wait-list control condition. Treatment was conducted at school. Assessments included teacher and parent ratings on the Strengths and Difficulties Questionnaire (SDQ) and the Disruptive Behavior Rating Scale (DBRS) pre- and post-treatment and at 6-month follow-up. Results showed a significant reduction in behavior problems for the treatment condition on both measures and effects were maintained at 6-month follow-up. Results were more robust for teacher ratings, with medium to large effect sizes. Tuning Your Temper appears to be a promising early intervention program for children with disruptive behavior problems at school.

ADHD and Anxiety Disorder Comorbidity in Children and Adults: Diagnostic and Therapeutic Challenges

PURPOSE OF THE REVIEW: In this review, we focus on overlapping features of ADHD and anxiety disorders, and will discuss how an anxiety disorder comorbidity leads to diagnostic and treatment challenges in patients with ADHD, in consideration of the accumulated available knowledge. RECENT FINDINGS: The presence of overlapping symptoms, changes in the diagnostic criteria, and the use of divergent diagnostic tools and informant effects can complicate the diagnosis of this comorbidity. Due to the ongoing debate about the etiology, psychopathology, and diagnostic features of the association between ADHD and anxiety disorders, choosing appropriate treatment options emerges as a challenge. A novel methodology, standardized interview tools, and new statistical analysis methods are needed to define the phenotype of this co-occurrence more clearly. It is important to uncover the developmental nature of this comorbidity with follow-up studies that may explain the etiology and underlying neurobiological basis, and ultimately lead to more effective treatment approaches.

Exploring the relationship between ADHD, its common comorbidities, and their relationship to organizational skills

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder affecting numerous executive functioning skills, such as organizational skills. While the relationship between the inattention aspect of ADHD and poor organizational skills is well documented, it is still unclear if lower organizational skills are only associated with ADHD or if they are also associated with other comorbid disorders commonly diagnosed in conjunction with ADHD. The purpose of the present study is to investigate the relationship between organizational skills and ADHD in adults, as well as the impact of comorbid disorders on ADHD in relation to organizational skills.

METHODS

Four hundred seven (n = 201 with a diagnosis of ADHD) adults from the general population were recruited online. Participants completed a measure of organizational skills, measures assessing levels of ADHD, depression, and anxiety, and extensive demographic information related to their diagnosis of ADHD or other possible diagnosis.

RESULTS

Participants with a diagnosis of ADHD were significantly more likely to have a comorbid diagnosis of depression and/or anxiety. Organizational skills were significantly lower in individuals who reported having received a diagnosis of ADHD, but not in those with a past diagnosis of depression and anxiety. However, organizational skills were lower in individuals currently experiencing higher levels of depression and anxiety. The results of regression analyses suggest that levels of organizational skills are most strongly predicted by inattention and more weakly predicted by comorbid disorders.

DISCUSSION

These results highlight the centrality of organizational skills deficit in ADHD as well as the influence of the inattention component over other components commonly observed in ADHD on organizational skills. Suggestions for treatment of ADHD in adults are discussed.

Overprotective Parenting Mediates the Relationship Between Early Childhood ADHD and Anxiety Symptoms: Evidence From a Cross-Sectional and Longitudinal Study

Attention Deficit/Hyperactivity Disorder (ADHD) is often comorbid with anxiety disorders in children. Both ADHD and anxiety in childhood has been linked to overprotective parenting styles. In the current study we examine a model wherein early ADHD symptoms predict overprotective parenting, which in turn predicts anxiety symptoms later in childhood. In Study 1 we utilize cross-sectional data in 102 child/parent dyads between the ages of 5 and 7 years old and Study 2 extends these findings by examining this same mediation model longitudinally in 376 child/parent dyads who were assessed when children were 3, 6, and 9 years old. Results from both studies supported a mediation model wherein the relationship between child ADHD symptoms and child anxiety symptoms was mediated by parental overprotection. This is the first study, to our knowledge, to examine overprotective parenting as a mechanism underlying the heterotypic continuity or sequential comorbidity of ADHD to anxiety symptoms.

