Revision and restandardization of the Conners Teacher Rating Scale (CTRS-R): factor structure, reliability, and criterion validity

Transcranial sonography of subcortical structures in tic/tourette disorder

Functional neuroimaging studies demonstrate disinhibition of the cortico-striatal-thalamo-cortical circuit. However, structural imaging studies revealed conflicting results, some suggesting smaller volumes of the caudate nucleus (CN) in children with Gilles de la Tourette syndrome (TS). Here we wanted to find out whether transcranial sonography (TCS) detects alterations of raphe nuclei, substantia nigra, lenticular nucleus (LN), or CN in children with Tic disorder or TS (TIC/TS).The study included 25 treatment-naive children (age: 12.2 ± 2.5 years) with a DSM-V based diagnosis of Tic disorder or TS (10 subjects), without other psychiatric or neurologic diagnosis, and 25 healthy controls (age: 12.17 ± 2.57 years), matched for age and sex. Parental rating of behavioral, emotional abnormalities, somatic complaints and social competencies of the participants were assessed using the Child Behavior Check List (CBCL/4-18R). TCS of deep brain structures was conducted through the preauricular acoustic bone windows using a 2.5-MHz phased-array ultrasound system. Fisher's exact test and Mann-Whitney-U test were used for comparisons between TIC/TS patients and healthy volunteers. The number of participants with hyperechogenic area of left CN in the TIC/TS sample was increased, compared to the healthy control group. TIC/TS patients with hyperechogenic CN showed an increased occurrence of thought- and obsessive-compulsive problems. This TCS study revealed pathologic structural changes in CN, its higher occurrence in TIC/TS compared to healthy controls and the relation to comorbidity of thought problems. Further research should focus on the molecular cause of these alterations, probably the disturbed iron metabolism.

Attention Deficit/Hyperactivity Disorder in Children with Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic neurological autoimmune disease; pediatric-onset multiple sclerosis (POMS) represents 5% to 10% of total MS population. Children with POMS may experience attention difficulties due to the disease's impact on the central nervous system. However, little is known regarding Attention Deficit Hyperactivity Disorder (ADHD) in POMS, and its relation to cognitive performance.

METHODS

A retrospective case review was conducted using medical records of 66 children and adolescent patients diagnosed with POMS between 2012 and 2021 in a MS center of a tertiary medical center. All patients had undergone routine clinical neurological examinations and had been assessed for a diagnosis of ADHD by a department pediatric neurologist. In addition, sociodemographic data, disease-related variables, and cognitive performance were collected.

RESULTS

Of the 66 patients, 31 (47%) had a diagnosis of ADHD; 29 (44%) had cognitive impairment. Moreover, we identified four different profiles of POMS: those with only ADHD (17, 26%); only cognitive impairment (15, 23%), ADHD and cognitive impairment (14, 21%), and only POMS (20, 30%). A significant difference in disease duration was found among the four profiles [F(3,65) = 8.17, p < .001, η² = 0.29], indicating that patients with ADHD and cognitive impairment were characterized by longer disease duration.

CONCLUSIONS

ADHD may be prominently involved in POMS, even during the early stages of the disease and early diagnosis is crucial in order to provide appropriate interventions and support.

Klinefelter Syndrome: A Genetic Disorder Leading to Neuroendocrine Modifications and Psychopathological Vulnerabilities in Children-A Literature Review and Case Report

Klinefelter syndrome (KS), characterized by an additional X-chromosome in males, manifests in a wide range of neuroendocrine and psychiatric symptoms. Individuals with KS often face increased risks of hormonal dysfunction, leading to depression and anxiety, although extended research during pediatric and adolescent age is still limited. This critical phase, decisive for KS children, is influenced by a combination of genetic, environmental and familial factors, which impact brain plasticity. In this report, we reviewed, in a narrative form, the crucial KS psychopathological hallmarks in children. To better describe neuroendocrine and neuropsychiatric outcomes in children with KS, we presented the case of an 11-year-old prepubertal child with mosaic KS who was referred to our Center of Developmental Psychopathology due to a decline in his academic performance, excessive daytime fatigue and increased distractibility over the past few months. Family history revealed psychiatric conditions among first- and second-degree relatives, including recently divorced parents and a 15-year-old sister. Early-onset persistent depressive disorder and anxious traits were diagnosed. Timely identification of susceptible children, with thorough examination of familial psychiatric history, environmental influences and neurocognitive profile, alongside targeted interventions, could potentially mitigate lifelong psychopathology-related disabilities in pediatric and adolescent KS cases, including those with mosaic KS.

Maternal smoking during pregnancy and cortical structure in children with attention-deficit/hyperactivity disorder

Maternal smoking during pregnancy (MSDP) is considered a risk factor for ADHD. While the mechanisms underlying this association are not well understood, MSDP may impact the developing brain in ways that lead to ADHD. Here, we investigated the effect of prenatal smoking exposure on cortical brain structures in children with ADHD using two methods of assessing prenatal exposure: maternal recall and epigenetic typing. Exposure groups were defined according to: (1) maternal recall (+MSDP: n = 24; -MSDP: n = 85) and (2) epigenetic markers (EM) (+EM: n = 14 -EM: n = 21). CIVET-1.1.12 and RMINC were used to acquire cortical brain measurements and perform statistical analyses, respectively. The vertex with highest significance was tested for association with Continuous Performance Test (CPT) dimensions. While no differences of brain structures were identified between +MSDP and -MSDP, +EM children (n = 10) had significantly smaller surface area in the right orbitofrontal cortex (ROFc), middle temporal cortex (RTc) and parahippocampal gyrus (RPHg) (15% FDR) compared to -EM children (n = 20). Cortical surface area in the RPHg significantly correlated with CPT commission errors T-scores. This study suggests that molecular markers may better define exposure to environmental risks, as compared to human recall.

Pharmacological management of fragile X syndrome: a systematic review and narrative summary of the current evidence

INTRODUCTION

Fragile X syndrome (FXS) is the most common inherited cause of Intellectual Disability. There is a broad phenotype that includes deficits in cognition and behavioral changes, alongside physical characteristics. Phenotype depends upon the level of mutation in the FMR1 (fragile X messenger ribonucleoprotein 1) gene. The molecular understanding of the impact of the FMR1 gene mutation provides an opportunity to target treatment not only at symptoms but also on a molecular level.

METHODS

We conducted a systematic review to provide an up-to-date narrative summary of the current evidence for pharmacological treatment in FXS. The review was restricted to randomized, blinded, placebo-controlled trials.

RESULTS

The outcomes from these studies are discussed and the level of evidence assessed against validated criteria. The initial search identified 2377 articles, of which 16 were included in the final analysis.

CONCLUSION

Based on this review to date there is limited data to support any specific pharmacological treatments, although the data for cannabinoids are encouraging in those with FXS and in future developments in gene therapy may provide the answer to the search for precision medicine. Treatment must be person-centered and consider the combination of medical, genetic, cognitive, and emotional challenges.

Exploring telediagnostic procedures in child neuropsychiatry: addressing ADHD diagnosis and autism symptoms through supervised machine learning

Recently, there has been an increase in telemedicine applied to child neuropsychiatry, such as the use of online platforms to collect remotely case histories and demographic and behavioral information. In the present proof-of-concept study, we aimed to understand to what extent information parents and teachers provide through online questionnaires overlaps with clinicians' diagnostic conclusions on attention-deficit/hyperactivity disorder (ADHD). Moreover, we intended to explore a possible role that autism spectrum disorders (ASD) symptoms played in this process. We examined parent- and teacher-rated questionnaires collected remotely and an on-site evaluation of intelligence quotients from 342 subjects (18% females), aged 3-16 years, and referred for suspected ADHD. An easily interpretable machine learning model-decision tree (DT)-was built to simulate the clinical process of classifying ADHD/non-ADHD based on collected data. Then, we tested the DT model's predictive accuracy through a cross-validation approach. The DT classifier's performance was compared with those that other machine learning models achieved, such as random forest and support vector machines. Differences in ASD symptoms in the DT-identified classes were tested to address their role in performing a diagnostic error using the DT model. The DT identified the decision rules clinicians adopt to classify an ADHD diagnosis with an 82% accuracy rate. Regarding the cross-validation experiment, our DT model reached a predictive accuracy of 74% that was similar to those of other classification algorithms. The caregiver-reported ADHD core symptom severity proved the most discriminative information for clinicians during the diagnostic decision process. However, ASD symptoms were a confounding factor when ADHD severity had to be established. Telehealth procedures proved effective in obtaining an automated output regarding a diagnostic risk, reducing the time delay between symptom detection and diagnosis. However, this should not be considered an alternative to on-site procedures but rather as automated support for clinical practice, enabling clinicians to allocate further resources to the most complex cases.