Modelling ADHD-Like Phenotypes in Zebrafish

The use of multiple species to model complex human psychiatric disorders, such as ADHD, can give important insights into conserved evolutionary patterns underlying multidomain behaviors (e.g., locomotion, attention, and impulsivity). Here we discuss the advantages and challenges in modelling ADHD-like phenotypes in zebrafish (Danio rerio), a vertebrate species that has been widely used in neuroscience and behavior research. Moreover, multiple behavioral tasks can be used to model the core symptoms of ADHD and its comorbidities. We present a critical review of current ADHD studies in zebrafish, and how this species might be used to accelerate the discovery of new drug treatments for this disorder.

Reciprocal Developmental Relations Between ADHD and Anxiety in Adolescence: A Within-Person Longitudinal Analysis of Commonly Co-Occurring Symptoms

Objective: Significant anxiety often occurs in the presence of ADHD symptoms; however, the reasons are not well understood. We aimed to establish whether the relations between ADHD symptons and anxiety are bidirectional or unidirectional.

METHOD

Weexamined the developmental relations between ADHD and anxiety symptoms across adolescence (ages 13, 15, and 17) in a community-ascertained, normative longitudinal sample of 1,483 youth (52% male). We used an autoregressive latent trajectory model with structured residuals (ALT-SR) to examine within-person developmental relations between ADHD and anxiety symptoms to determine whether it is ADHD symptoms that lead to anxiety symptoms and/or the reverse.

RESULTS

Results suggested that there are reciprocal within-person developmental relations between ADHD and anxiety symptoms.

CONCLUSIONS

Our findings support the recommendation that targeting ADHD symptoms can be fruitful for addressing anxiety symptoms; however, they suggest that targeting anxiety symptoms may also benefit ADHD symptoms. Results also underline the importance of careful assessment for underlying ADHD symptoms among adolescents presenting with anxiety.

A multi-trajectory analysis of commonly co-occurring mental health issues across childhood and adolescence

Developmental trajectories of mental health issues can often be usefully summarised in a small number of clinically meaningful subtypes. Given the high levels of heterotypic and homotypic comorbidity in child and adolescent mental health symptoms, we explored whether it was possible to identify clinically meaningful developmental subtypes of multiple commonly co-occurring mental health issues. We evaluated the combined developmental trajectories of the most common and commonly co-occurring child and adolescent mental health issues: attention-deficit/hyperactivity disorder (ADHD), internalising, and externalising symptoms in a normative sample of youth with data (n = 1620) at ages 7, 8, 9, 10, 11, 12, 13 and 15 using group-based multi-trajectory modelling. Multinomial logistic regression was used to evaluate predictors of group membership. Our optimal model included six trajectory groups, labelled 'unaffected', 'normative maturing', 'internalising', 'multimorbid late onset', 'multimorbid remitting', and 'multimorbid with remitting externalising'. Examining covariates of group membership suggested that males and bully victims tend to have complex mental health profiles; academic achievement and smoking during pregnancy have general associations with mental health irrespective of symptom developmental trajectories or combination; and maternal post-natal depression is primarily related to symptoms that are already in evidence by the beginning of the school years. Results suggest that developmental trajectories of commonly co-occurring mental health issues can be usefully summarised in terms of a small number of developmental subtypes. These subtypes more often than not involve multiple co-occurring mental health issues. Their association with mental health covariates depends on the combination and developmental timing of symptoms in ways that suggest they can be clinically informative.

Anxiety and emotional-behavioral problems of adolescents in China: evidence for a serial mediation model of alexithymia and dependency

High prevalence of emotional and behavioral problems among Chinese adolescence has been reported. This study seeks to investigate the mediating effect of alexithymia and dependency on anxiety and emotional-behavioral problems among adolescents. The study population included 519 adolescents. The assessments included the completion of standardized scales such as the Multidimensional Anxiety Scale (MASC), the Toronto Alexithymia Scale (TAS-20), the Depressive Experiences Questionnaire (DEQ), the Strengths and Difficulties Questionnaire (SDQ). Independent-sample t-tests, bivariate correlation, and serial mediation analyses were performed using SPSS23.0. Bivariate analyses revealed that anxiety, emotional-behavioral problem, alexithymia, and dependency were positively correlated. Alexithymia and dependency play a significant role in mediating the effect of multidimensional anxiety on emotional-behavioral problems. The effects of the two mediating paths were 69.86% and 7.81% for indirect effect through alexithymia, dependency, and specific indirect effect by alexithymia and dependency was 12.33%. Anxiety and emotional-behavioral problems mediate the relationship between alexithymia and dependency.

Higher-order dimensions of psychopathology in a neurodevelopmental transdiagnostic sample

Hierarchical dimensional models of psychopathology derived for adult and child community populations offer more informative and efficient methods for assessing and treating symptoms of mental ill health than traditional diagnostic approaches. It is not yet clear how many dimensions should be included in models for youth with neurodevelopmental conditions. The aim of this study was to delineate the hierarchical dimensional structure of psychopathology in a transdiagnostic sample of children and adolescents with learning-related problems, and to test the concurrent predictive value of the model for clinically, socially, and educationally relevant outcomes. A sample of N = 403 participants from the Centre for Attention Learning and Memory (CALM) cohort were included. Hierarchical factor analysis delineated dimensions of psychopathology from ratings on the Conner's Parent Rating Short Form, the Revised Children's Anxiety and Depression Scale, and the Strengths and Difficulties Questionnaire. A hierarchical structure with a general p factor at the apex, broad internalizing and broad externalizing spectra below, and three more specific factors (specific internalizing, social maladjustment, and neurodevelopmental) emerged. The p factor predicted all concurrently measured social, clinical, and educational outcomes, but the other dimensions provided incremental predictive value. The neurodevelopmental dimension, which captured symptoms of inattention, hyperactivity, and executive function and emerged from the higher-order externalizing factor, was the strongest predictor of learning. This suggests that in struggling learners, cognitive and affective behaviors may interact to influence learning outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Temperament Traits Mark Liability for Coexisting Psychiatric Symptoms in Children With Elevated ADHD Symptoms

Objective: Among children with ADHD, coexisting psychiatric disorders are common and associated with greater impairment and symptom persistence. Given that temperament traits are easily measured, developmentally stable, and variable among youth with ADHD, temperament profiles may be clinically useful for predicting liability for coexisting psychiatric symptoms in this population. Methods: Eighty-three children with ADHD symptoms participated. Caregivers rated their child's surgency, negative emotionality, and effortful control, as well as severity of internalizing and externalizing psychiatric symptoms. Hierarchical linear regressions were conducted to estimate associations between temperament traits and psychiatric symptoms, controlling for severity of ADHD. Results: Temperament ratings explained significant variance in psychiatric symptoms above and beyond ADHD symptoms alone. Symptoms of each coexisting psychiatric disorder was associated with a distinct temperament and ADHD symptom profile. Conclusion: Temperament ratings appear to have clinical utility for predicting coexisting psychiatric symptoms in children with elevated ADHD symptoms.