Early life manganese exposure and reported attention-related behaviors in Italian adolescents

Background

Manganese (Mn) is an essential nutrient and neurotoxicant, and the neurodevelopmental effects of Mn may depend on exposure timing. Less research has quantitatively compared the impact of Mn exposure on neurodevelopment across exposure periods.

Methods

We used data from 125 Italian adolescents (10-14 years) from the Public Health Impact of Metals Exposure Study to estimate prospective associations of Mn in three early life exposure periods with adolescent attention-related behaviors. Mn was quantified in deciduous teeth using laser ablation-inductively coupled plasma-mass spectrometry to represent prenatal (2nd trimester-birth), postnatal (birth ~1.5 years), and childhood (~1.5-6 years) exposure. Attention-related behavior was evaluated using the Conners Behavior Rating Scales in adolescence. We used multivariable linear regression models to quantify associations between Mn in each exposure period, and multiple informant models to compare associations across exposure periods.

Results

Median tooth Mn levels (normalized to calcium) were 0.4 area under the curve (AUC) 55Mn:43Ca × 104, 0.1 AUC 55Mn:43Ca × 104, and 0.0006 55Mn:43Ca for the prenatal, postnatal, and childhood periods. A doubling in prenatal tooth Mn levels was associated with 5.3% (95% confidence intervals [CI] = -10.3%, 0.0%) lower (i.e., better) teacher-reported inattention scores, whereas a doubling in postnatal tooth Mn levels was associated with 4.5% (95% CI = -9.3%, 0.6%) and 4.6% (95% CI = -9.5%, 0.6%) lower parent-reported inattention and attention deficit/hyperactivity disorder index scores, respectively. Childhood Mn was not beneficially associated with reported attention-related behaviors.

Conclusion

Protective associations in the prenatal and postnatal periods suggest Mn is beneficial for attention-related behavior, but not in the childhood period.

Perceptual alterations in the relationship between sensory reactivity, intolerance of uncertainty, and anxiety in autistic children with and without ADHD

Sensory differences and anxiety disorders are highly prevalent in autistic individuals with and without ADHD. Studies have shown that sensory differences and anxiety are associated and that intolerance of uncertainty (IU) plays an important role in this relationship. However, it is unclear as to how different levels of the sensory processing pathway (i.e., perceptual, affective, or behavioral) contribute. Here, we used psychophysics to assess how alterations in tactile perception contribute to questionnaire measures of sensory reactivity, IU, and anxiety. Thirty-eight autistic children (aged 8-12 years; 27 with co-occurring ADHD) were included. Consistent with previous findings, mediation analyses showed that child-reported IU fully mediated an association between parent-reported sensory reactivity and parent-reported anxiety and that anxiety partially mediated an association between sensory reactivity and IU. Of the vibrotactile thresholds, only simultaneous frequency discrimination (SFD) thresholds correlated with sensory reactivity. Interestingly, we found that sensory reactivity fully mediated an association between SFD threshold and anxiety, and between SFD threshold and IU. Taken together, those findings suggest a mechanistic pathway whereby tactile perceptual alterations contribute to sensory reactivity at the affective level, leading in turn to increased IU and anxiety. This stepwise association can inform potential interventions for IU and anxiety in autism.

Efficacy of stimulants for preschool attention-deficit/hyperactivity disorder: A systematic review and meta-analysis

Background

Robust synthesis of evidence to support treatment recommendations for preschoolers with attention-deficit/hyperactivity disorder (ADHD) is lacking. The aim of this systematic review and meta-analysis was to review currently available evidence to evaluate the efficacy and acceptability of stimulants for preschool children with ADHD.

Methods

We searched electronic databases (CENTRAL, Embase, PubMed) from the database inception to March, 2022; and clinical trial registries through WHO ICTRP from the database inception to July, 2022, and selected double-blinded randomized controlled trials (RCTs) that compared stimulants against placebo for the treatment of preschoolers (age ≤ 7 years) with ADHD. Change in ADHD symptom severity was the primary outcome (efficacy) and all-cause dropout rates (acceptability) was the secondary outcome. Data were pooled with random-effects models weighted by the inverse of the variance. Risk of bias of individual studies were assessed with the Cochrane Risk of Bias tool version 2. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the quality of evidence. This study is registered with PROSPERO (CRD42022348597).

Results

Five RCTs (three methylphenidate immediate-release, one methylphenidate extended-release, and one lisdexamfetamine) were included. The analysis of efficacy was based on 489 participants. Meta-analysis of change in ADHD symptom severity demonstrated a significant effect in favor of stimulants over placebo (standardized mean difference = -0.59; 95% CI -0.77, -0.41; p < 0.0001). There was no evidence of heterogeneity but some concerns about publication bias. Regardless, the confidence of evidence was considered moderate. For acceptability, stimulants did not lead to an increased rate of all-cause discontinuation rates in comparison to placebo (OR = 0.59; 95% CI 0.15, 2.37; p = 0.45) but the confidence of estimate was very low.

Conclusions

Our findings demonstrated that stimulants are efficacious in reducing ADHD symptoms among preschool children. Clinicians should consider the use of stimulants when making treatment recommendations for preschoolers with ADHD.

Relation between sleep disorders and attention deficit disorder with hyperactivity in children and adolescents: A systematic review

BACKGROUND

Sleep problems have a high recurrence in children and adolescents with attention deficit disorder with hyperactivity (ADHD) experience high rates of sleep problems.

OBJECTIVE

Understand the relationship between sleep disorders and ADHD symptoms.

METHODS AND PROCEDURES

A systematic review was performed using electronic databases, including PubMed, Cochrane Library, Scopus, Lilacs, and Psychology Database (ProQuest) systems. The quality of each article was assessed using a 5-criteria checklist, measuring relevant dimensions.

OUTCOMES AND RESULTS

The review analyzed fifteen articles, were included that raised the realizations among sleep problems in the population of children with ADHD, obtaining a total of 1645 children and adolescents with ADHD that were compared with typical development groups. The articles selected for this systematic review of observational design have a high quality.

CONCLUSIONS AND IMPLICATIONS

Children and adolescents with ADHD have sleep problems, which may exacerbate or be the cause of the ADHD clinic, affecting the quality of life of children and their families. Early inquiry and a timely approach can contribute to reducing the severity of ADHD symptoms.

Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age-inappropriate levels of inattention, hyperactivity, and impulsivity, and is associated with long-term social, academic, and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Research has shown that children and adolescents with ADHD have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega-3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. This review is an update of a previously published Cochrane Review. Overall, there was little evidence that PUFA supplementation improved symptoms of ADHD in children and adolescents.

OBJECTIVES

To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents.

SEARCH METHODS

We searched 13 databases and two trials registers up to October 2021. We also checked the reference lists of relevant studies and reviews for additional references.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared PUFA with placebo or PUFA plus alternative therapy (medication, behavioural therapy, or psychotherapy) with the same alternative therapy alone in children and adolescents (aged 18 years and under) diagnosed with ADHD.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was severity or improvement of ADHD symptoms. Our secondary outcomes were severity or incidence of behavioural problems; quality of life; severity or incidence of depressive symptoms; severity or incidence of anxiety symptoms; side effects; loss to follow-up; and cost. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included 37 trials with more than 2374 participants, of which 24 trials were new to this update. Five trials (seven reports) used a cross-over design, while the remaining 32 trials (52 reports) used a parallel design. Seven trials were conducted in Iran, four each in the USA and Israel, and two each in Australia, Canada, New Zealand, Sweden, and the UK. Single studies were conducted in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Of the 36 trials that compared a PUFA to placebo, 19 used an omega-3 PUFA, six used a combined omega-3/omega-6 supplement, and two used an omega-6 PUFA. The nine remaining trials were included in the comparison of PUFA to placebo, but also had the same co-intervention in the PUFA and placebo groups. Of these, four trials compared a combination of omega-3 PUFA plus methylphenidate to methylphenidate. One trial each compared omega-3 PUFA plus atomoxetine to atomoxetine; omega-3 PUFA plus physical training to physical training; and an omega-3 or omega-6 supplement plus methylphenidate to methylphenidate; and two trials compared omega-3 PUFA plus dietary supplement to dietary supplement. Supplements were given for a period of between two weeks and six months. Although we found low-certainty evidence that PUFA compared to placebo may improve ADHD symptoms in the medium term (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.47 to 2.60; 3 studies, 191 participants), there was high-certainty evidence that PUFA had no effect on parent-rated total ADHD symptoms compared to placebo in the medium term (standardised mean difference (SMD) -0.08, 95% CI -0.24 to 0.07; 16 studies, 1166 participants). There was also high-certainty evidence that parent-rated inattention (medium-term: SMD -0.01, 95% CI -0.20 to 0.17; 12 studies, 960 participants) and hyperactivity/impulsivity (medium-term: SMD 0.09, 95% CI -0.04 to 0.23; 10 studies, 869 participants) scores were no different compared to placebo. There was moderate-certainty evidence that overall side effects likely did not differ between PUFA and placebo groups (RR 1.02, 95% CI 0.69 to 1.52; 8 studies, 591 participants). There was also moderate-certainty evidence that medium-term loss to follow-up was likely similar between groups (RR 1.03, 95% CI 0.77 to 1.37; 13 studies, 1121 participants).