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

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

Targeting working memory to modify emotional reactivity in adult attention deficit hyperactivity disorder: a functional magnetic resonance imaging study

Understanding the neural mechanisms of emotional reactivity in Attention-Deficit/Hyperactivity Disorder (ADHD) may help develop more effective treatments that target emotion dysregulation. In adult ADHD, emotion regulation problems cover a range of dimensions, including emotional reactivity (ER). One important process that could underlie an impaired ER in ADHD might be impaired working memory (WM) processing. We recently demonstrated that taxing WM prior to the exposure of emotionally salient stimuli reduced physiological and subjective reactivity to such cues in heavy drinkers, suggesting lasting effects of WM activation on ER. Here, we investigated neural mechanisms that could underlie the interaction between WM and ER in adult ADHD participants. We included 30 male ADHD participants and 30 matched controls. Participants performed a novel functional magnetic resonance imaging paradigm in which active WM-blocks were alternated with passive blocks of negative and neutral images. We demonstrated group-independent significant main effects of negative emotional images on amygdala activation, and WM-load on paracingulate gyrus and dorsolateral prefrontal cortex activation. Contrary to earlier reports in adolescent ADHD, no impairments were found in neural correlates of WM or ER. Moreover, taxing WM did not alter the neural correlates of ER in either ADHD or control participants. While we did find effects on the amygdala, paCG, and dlPFC activation, we did not find interactions between WM and ER, possibly due to the relatively unimpaired ADHD population and a well-matched control group. Whether targeting WM might be effective in participants with ADHD with severe ER impairments remains to be investigated.

Effects of prolonged methylphenidate treatment on amygdala reactivity and connectivity: a randomized controlled trial in stimulant treatment-naive, male participants with ADHD

Background

Problems with emotional processing are widely reported in individuals with attention-deficit/hyperactivity disorder (ADHD). Although methylphenidate (MPH) effectively alleviates inattention and hyperactivity symptoms in ADHD, its effects on emotional processing and internalizing symptoms have remained elusive. While we previously found that acute MPH administration modulated neural mechanisms underlying emotional processing in an age-dependent manner, the effects of prolonged administration remained unknown.

Objectives

Therefore, we investigated: (i) whether prolonged MPH treatment influences neural substrates (amygdala reactivity and connectivity) of emotional processing, and (ii) whether these effects are modulated by age.

Methods

The "effects of Psychotropic drugs On Developing brain-MPH" ("ePOD-MPH") randomized controlled trial was a 16-week double-blind, placebo-controlled, multi-center trial with MPH in 50 boys (10-12 years of age) and 49 men (23-40 years of age), all stimulant treatment-naive and diagnosed with ADHD. Participants performed an emotional face-matching task during functional magnetic resonance imaging. We assessed their symptoms of ADHD and internalizing symptoms at baseline, during the trial (8 weeks), and 1 week after the trial end (17 weeks).

Results and Conclusions

We did not find effects of prolonged MPH treatment on emotional processing, as measured by amygdala reactivity and connectivity and internalizing symptoms in this trial with stimulant treatment-naive participants. This differs from our findings on emotional processing following acute MPH administration and the effects of prolonged MPH treatment on the dopamine system, which were both modulated by age. Interestingly, prolonged MPH treatment did improve ADHD symptoms, although depressive and anxiety symptoms showed a medication-independent decrease. Furthermore, our data indicate that baseline internalizing symptoms may be used to predict MPH treatment effects on ADHD symptoms, particularly in (male) adults with ADHD.

Developmental Relations Between Internalising Problems and ADHD in Childhood: a Symptom Level Perspective

ADHD and internalising problems commonly co-occur with up to 50% of children diagnosed with ADHD also suffering from anxiety or depression. However, their developmental relations are currently not well understood. Longitudinal symptom level analyses can provide valuable insights into how difficulties in these areas of psychosocial functioning affect each other. Using Gaussian Graphical Models and Graphical Vector Autoregression Models, this study estimated cross-sectional and longitudinal networks of ADHD and internalising symptoms in 1387 children using parent- and teacher-reported Social Behaviour Questionnaires (SBQ) when children were aged 7, 9 and 11. Cross-sectional and longitudinal networks suggested that ADHD shares reciprocal relations with internalising symptoms through a number of potential bridge symptoms that are primarily connected to anxiety symptoms. High scores on child cannot sit still, is restless, or hyperactive were found to be the strongest bridge symptom acting as an antecedent to higher internalising symptoms whereas child is worried was the strongest antecedent for higher ADHD symptoms. Findings of this study highlight several potential bridge symptoms that may serve as key intervention targets and further emphasise the need for clinicians to assess children presenting with ADHD symptoms for internalising problems and vice versa.

The Influence of State and Trait Anxiety on the Achievement of a Virtual Reality Continuous Performance Test in Children and Adolescents with ADHD Symptoms

The three types of presentations of ADHD often co-occur with other disorders, anxiety being one of the most prevalent. For this reason and because there are few studies that have examined the influence of anxiety on attentional activities, this study aims to determine how internalizing difficulties (anxiety levels) can influence performance in a virtual reality continuous performance test. The study used a non-probabilistic clinical sample comprising 68 boys (66%) and 35 girls (34%) aged between 6 and 16 (M = 12.24; SD = 2.45) who had been referred to clinical services for the evaluation of ADHD symptoms. Once informed consent was given, the children were administered the STAI-C scale and a virtual reality continuous performance test by expert researchers. Hierarchical regression models showed that only state anxiety demonstrated significant explanatory power over attentional variables. These findings confirm how important it is for children to feel relaxed when they undergo psychological evaluation tests, as otherwise the individual’s intervention design would be based on biased data. Similarly, the findings also suggested an effect of IQ in the interpretation of continuous performance scores.

Links between parent-reported measures of poor sleep and executive function in childhood autism and attention deficit hyperactivity disorder

OBJECTIVES

This study sought to assess whether poor sleep is associated with aspects of executive function (EF) among children with autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), or typical development (TD), after adjusting for demographic variables, stimulant medications, intelligence, anxiety, inattention, and hyperactivity.

DESIGN

Cross-sectional.

SETTING

Children recruited through ongoing studies at the Kennedy Krieger Institute.

PARTICIPANTS

We studied 735 children (323 TD; 177 ASD; 235 ADHD) aged 8 to 12 years.

MEASUREMENTS

We investigated associations of parent-reported sleep measures from the Children's Sleep Habits Questionnaire (CSHQ) with parent-report measures of EF and performance-based processing speed with each clinical population. EF was measured using 8 clinical T scores that fall under 2 domains (behavioral regulation and metacognition) from the Behavior Rating Inventory of EF (BRIEF) and the processing speed index from the Wechsler Intelligence Scale for Children-IV or -V.

RESULTS

Higher CSHQ scores were associated with poorer EF on all BRIEF scales, across all child groups, after adjustment for demographic factors, stimulant medications, and IQ. Among children with ADHD, these associations largely remained after adjusting for anxiety. Among those ASD, anxiety partially accounted for these associations, especially for behavioral regulation EF outcomes. Co-occurring symptoms of inattention and hyperactivity/impulsivity further accounted for the associations between sleep and EF. Poor sleep was not significantly associated with processing speed.

CONCLUSIONS

Strong links exist between parent-reported poor sleep and executive dysfunction in children with typical development. Targeting anxiety may alleviate executive dysfunction, especially among children with ASD.

ADHD symptoms, the current symptom scale, and exploratory structural equation modeling: A psychometric study

The aim of the study was to use exploratory structural equation modelling (ESEM) to investigate support for an ADHD factor model with group factors for inattention (IA), hyperactivity (HY), and impulsivity (IM), as proposed in in ICD-10. A total of 202 adults (121 females and 81 males), aged between 18 and 35 years, from the general community, completed the Current Symptoms Scale (CSS). The results for the model showed good global fit, good convergent and divergent validities. However, the IA and IM factors, but not the HY factor, were clearly defined and demonstrated acceptable reliabilities. Taken together, these finding indicate that a revised ESEM model without the HY factor (i.e. with only the IA and IM symptoms) is an appropriate structure for modeling adult ratings of the ADHD behaviors described in the CSS. The taxonomic, theoretical and clinical implications of the findings for ADHD in general are discussed.