AUTHORS' CONCLUSIONS

Although we found low-certainty evidence that children and adolescents receiving PUFA may be more likely to improve compared to those receiving placebo, there was high-certainty evidence that PUFA had no effect on total parent-rated ADHD symptoms. There was also high-certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups. We found moderate-certainty evidence that overall side effects likely did not differ between PUFA and placebo groups. There was also moderate-certainty evidence that follow-up was similar between groups. It is important that future research addresses the current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow-up times.

Neurobehavioral phenotypes of delay discounting and cognitive control in child attention-deficit/hyperactivity disorder and obesity: Shared or distinct?

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) and obesity have been independently associated with deficient cognitive control (CC) and heightened preference for immediate reward.

OBJECTIVES

We aimed to identify specific shared and distinct neurobehavioral phenotypes of child obesity and ADHD by simultaneously measuring CC and preference for immediate reward in children with and without ADHD who varied in body weight.

METHODS

This case-control study included 323 8-12 year olds (ADHD n = 215, typically developing (TD) screened for ADHD symptoms [TD] controls n = 108) varying in body weight. Children completed a go/no-go task (assessing CC), as well as a classical money delay discounting (DD) task and novel experiential game time DD task (assessing preference for immediate over delayed rewards).

RESULTS

For game time DD, there was a body mass index z-score (BMIz)*ADHD interaction, such that TD children with overweight/obesity showed game time DD levels that were greater than those of TD children without overweight/obesity and similar to those of children with ADHD. Only children with ADHD showed poorer CC compared to TD children, with no effects of body weight.

CONCLUSIONS

Heightened game time DD with delays and rewards experienced in real-time may represent a neurobehavioral phenotype that is shared between ADHD and overweight/obesity in childhood, whereas deficient CC may be specific to children with ADHD.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

PRIMARY OUTCOMES

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

SECONDARY OUTCOMES

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

AUTHORS' CONCLUSIONS

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

Cardiovascular Disease Risk in Children and Adolescents with Attention Deficit/Hyperactivity Disorder

Objective

The aim of this case-controlled study is to evaluate chronic inflammation, subclinical atherosclerosis and cardiovascular disease risk in children and adolescents with ADHD.

Methods

A total of 51 medication-free children and adolescents with ADHD and 51 healthy controls were included in this study. K-SADS-PL was used to determine the diagnosis of ADHD and other psychiatric disorders. Conners' Parent Rating Scale-Revised Short Form and the Conners' Teacher Rating Scale-Revised Short Form severity of ADHD was used to evaluate severity of ADHD. In order to evaluate subclinical atherosclerosis, common carotid intima media thickness (IMT), epicardial adipose tissue thickness (EAT), and periaortic adipose tissue thickness (PAT) were assessed as well as clinical parameters.

Results

The IMT (0.037 ± 0.005 cm vs. 0.026 ± 0.003 cm), EAT (0.472 ± 0.076 cm vs. 0.355 ± 0.051 cm), and PAT (0.135 ± 0.016 cm vs. 0.118 ± 0.009 cm) measurements were significantly higher in the ADHD group than in the control group. Additionally, partial correlation analyses revealed that a positive correlation was observed between IMT and EAT, and PAT measurements separately. Multivariate linear regression analysis revealed that, body mass index (BMI) positively predicted IMT. Also, age and BMI positively predicted the EAT levels of the subjects with ADHD.

Conclusion

Our results suggest that children and adolescents with ADHD have a risk for cardiovascular disease. For this reason, subclinical atherosclerosis should be taken into consideration in the follow-up and treatment of ADHD for cardiovascular disease risk.

Association of Liver Transplant and Attention-Deficit Hyperactivity Disorder: A Single-Center Experience

OBJECTIVES

This prospective cohort study aimed to determine the prevalence of attention-deficit hyperactivity disorder and to reveal how the diagnosis of attention-deficit/hyperactivity disorder can be made most accurately in children with liver transplant.

MATERIALS AND METHODS

We studied a group of 62 children from 6 and 18 years old who underwent liver transplant at least 1 year previous to our study and who were followed up in the Department of Pediatric Gastroenterology. A child and adolescent psychiatrist evaluated all liver transplant patients for attention- deficit hyperactivity disorder based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The Kiddie Schedule for Affective Disorders and Schizophrenia (in Turkish) was applied to the children. The Kiddie Schedule and the Conners Parent Rating Scale were applied to the children's parents. The Conners Teacher Rating Scale was applied to the children's teachers.

RESULTS

The frequency of attention-deficit hyperactivity disorder in the sample was found to be 24.5% according to Kiddie Schedule, 45.9% according to the Conners Parent Rating Scale, and 24% according to the Conners Teacher Rating Scale. However, clinical examination showed that 9.67% of the children had attention-deficit hyperactivity disorder.

CONCLUSIONS

We concluded that detailed clinical examination is more important than neuropsychological tests and scales when diagnosing attention-deficit hyperactivity disorder in pediatric liver transplant recipients.

Investigating Direct and Indirect Genetic Effects in Attention-Deficit/Hyperactivity Disorder Using Parent-Offspring Trios

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is highly heritable, but little is known about the relative effects of transmitted (i.e., direct) and nontransmitted (i.e., indirect) common variant risks. Using parent-offspring trios, we tested whether polygenic liability for neurodevelopmental and psychiatric disorders and lower cognitive ability is overtransmitted to ADHD probands. We also tested for indirect or genetic nurture effects by examining whether nontransmitted ADHD polygenic liability is elevated. Finally, we examined whether complete trios are representative of the clinical ADHD population.

METHODS

Polygenic risk scores (PRSs) for ADHD, anxiety, autism, bipolar disorder, depression, obsessive-compulsive disorder, schizophrenia, Tourette syndrome, and cognitive ability were calculated in UK control subjects (n = 5081), UK probands with ADHD (n = 857), their biological parents (n = 328 trios), and also a replication sample of 844 ADHD trios.

RESULTS

ADHD PRSs were overtransmitted and cognitive ability and obsessive-compulsive disorder PRSs were undertransmitted. These results were independently replicated. Overtransmission of polygenic liability was not observed for other disorders. Nontransmitted alleles were not enriched for ADHD liability compared with control subjects. Probands from incomplete trios had more hyperactive-impulsive and conduct disorder symptoms, lower IQ, and lower socioeconomic status than complete trios. PRS did not vary by trio status.

CONCLUSIONS

The results support direct transmission of polygenic liability for ADHD and cognitive ability from parents to offspring, but not for other neurodevelopmental/psychiatric disorders. They also suggest that nontransmitted neurodevelopmental/psychiatric parental alleles do not contribute indirectly to ADHD via genetic nurture. Furthermore, ascertainment of complete ADHD trios may be nonrandom, in terms of demographic and clinical factors.

Increased Serum Brain-derived Neurotrophic Factor, Nerve Growth Factor, Glial-derived Neurotrophic Factor and Galanin Levels in Children with Attention Deficit Hyperactivity Disorder, and the Effect of 10 Weeks Methylphenidate Treatment

OBJECTIVE

This study aimed to investigate the levels of serum brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), glial cell-derived neurotrophic factor (GDNF) and galanin in children with attention deficit hyperactivity disorder (ADHD).

METHODS

The study included 58 cases with ADHD and 60 healthy controls. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL) together with Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) criteria were used for diagnostic evaluation. Sociodemographic data form and Conners' Parent/Teacher Rating Scale-Revised:Long Form were applied to all cases. The serum levels of BDNF, NGF, GDNF, and galanin were evaluated in all subjects. Afterwards, methylphenidate was started in the ADHD group. ADHD cases were reevaluated in terms of the serum levels of BDNF, NGF, GDNF, galanin at the 10th week of treatment.

RESULTS

Before the treatment, the levels of BDNF, NGF, GDNF, galanin were significantly higher in the ADHD group compared to the control group. The levels of BDNF, NGF, GDNF, galanin were found to be significantly lower after treatment in ADHD group compared to pre-treatment. No correlation was between scale scores and the serum levels of BDNF, NGF, GDNF, galanin.

CONCLUSION

The levels of neurotrophic factors and galanin were thought to be parameters worth evaluating in ADHD. Further studies on the subject with longer-term treatments and larger sample groups are required.

The orphan receptor GPR88 controls impulsivity and is a risk factor for Attention-Deficit/Hyperactivity Disorder

The neural orphan G protein coupled receptor GPR88 is predominant in the striatum and cortex of both rodents and humans, and considered a potential target for brain disorders. Previous studies have shown multiple behavioral phenotypes in Gpr88 knockout mice, and human genetic studies have reported association with psychosis. Here we tested the possibility that GPR88 contributes to Attention Deficit Hyperactivity Disorder (ADHD). In the mouse, we tested Gpr88 knockout mice in three behavioral paradigms, best translatable between rodents and humans, and found higher motor impulsivity and reduced attention together with the reported hyperactivity. Atomoxetine, a typical ADHD drug, reduced impulsivity in mutant mice. Conditional Gpr88 knockout mice in either D1R-type or D2R-type medium spiny neurons revealed distinct implications of the two receptor populations in waiting and stopping impulsivity. Thus, animal data demonstrate that deficient GPR88 activity causally promotes ADHD-like behaviors, and identify circuit mechanisms underlying GPR88-regulated impulsivity. In humans, we performed a family-based genetic study including 567 nuclear families with DSM-IV diagnosis of ADHD. There was a minor association for SNP rs2036212 with diagnosis, treatment response and cognition. A stronger association was found for SNP rs2809817 upon patient stratification, suggesting that the T allele is a risk factor when prenatal stress is involved. Human data therefore identify GPR88 variants associated with the disease, and highlight a potential role of life trajectories to modulate GPR88 function. Overall, animal and human data concur to suggest that GPR88 signaling should be considered a key factor for diagnostic and treatment of ADHD.

Kynurenine and oxidative stress in children having learning disorder with and without attention deficit hyperactivity disorder: possible role and involvement

Background

The etiological and pathophysiological factors of learning disorder (LD) and attention deficit hyperactivity disorder (ADHD) are currently not well understood. These disorders disrupt some cognitive abilities. Identifying biomarkers for these disorders is a cornerstone to their proper management. Kynurenine (KYN) and oxidative stress markers have been reported to influence some cognitive abilities. Therefore, the aim was to measure the level of KYN and some oxidative stress indicators in children with LD with and without ADHD and to investigate their correlations with the abilities of children with LD.

Methods

The study included 154 participants who were divided into 3 groups: one for children who have LD (N = 69); another for children with LD and ADHD (N = 31); and a group for neurotypical (NT) children (N = 54). IQ testing, reading, writing, and other ability performance evaluation was performed for children with LD. Measuring plasma levels of KYN, malondialdehyde, glutathione peroxidase, and superoxide dismutase by enzyme-linked immunosorbent assay was performed for all participants.

Results

Some IQ measures and learning skills differed between the first two groups. The biochemical measures differed between children with LD (with and without ADHD) and NT children (p < 0.001). However, the biochemical measures did not show a significant statistical difference between the first two groups. KYN and glutathione peroxidase levels were correlated with one-minute writing and at-risk quotient, respectively (p = 0.03;0.04). KYN and malondialdehyde showed the highest sensitivity and specificity values.

Conclusion

These biochemical measures could be involved or have a role in the abilities’ performance of children with specific learning disorder.

Behavioral Parent Training for Preschool ADHD: Family-Centered Profiles Predict Changes in Parenting and Child Outcomes

OBJECTIVE

Behavioral parent training (BPT) is the first line of treatment for preschool-aged children with attention-deficit hyperactivity disorder (ADHD); however, clinically significant improvements are not universal. In the current study, we employ a person-centered approach to create subgroups of families based on the intersection of multiple parent, child, and family pre-treatment factors. Further, we explore the utility of pre-treatment family profiles in predicting post-treatment differences in observed parenting behavior (i.e., behavioral control, parental warmth) and clinically significant change in child ADHD and oppositional symptoms.

METHOD

Longitudinal data were collected using observational and parent-, teacher- and clinician-reported assessments from 130 parent-child dyads (Mage= 3.57, range = 3.0- 4.11, 73.8% male, 69.2% White, 25.6% Hispanic) participating in BPT.

RESULTS

Findings from the current study suggest three distinct family profiles, which consisted of one profile with high family stress (HFS) as evidenced by elevated symptomatology across parent, child, and family-level domains, a second profile with elevated parental anxiety (PA), and a final profile with elevated parental depression (PD). These family-centered profiles were differentially associated with changes in observed parenting practices. Specifically, the PD profile (39%) demonstrated minimal improvements in behavioral control and warmth following treatment. In contrast, the HFS profile (30%) only improved in behavioral control and the PA profile (31%) improved in both parenting domains following treatment. In addition, marginally significant differences in child oppositional and ADHD symptoms were observed across profiles.

CONCLUSIONS

Family-centered approaches may be useful for selecting and implementing interventions.

A Cross-Sectional Comparative Study of Sleep Disturbances in Children with ADHD and Matched Controls

Background: Systematic reviews conducted on sleep disturbances in attention deficit hyperactivity disorder (ADHD) have found inconsistent results due to the presence of several moderating variables which were not controlled for in previous studies. The aim of this study was to examine sleep disturbances in children with ADHD compared to their typically developing peers after controlling for moderating variables (age, sex, medication status, body mass index, and psychiatric and medical comorbidities). Methods: ADHD was diagnosed using DSM-IV-TR criteria (Diagnostic and Statistical Manual of Mental Disorders) and Conners’ Parent Rating Scales. Children recruited (aged 6−12 years) for the ADHD group (n = 40) met the following criteria: IQ > 80, unmedicated, and no psychiatric or medical comorbidities. The control group consisted of age- and sex-matched typically developing peers (n = 40). Sleep was assessed subjectively (through parent reported questionnaires and sleep logs) and objectively (using video polysomnography). Results: 65% of children with ADHD had a sleep disorder, as compared to 17% of controls. The ADHD group reported more sleep disturbances and disorders, both on subjective measures and objective measures. Conclusions: Sleep disturbances and primary sleep disorders in children with ADHD exist independent of moderating variables and differences in sleep assessment methods, thereby bolstering support for previously documented literature on the ADHD and sleep connection.

Impact of Attention-Deficit/Hyperactivity Disorder Comorbidity on Phenomenology and Treatment Outcomes of Pediatric Obsessive-Compulsive Disorder

Objective: This study, with a case-control design, investigates the impact of attention-deficit/hyperactivity disorder (ADHD) comorbidity on the phenomenology and treatment outcomes in a clinical sample of pediatric obsessive-compulsive disorder (OCD). Methods: The data were derived from an evaluation of the sociodemographic and clinical characteristics of 364 children with OCD who were regularly followed up over a 4-year period. Between-group analyses of psychiatric scales were used to compare patients with ADHD comorbidity (n = 144, 39.5%) with their ADHD-free opponents. The clinical course and treatment outcomes of each patient were evaluated based on 4-year clinical follow-up data. Results: Substantial clinical variations in pediatric OCD caused by ADHD comorbidity were identified, including a male preponderance, higher rates of concurrent conduct problems, tic disorders, and learning disabilities, as well as prolonged symptom and treatment durations accompanied by poor response to first-line treatments and higher rates of treatment resistance. Contrary to previous findings, ADHD comorbidity had no impact on the age of OCD onset, and the severity of OCD symptoms was lower in ADHD. With ADHD comorbidity, the OCD symptom course tended to be chronically stable, which may have resulted in complaints persisting into adulthood. In ADHD-free patients, contamination, doubt, religious, somatic obsessions, and cleaning were all more common than in those with ADHD. There was a positive correlation between compulsion scores and the severity of ADHD symptoms, which may be related to increased compulsive coping in ADHD. Impulsivity or compulsivity dominance in the symptom presentation of OCD-ADHD comorbidity may determine phenomenological distinctions such as whether concurrent traits are more prone to tics, conduct problems, or internalizing problems. The primordial associations for clinical characteristics, which were independently associated with ADHD comorbidity, were adjusted using multivariate logistic regression analysis. Clinical variables such as being male, absence of cleaning compulsion, the existence of concurrent conduct problems, tic disorders, and dyslexia, as well as longer treatment duration and poorer treatment response, were all independent predictors of ADHD comorbidity. With an 80.8% accurate classification and relatively fine goodness-of-fit model, the regression model consisting of those predictors had good predictiveness for ADHD comorbidity (R² = 0.543). Conclusions: The close association between pediatric OCD, ADHD, and tic disorders can be defined as a specific subtype of pediatric OCD, characterized by more conduct problems, a chronically stable course of OCD symptoms, and poorer treatment outcomes. Correlational analyses in a longitudinal design and the inclusion of an impulsivity scale would be beneficial for further research to interpret the impulsivity-related correlates in the findings on tic and conduct problems.