ASRS Questionnaire and Tobacco Use: Not Just a Cigarette. A Screening Study in an Italian Young Adult Sample

Young adults exhibit greater sensitivity than adults to nicotine reinforcement, and Attention Deficit Hyperactivity Disorder (ADHD) increases the risk for early-onset smoking. We investigated the correlation between ADHD Self-Report Scale (ASRS) scores and smoking, evaluated the prevalence of ADHD symptomatology (not diagnoses) in smokers and non-smokers and its comorbidity with benzodiazepine and gambling addictions. A total of 389 young adults from 14 schools in Northern Italy fill out a survey and the Adult ADHD Self-Report Scale (ASRS). A total of 15.2% of subjects tested positive at the ASRS, which correlated with smoking; moreover, smokers had twice the probability of testing positive at the ASRS. ADHD symptomatology, especially when comorbid with tobacco abuse, is an important condition to monitor because early nicotine exposure could be a gateway for other addictive behaviors.

Prospective Examination of Adolescent Sleep Patterns and Behaviors Before and During COVID-19

Study Objectives

To prospectively examine changes in adolescent sleep before and during the COVID-19 pandemic in adolescents with and without ADHD.

Methods

Participants were 122 adolescents (ages 15–17; 61% male; 48% with ADHD). Parents reported on adolescents’ sleep duration and difficulties initiating and maintaining sleep (DIMS); adolescents reported on sleep patterns, sleep duration, delayed sleep/wake behaviors, and daytime sleepiness before (September 2019 to February 2020) and during (May–June 2020) COVID-19. Adolescents also reported on their health behaviors, COVID-19-related negative affect, and difficulties concentrating due to COVID-19.

Results

Parents reported adolescents had more DIMS during COVID-19 than before COVID-19, with clinically elevated rates increasing from 24% to 36%. Both bedtimes and waketimes shifted later during COVID-19, and adolescents reported more delayed sleep/wake behaviors. Adolescents also reported less daytime sleepiness and longer school night sleep duration during COVID-19. In considering differences between adolescents with and without ADHD, adolescents with ADHD did not experience an increase in school night sleep duration and were less likely to obtain recommended sleep duration during COVID-19. In the full sample, controlling for ADHD status, COVID-19-related sadness/loneliness was associated with increases in DIMS, and spending less time outside and more COVID-19-related worries/fears were associated with increases in delayed sleep/wake behaviors during COVID-19.

Conclusions

COVID-19 had negative and positive impacts on adolescent sleep. Adolescents with ADHD did not experience the benefit of increased school night sleep duration during COVID-19 like adolescents without ADHD. Negative affect and health behaviors may be useful intervention targets for reducing negative impacts of COVID-19 for adolescent sleep.

An ecological momentary assessment study of the role of emotional dysregulation in co-occurring ADHD and internalising symptoms in adulthood

Previous ecological momentary assessment (EMA) research in children has suggested that emotional dysregulation problems are commonly associated with ADHD symptoms and may help explain their relatively strong co-occurrence with anxiety and depression (collectively referred to as 'internalising problems'); however, this has yet to be replicated for adults. In this study, we used data from a n=260 longitudinal cohort and EMA study, to evaluate the hypothesis that emotional dysregulation mediates the association between ADHD symptoms and internalising problems in emerging adulthood. Emotional dysregulation was based on affect data collected in near real time and in ecological context over a 14-day period, providing a measure of emotional lability in the context of participants' daily lives. Cross-sectional mediation was tested using structural equation modelling. Emotional lability significantly mediated the association between ADHD symptoms and internalising problems. Results suggest that interventions that address the emotional dysregulation aspects of ADHD are likely to be beneficial for preventing and managing secondary internalising symptoms.