Withdrawing methylphenidate in relation to serum levels of ferritin and zinc in children and adolescents with attention-deficit/hyperactivity disorder

Iron and zinc have been associated with attention-deficit/hyperactivity disorder (ADHD), executive functioning, and response to methylphenidate, given their link with the dopaminergic system. This study aimed to investigate the effect of withdrawing methylphenidate after long-term treatment on serum levels of ferritin and zinc; and if baseline (pre-discontinuation) serum levels of these nutritional markers moderated the effects of withdrawing methylphenidate on ADHD and oppositional defiant disorder (ODD) symptoms, and working memory. Blood samples were collected from 63 children and adolescents who participated in a randomized, placebo-controlled methylphenidate discontinuation study. They were assigned to either seven weeks of continued treatment with methylphenidate or to gradual withdrawal to placebo. With mixed models for repeated measures we (i) compared changes in ferritin and zinc serum levels between both groups, and (ii) investigated moderating effects of ferritin and zinc on the effects of discontinuation on ADHD and ODD symptoms, and working memory. We additionally explored correlations of baseline and change serum levels with respective symptom scores. Withdrawing methylphenidate led to a decrease in ferritin levels. Higher baseline ferritin was associated with a larger increase (i.e., worsening) of teacher-rated hyperactivity-impulsivity and ODD symptoms after withdrawal; and higher baseline zinc with a larger increase in number of errors on the working memory task after withdrawal. Serum levels did not correlate with ADHD and ODD symptoms. Our preliminary results suggest that ferritin and zinc may be potential biomarkers for the effectiveness of long-term treatment with methylphenidate.

Altered Arginine/Nitric Oxide Pathway in Children Diagnosed Attention Deficit Hyperactivity Disorder, and the Effect of 10 Weeks Methylphenidate Treatment

Objective

In this study, we investigated the levels of arginine, nitric oxide (NO), asymmetric dimethylarginine (ADMA), and adrenomedullin that are presumed to play a role in attention deficit hyperactivity disorder (ADHD) etiology, and to compare the findings with healthy controls.

Methods

Thirty ADHD patients and thirty healthy control subjects aged 6−12 years were included in the study. Sociodemographic data form, Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version; Conners’ Parent/Teacher Rating Scale-Revised Long Form; Children’s Depression Inventory; and The State-Trait Anxiety Inventory for Children were applied to all cases. All participants included in the study were evaluated in terms of their serum arginine, NO, ADMA, and adrenomedullin levels. Subsequently, methylphenidate treatment was started in ADHD patients and blood parameters were tested again in the tenth week of treatment.

Results

At the start of the study, arginine and ADMA levels were significantly higher and NO and adrenomedullin levels were significantly lower in the ADHD group compared to the control group. Post-treatment arginine and ADMA levels were found to be significantly lower than in the pre-treatment period. There were no significant differences in NO and adrenomedullin levels before and after treatment. There was no correlation between scale scores and blood parameters.

Conclusion

These variations in the blood parameters of the ADHD group seem to be worth further investigation. Studies to be conducted with larger sample groups after longer-term treatment may provide new information about the alterations in neurobiological processes related to ADHD etiology and treatment.

The effect of Rosa canina L. and a polyherbal formulation syrup in patients with attention-deficit/hyperactivity disorder: a study protocol for a multicenter randomized controlled trial

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral disorder in childhood and adolescence. A number of these patients do not respond to the current pharmacological treatments and there may also be drug side effects. This study aims to determine the efficacy and safety of two herbal medicine products, including Rosa canina L. (RC) and a polyherbal formulation (PHF) syrup, on the clinical manifestations of ADHD in children and adolescents.

METHODS

Ninety ADHD patients based on DSM-5 diagnostic criteria will be randomly assigned equally into three groups: (1) RC syrup + methylphenidate (MP), (2) PHF syrup + MP, and (3) placebo + MP according to the inclusion criteria (30 subjects in each group). The syrup dosage is 5cc every 8 h, and MP will have a stabilized dose for 8 weeks during the study. Moreover, Conner's questionnaires will be completed by the teacher and parents before the intervention and then every 4 weeks. Also, the Child Symptom Inventory-fourth edition (CSI-4) and temperament questionnaires will be completed before the intervention and every 4 weeks until 2 months.

DISCUSSION

This trial is the first experiment to determine the effects of RC and PHF syrups on the clinical manifestations of ADHD in children and adolescents. Our findings provide new insight into the effect of these herbal products on the clinical manifestations of ADHD.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20190923044855N1 . Registered on 14 January 2020. The trial was registered at https://www.irct.ir/ .

Role of calcium metabolism in ADHD: The relationship between parathyroid hormone and ADHD symptom severity

BACKGROUND

Vitamin D has been found to be associated with the pathogenesis of attention deficit hyperactivity disorder (ADHD). However, the potential role of parathyroid hormone (PTH) is still unclear.

AIM

We aimed to investigate the association between calcium metabolism and ADHD symptomatology.

METHODS

We included 106 participants aged between 7 and 13 years old (51 ADHD patients, mean age: 9.54 ± 1.77, 55 healthy controls mean age: 9.97 ± 0.94) to this study. K-SADS-PL and Conners' Parent/Teacher Rating Scales, Stroop Test were performed. Blood samples to measure serum levels of Vitamin D, PTH, calcium (Ca), magnesium (Mg), phosphorus (P), and alkaline phosphatase (ALP) were collected in the spring (March-April-May) to prevent seasonal variability.

RESULTS

PTH, P, and ALP values were significantly lower and Vitamin D, Ca, and Mg values were significantly higher in the ADHD group (P < 0.05, for all). Both groups had Vitamin D deficiency. Control group has lower Vitamin D levels than the ADHD group (respectively; 17.66 ± 9.07, 21.99 ± 10.99, P < 0.05). There was a negative correlation between PTH and CTRS hyperactivity, CGI-RI and CGI-EL sub-scores, CGI-Total, DSM-IV-Inattention, DSM-IV Hyperactivity/Impulsivity, DSM-IV-Total scores (P < 0.05, for all).

CONCLUSIONS

We found lower PTH levels in ADHD patients and a strong and negative correlation between PTH and symptom severity. Future studies are needed to clarify if these findings are due to the key role of PTH in ADHD pathology or PTH's function in activating vitamin D.

Influence of sex on tic severity and psychiatric comorbidity profile in patients with pediatric tic disorder

AIM

To investigate sex-related differences in tic severity, tic-related impairments, and psychiatric comorbidities in childhood.

METHOD

In this cross-sectional study, tic severity/impairment and demographic factors were collected from 270 children and young people (aged 5-17y, mean 10y 6mo, SD 3y 4mo; 212 males and 58 females) with a tic disorder diagnosis at a specialty clinic. Psychiatric diagnoses and corresponding screening questionnaire scores were collected for attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), major depressive disorder, and anxiety disorders. Logistic regression was used to compare the effect of sex and age on psychiatric comorbid diagnoses. The Mann-Whitney U test and t-tests were used to assess differences in questionnaire score distribution between sexes.

RESULTS

Females had more severe motor tics (12.55 vs 10.81, p=0.01) and higher global severity scores (38.79 vs 32.66, p=0.03) on the Yale Global Tic Severity Scale. Females were less likely to be diagnosed with ADHD (odds ratio=0.48, 95% confidence interval=0.26-0.89). No significant sex difference was observed in diagnosis rates or symptom severity scores for anxiety or OCD. Females had significantly higher scores than males on the Children's Depression Inventory, Second Edition.

INTERPRETATION

The higher level of motor tic severity and global severity in females further supports the differential natural history of tic disorders in females. Females with tic disorders may be underdiagnosed for ADHD.

A network perspective on abnormal child behavior in primary school students

Abnormal child behavior is a complex entity including among others disorders such as ADHD, a neuropsychiatric disorder interfering with the normal development of the child, and combining many comorbidities. There are no specific tools designed to assess abnormal child behavior, although well-known ADHD screening tools such as the CTRS-R:S go beyond the disorder itself and cover the wider construct. This can be understood as the complex system of mutually influencing entities, that is why the aim of this study was to investigate the items of the CTRS-R:S as a psychological network. We analyzed a data set of 525 children in French-speaking primary schools from Belgium, and estimated a Bayesian Gaussian Graphical Model with a Bayes Factor of 30. We identified highly connected nodes from each community of the CTRS-R:S to build an additional network of communities. In the domain network, Oppositional and Cognitive skills share the strongest connection in the network. The 28-item network was overall positively connected albeit the presence of some negative connections. The spinglass algorithm identified eight domains in the CTRS-R:S network that causally influence each other. The network approach is a useful framework to investigate the domains of abnormal child behavior as well as the interplay between individual symptoms.

The effects of stimulant dose and dosing strategy on treatment outcomes in attention-deficit/hyperactivity disorder in children and adolescents: a meta-analysis

Clinical guidelines currently recommend practitioners titrate stimulant medications, i.e., methylphenidate (MPH) and amphetamines (AMP), to the dose that maximizes symptom control without eliciting intolerable adverse events (AEs) when treating attention-deficit/hyperactivity disorder (ADHD) in school-aged children/adolescents. However, robust evidence-base regarding the effects of doses and dosing strategies of stimulants on clinical outcomes in the treatment of children/adolescents with ADHD is currently lacking and stimulants are often underdosed in clinical practice. To address this gap and provide rigorous evidence-base in relation to the dose and dosing strategy of stimulants, we conducted the largest systematic review and dose-response meta-analysis examining change in ADHD symptoms (efficacy), and treatment discontinuations due to AEs (tolerability) and any reason (acceptability). We conducted one-stage random-effects dose-response meta-analyses examining MPH and AMP separately, stratifying trials based on fixed-dose and flexible-dose design. Daily doses of stimulants were converted to MPH- and AMP-equivalent doses by adjusting for different pharmacokinetics across formulations. We also conducted pairwise meta-analyses to provide indirect comparisons between flexible-dose versus fixed-dose trials. Our study included 65 RCTs involving 7 877 children/adolescents. Meta-analyses of fixed-dose trials for both MPH and AMP demonstrated increased efficacy and increased likelihood of discontinuation due to AEs with increasing doses of stimulants. The incremental benefits of stimulants in terms of efficacy decreased beyond 30 mg of MPH or 20 mg of AMP in fixed-dosed trials. In contrast, meta-analyses of flexible-dose trials for both MPH and AMP demonstrated increased efficacy and reduced likelihood of discontinuations for any reason with increasing stimulant doses. The incremental benefits of stimulants in terms of efficacy remained constant across the FDA-licensed dose range for MPH and AMP in flexible-dose trials. Our results suggest that flexible titration as needed, i.e., considering the presence of ADHD symptoms, and tolerated, i.e., considering the presence of dose-limiting AEs, to higher doses of stimulants is associated with both improved efficacy and acceptability because practitioners can increase/reduce doses based on control of ADHD symptoms/dose-limiting AEs. Although fixed-dose trials that are required by the FDA are valuable to characterize dose-dependency, they may underestimate the true potential benefit of trialing dose-increases of stimulants in clinical practice by not allowing dose adjustment based on response and tolerability. Additional research is required to investigate potential long-term effects of using high doses of stimulants in clinical practice.

Effects of family history of substance use disorder on reward processing in adolescents with and without attention-deficit/hyperactivity disorder

Patients with attention‐deficit/hyperactivity disorder (ADHD) often develop early onset substance use disorder (SUD) and show poor treatment outcomes. Both disorders show similar reward‐processing alterations, but it is unclear whether these are associated with familial vulnerability to SUD. Our aim was to investigate effects of family history of SUD (FH) on reward processing in individuals with and without ADHD, without substance misuse. Behavioural and functional magnetic resonance imaging (fMRI) data from a modified monetary incentive delay task were compared between participants with and without FH (FH positive [FH+]: n = 76 and FH negative [FH−]: n = 69; 76 with ADHD, aged 16.74 ± 3.14, 82 males), while accounting for continuous ADHD scores. The main analysis showed distinct positive association between ADHD scores and reaction times during neutral versus reward condition. ADHD scores were also positively associated with anticipatory responses of dorsolateral prefrontal cortex, independent of FH. There were no main FH effects on brain activation. Yet, FH+ participants showed distinct neural alterations in ventrolateral prefrontal cortex (VLPFC), dependent on ADHD. This was driven by positive association between ADHD scores and VLPFC activation during reward outcome, only in FH+. Sensitivity analysis with stricter SUD index showed hyperactivation of anterior cingulate cortex for FH+, independent of ADHD, during reward anticipation. There were no FH or ADHD effects on activation of ventral striatum in any analysis. Findings suggest both FH and ADHD effects in circuits of reward and attention/memory during reward processing. Future studies should examine whether these relate to early substance use initiation in ADHD and explore the need for adjusted SUD prevention strategies.

Amygdala reactivity and ventromedial prefrontal cortex coupling in the processing of emotional face stimuli in attention-deficit/hyperactivity disorder

Impaired emotion recognition is common in individuals with attention-deficit/hyperactivity disorder (ADHD) and may, via deficient emotion self-regulation, relate to the frequently co-occurring affective and social problems. The present study used an emotional face-matching task and functional magnetic resonance imaging (fMRI) to investigate neural responses during the processing of angry and fearful faces and visuo-spatial control stimuli. Additionally, measures for emotion dysregulation, ADHD type, and age were investigated in relation to the behavioral and neural fMRI data. We utilized a sample of 61 adolescents/young adults with ADHD and 51 age-matched healthy controls (age range: 12-28 years). Participants with ADHD had higher emotion dysregulation scores than controls. They also reacted slower and less accurate in response to emotional but not visuo-spatial control stimuli. Neural response differences between emotional and visuo-spatial trials were significantly smaller in cases, particularly in the left amygdala. While coupling between the right amygdala and bilateral ventromedial prefrontal cortex was stronger for emotional than visuo-spatial stimuli in control subjects, levels of positive coupling between the trial types did not significantly differ in participants with ADHD. Neither emotion dysregulation scores, nor ADHD type or age were related to the behavioral and neural processing alterations during the emotional face-matching task. Results indicate that emotion recognition deficits in ADHD are particularly associated with lower amygdala activation to emotional stimuli and alterations in the functional connections of the amygdala to medial prefrontal areas. Emotion recognition deficits and associated neural alterations were unrelated to emotion dysregulation, ADHD type, or age.

The Efficacy of Visual Activity Schedule Intervention in Reducing Problem Behaviors in Children With Attention-Deficit/Hyperactivity Disorder Between the Age of 5 and 12 Years: A Systematic Review

Objectives

Children with attention-deficit/hyperactivity disorder (ADHD) tend to be noisy and violate rules with their disruptive behaviors, resulting in greater difficulties with off-task behaviors and being at risk for social refusal. The visual activity schedule (VAS) intervention program is a frequently used method to teach multiple skills involving on-task, use of schedules, transition behaviors, social initiation, independent play skills, classroom skills, and academic skills. The current systematic review aimed to examine the efficacy of using VAS intervention in reducing problem behaviors in children with ADHD between 5 and 12 years of age.

Methods

Systematic searches were conducted using two electronic databases (PubMed and Scopus) to identify relevant studies published in English between 2010 and 2020. Four studies met the inclusion criteria: two studies examined the effect of schedule-based tasks and the use of an iPad on classroom skills, while the other two examined randomized clinical trials (RCTs) of psychosocial treatment for ADHD inattentive type and a cross-sectional study examined the impact of the group size on task behavior and work productivity in children with ADHD.

Results

The findings indicate that the interventions used in all four studies could lead to increased satisfaction among participants and parents, as well as a reduction in problem behavior. In terms of the research indicators, the RCT had low quality, while the others were of high quality.

Conclusion

A larger number of studies and the ADHD clinical population would help to increase the generalizability of future reviews of treatments in this context.

Effects of substance misuse on inhibitory control in patients with attention-deficit/hyperactivity disorder

Patients with attention‐deficit/hyperactivity disorder (ADHD) are often diagnosed with comorbid substance misuse (SM), which is associated with poor treatment efficacy. Although literature indicates similar inhibitory control deficits in both conditions, it is unclear whether SM in ADHD exaggerates pre‐existing deficits, with additive or distinct impairments in patients. Our aim was to examine SM effects on inhibitory control in ADHD. Behavioural and functional magnetic resonance imaging (fMRI) data from a stop‐signal task were compared across ADHD patients with and without SM (ADHD + SM and ADHD‐only, respectively) and controls (n = 33/group; 79 males, mean age 18.02 ± 2.45). To limit substance use disorder (SUD) trait effects, groups were matched for parental SUD. Overall, we found worse performance for ADHD‐only and/or ADHD + SM compared with controls but no difference between the ADHD groups. Moreover, the ADHD groups showed decreased frontostriatal and frontoparietal activity during successful and failed stop trials. There were no differences between the ADHD groups in superior frontal nodes, but there was more decreased activation in temporal/parietal nodes in ADHD‐only compared with ADHD + SM. During go‐trials, ADHD + SM showed decreased activation in inferior frontal nodes compared with ADHD‐only and controls. Findings during response inhibition showed deficits in inhibition and attentional processes for ADHD patients with and without SM. Despite no evidence for SM effects during response inhibition, results during go‐trials suggest distinct effects on nodes that are associated with several executive functions. Future studies should investigate whether distinct deficits in ADHD + SM relate to poor treatment results and can direct development of distinct ADHD treatment strategies for these patients.

Physical development and mental health in South African perinatally HIV-positive adolescents on antiretroviral therapy and their caregivers with and without household food insecurity

Background

Perinatally acquired HIV-infected (PHIV+) adolescents have shown impairments in neurocognitive function and mental health problems compared with their peers. The contribution of food insecurity to such impairments has not been explored.

Objectives

The aim of this report has been to explore the contribution of food insecurity to neurocognitive impairment and mental health problems in adolescents with perinatally-acquired HIV infection.

Method

A total of 248 PHIV+ adolescents and healthy controls aged between 9 and 12 years completed a neuropsychological battery, the Childhood Behaviour Checklist (CBCL) and the Becks Youth Inventory. Head circumference, body mass index (BMI), height for age (HAZ), Tanner pubertal staging, albumin, haemoglobin, CD4 and viral loads were also measured. Participants’ caregivers were interviewed about their mental health and household food security. T-tests were used to assess for differences in food secure and food insecure households.

Results

Caregivers of PHIV+ adolescents reported higher levels of depressive symptoms and household food insecurity. Increased food insecurity was associated with more behavioural problems in adolescents, as well as lower haemoglobin and albumin levels, faster processing speed and increased Tanner staging in boys. Body mass index and HAZ were not affected by food insecurity.

Conclusion

These findings suggest that household food insecurity is associated with some altered behavioural, physical and physiological outcomes, which could complicate and compound the existing difficulties in PHIV+ households.

Effects of Parent-Teacher Training on Academic Performance and Parental Anxiety in School-Aged Children With Attention-Deficit/Hyperactivity Disorder: A Cluster Randomized Controlled Trial in Shanghai, China

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common chronic neurodevelopmental disorder in childhood, placing a heavy burden on family and society. The treatment of school-aged children with ADHD emphasizes multimodal interventions, but most current research focuses solely on parent training and family functioning. The aim of this study was to examine the effect of parent-teacher training on academic performance and parental anxiety. In an open-label cluster randomized controlled trial from January 2018 to January 2019, 14 primary schools in Shanghai were randomly assigned into the intervention group and the control group, and ADHD screening was conducted for students from grades one to five. Children in both groups received medication as prescribe by their pediatricians. In the intervention group, families and teachers also received parent-teacher training. The training included ADHD behavioral interventions for parents, as well as classroom management skills for teachers. This study screened 9,295 students, 99 children in the control group and 105 children in the intervention group were included in the analysis. The intervention group demonstrated significant improvement in ADHD symptoms and academic performance and decreases in parent stress compared to that in the control group (P < 0.05). This training improved the parents' perception of ADHD knowledge, treatment options, and drug side effects awareness (P < 0.05). Our study aims to underscore the suitability of such programs in the local nuances of the Chinese context, show application feasibility to pediatricians and psychiatrists, and provide supporting evidence for their utilization within the country's health and educational systems.

Emotion dysregulation and integration of emotion-related brain networks affect intraindividual change in ADHD severity throughout late adolescence

The course of attention deficit hyperactivity disorder (ADHD) from adolescence into adulthood shows large variations between individuals; nonetheless determinants of interindividual differences in the course are not well understood. A frequent problem in ADHD, associated with worse outcomes, is emotion dysregulation. We investigated whether emotion dysregulation and integration of emotion-related functional brain networks affect interindividual differences in ADHD severity change. ADHD severity and resting state neuroimaging data were measured in ADHD and unaffected individuals at two points during adolescence and young adulthood. Bivariate latent change score models were applied to investigate whether emotion dysregulation and network integration affect ADHD severity changes. Emotion dysregulation was gauged from questionnaire subscales for conduct problems, emotional problems and emotional lability. Better emotion regulation was associated with a better course of ADHD (104 participants, 44 females, age range: 12-27). Using graph analysis, we determined network integration of emotion-related functional brain networks. Network integration was measured by nodal efficiency, i.e., the average inverse path distance from one node to all other nodes. A pattern of low nodal efficiency of cortical regions associated with emotion processing and high nodal efficiency in subcortical areas and cortical areas involved in implicit emotion regulation predicted a better ADHD course. Larger nodal efficiency of the right orbitofrontal cortex was related to a better course of ADHD (99 participants, 42 females, age range: 10-29). We demonstrated that neural and behavioral covariates associated with emotion regulation affect the course of ADHD severity throughout adolescence and early adulthood beyond baseline effects of ADHD severity.

Gaboxadol in Fragile X Syndrome: A 12-Week Randomized, Double-Blind, Parallel-Group, Phase 2a Study

Background: Fragile X syndrome (FXS), the most common single-gene cause of intellectual disability and autism spectrum disorder (ASD), is caused by a >200-trinucleotide repeat expansion in the 5' untranslated region of the fragile X mental retardation 1 (FMR1) gene. Individuals with FXS can present with a range of neurobehavioral impairments including, but not limited to: cognitive, language, and adaptive deficits; ASD; anxiety; social withdrawal and avoidance; and aggression. Decreased expression of the γ-aminobutyric acid type A (GABA_A) receptor δ subunit and deficient GABAergic tonic inhibition could be associated with symptoms of FXS. Gaboxadol (OV101) is a δ-subunit-selective, extrasynaptic GABA_A receptor agonist that enhances GABAergic tonic inhibition, providing the rationale for assessment of OV101 as a potential targeted treatment of FXS. No drug is approved in the United States for the treatment of FXS. Methods: This 12-weeks, randomized (1:1:1), double-blind, parallel-group, phase 2a study was designed to assess the safety, tolerability, efficacy, and optimal daily dose of OV101 5 mg [once (QD), twice (BID), or three-times daily (TID)] when administered for 12 weeks to adolescent and adult men with FXS. Safety was the primary study objective, with key assessments including treatment-emergent adverse events (TEAEs), treatment-related adverse events leading to study discontinuation, and serious adverse events (SAEs). The secondary study objective was to evaluate the effect of OV101 on a variety of problem behaviors. Results: A total of 23 participants with FXS (13 adolescents, 10 adults) with moderate-to-severe neurobehavioral phenotypes (Full Scale Intelligence Quotient, 41.5 ± 3.29; ASD, 82.6%) were randomized to OV101 5 mg QD (n = 8), 5 mg BID (n = 8), or 5 mg TID (n = 7) for 12 weeks. OV101 was well tolerated across all 3 treatment regimens. The most common TEAEs were upper respiratory tract infection (n = 4), headache (n = 3), diarrhea (n = 2), and irritability (n = 2). No SAEs were reported. Improvements from baseline to end-of-treatment were observed on several efficacy endpoints, and 60% of participants were identified as treatment responders based on Clinical Global Impressions-Improvement. Conclusions: Overall, OV101 was safe and well tolerated. Efficacy results demonstrate an initial signal for OV101 in individuals with FXS. These results need to be confirmed in a larger, randomized, placebo-controlled study with optimal outcomes and in the most appropriate age group. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03697161.

Sex differences in anxiety and depression in children with attention deficit hyperactivity disorder: Investigating genetic liability and comorbidity

It is unknown why attention deficit hyperactivity disorder (ADHD) is more common in males, whereas anxiety and depression show a female population excess. We tested the hypothesis that anxiety and depression risk alleles manifest as ADHD in males. We also tested whether anxiety and depression in children with ADHD show a different etiology to typical anxiety and depression and whether this differs by sex. The primary clinical ADHD sample consisted of 885 (14% female) children. Psychiatric symptoms were assessed using standardized interviews. Polygenic risk scores (PRS) were derived using large genetic studies. Replication samples included independent clinical ADHD samples (N = 3,794; 25.7% female) and broadly defined population ADHD samples (N = 995; 33.4% female). We did not identify sex differences in anxiety or depression PRS in children with ADHD. In the primary sample, anxiety PRS were associated with social and generalized anxiety in males, with evidence of a sex-by-PRS interaction for social anxiety. These results did not replicate in the broadly defined ADHD sample. Depression PRS were not associated with comorbid depression symptoms. The results suggest that anxiety and depression genetic risks are not more likely to lead to ADHD in males. Also, the evidence for shared etiology between anxiety symptoms in those with ADHD and typical anxiety was weak and needs replication.

Transcranial Direct Current Stimulation Improves Reward Processing in Children With ADHD

Objective: Individuals with ADHD have deficits in reward processing and related cognitive tasks such as delay discounting and risky decision-making. The ventromedial prefrontal cortex (vmPFC) and dorsolateral prefrontal cortex (dlPFC) are two distinct cortical areas that are involved in reward processing. Methods: Twenty children with ADHD received transcranial direct current stimulation (tDCS) in three separate sessions with one of three montages each, including anodal/cathodal tDCS over the left dlPFC and right vmPFC respectively, the reversed montage, and a sham stimulation condition. During stimulation, in each session, participants performed the balloon analogue risk taking and chocolate delay discounting tasks. Results: A significant effect of stimulation condition on emotional processing was observed. Specifically, anodal tDCS over the right vmPFC, coupled with cathodal tDCS over the left dlPFC, reduced risky decision-making and delay discounting. Conclusion: These results imply that the left dlPFC and right vmPFC are involved in reward processing in children with ADHD. This finding is discussed in the light of the delay aversion theory of ADHD.

Sex-dependent complex association of TPH2 with multiple dimensions of ADHD

BACKGROUND

Tryptophan hydroxylase 2 (TPH2) is a key enzyme in the biosynthesis of serotonin in the brain. This study aims to investigate the role of a functional variant in TPH2 (rs17110747) in the pathophysiology of ADHD. This variant has been implicated in mood disorders in recent meta-analysis. This study uses a comprehensive approach that combines association testing and pharmaco-dynamic evaluation of behaviour, in a large sample of children with ADHD (n = 570).

METHODS

The association between various ADHD relevant traits and rs17110747 was analyzed using family-based association tests (FBAT). Children were assessed by parents, teachers and research staff under three experimental conditions (EC): baseline, placebo, and methylphenidate using a double-blind placebo-controlled crossover trial.

OUTCOMES

FBAT analysis conducted in a sample stratified based on sex of the proband, showed that there was a highly significant overtransmission of the G allele from parents to affected girls. In addition, significant association with several behavioral and cognitive dimensions of ADHD was observed only when the proband was female. Further, girls with the G/G genotype (rs17110747) had greater response to placebo when evaluated by parents.

INTERPRETATION

These results suggest that there may be a complex association of TPH2 in the etiology of ADHD, with a sex-specific effect.

Maternal serotonin transporter genotype and offsprings' clinical and cognitive measures of ADHD and ASD

Serotonin (5-HT) is an important factor for prenatal neurodevelopment whereby its neurotrophic actions can be regulated through maternal-fetal interactions. We explored if maternal 5-HTTLPR genotype is associated with clinical and cognitive measures of attention-deficit/hyperactivity disorder (ADHD) and comorbid autism spectrum disorder (ASD) in typically-developing and ADHD-diagnosed offspring, beyond classical inheritance and environmental- and comorbidity-mediators/confounders. Family-based variance decomposition analyses were performed incorporating 6-31 year-old offsprings' as well as parental genotypes of 462 ADHD and control families from the NeuroIMAGE cohort. Dependent measures were offsprings' ADHD symptom- and ASD trait-scores and cognitive measures including executive functioning (including response inhibition and cognitive flexibility), sustained attention, reward processing, motor control, and emotion recognition. Offsprings' stereotyped behavior was predicted by an interaction between maternal 5-HTTLPR genotype and offsprings' sex. Furthermore, offspring of mothers with low-expressing genotypes demonstrated larger reward-related reductions in reaction time. While specifically adult male offspring of these mothers reported a faster reversal learning with less errors, specifically young female offspring of these mothers were more accurate in identifying happy faces. Adult offspring from the mothers with low-expressing 5-HTTLPR genotypes were also slower in identifying happy faces. However, this association seemed to be mediated by offsprings' high anxiety levels. In sum, we found some support for a role of the maternal 5-HT system in modulating fetal brain development and behavior. Offsprings' cognitive measures might be more sensitive to small alterations within the maternal 5-HT system than their ADHD and ASD clinical phenotypes. Further studies are needed to specify the association between maternal genotype and risk for neurodevelopmental disorders.

Gestational Age at Term and Educational Outcomes at Age Nine

OBJECTIVES

To estimate associations between gestational age (GA) and teacher-reported academic outcomes at age 9 years among children born at term (37-41 weeks).

METHODS

A secondary data analysis of 1405 children participating in a national US birth cohort study was conducted. At age 9 years, students were evaluated by their teachers in the areas of mathematics, science and social studies, and language and literacy. Unadjusted and adjusted logistic regression models of associations between GA and teacher-reported academic outcomes were estimated and neonatal morbidities were explored as potential pathways.

RESULTS

A continuous measure of GA in weeks was significantly associated with above-average rankings in all areas. The associations were similar across outcomes (eg, mathematics [odds ratio (OR): 1.13; confidence interval (CI): 1.02-1.25], science and social studies [OR: 1.13; CI: 1.01-1.26], and language and literacy [OR: 1.16; CI: 1.05-1.28]) in a model that adjusted for child sex, maternal characteristics, and obstetric risk factors and delivery complications. Other specifications indicate a positive association between late term (41 weeks) and mathematics and a negative association between early term (37-38 weeks) and language and literacy, compared with term (39-40). The associations did not appear to operate through neonatal morbidity.

CONCLUSIONS

The findings highlight the importance of GA, even at term. Whereas current guidelines suggest waiting until at least 39 weeks to deliver when possible, our findings add to a small group of studies suggesting that GA through 41 weeks is associated with improvements in some educational outcomes.

Functional network topology of the right insula affects emotion dysregulation in hyperactive-impulsive attention-deficit/hyperactivity disorder

Emotion dysregulation is common in attention-deficit/hyperactivity disorder (ADHD). It is highly prevalent in young adult ADHD and related to reduced well-being and social impairments. Neuroimaging studies reported neural activity changes in ADHD in brain regions associated with emotion processing and regulation. It is however unknown whether deficits in emotion regulation relate to changes in functional brain network topology in these regions. We used a combination of graph analysis and structural equation modelling (SEM) to analyze resting-state functional connectivity in 147 well-characterized young adults with ADHD and age-matched healthy controls from the NeuroIMAGE database. Emotion dysregulation was gauged with four scales obtained from questionnaires and operationalized through a latent variable derived from SEM. Graph analysis was applied to resting-state data and network topology measures were entered into SEM models to identify brain regions whose local network integration and connectedness differed between subjects and was associated with emotion dysregulation. The latent variable of emotion dysregulation was characterized by scales gauging emotional distress, emotional symptoms, conduct symptoms, and emotional lability. In individuals with ADHD characterized by prominent hyperactivity-impulsivity, the latent emotion dysregulation variable was related to an increased clustering and local efficiency of the right insula. Thus, in the presence of hyperactivity-impulsivity, clustered network formation of the right insula may underpin emotion dysregulation in young adult ADHD.

The effect of sleep deprivation and restriction on mood, emotion, and emotion regulation: three meta-analyses in one

STUDY OBJECTIVES

New theory and measurement approaches have facilitated nuanced investigation of how sleep loss impacts dimensions of affective functioning. To provide a quantitative summary of this literature, three conceptually related meta-analyses examined the effect of sleep restriction and sleep deprivation on mood, emotion, and emotion regulation across the lifespan (i.e. from early childhood to late adulthood).

METHODS

A total of 241 effect sizes from 64 studies were selected for inclusion, and multilevel meta-analytic techniques were used when applicable.

RESULTS

There was a moderate, positive effect of sleep loss on negative mood (g = 0.45), which was stronger for studies with younger samples, as well as a large, negative effect of sleep loss on positive mood (g = -0.94). For negative mood only, studies that used total sleep deprivation had larger effect sizes than studies that restricted sleep. After correcting for publication bias, a modest but significant negative effect for sleep loss on emotion (g = -0.11) was found; the valence of emotional stimuli did not change the direction of this effect, and type of sleep manipulation was also not a significant moderator. Finally, sleep restriction had a small, negative effect on adaptive emotion regulation (g = -0.32), but no significant impact on maladaptive emotion regulation (g = 0.14); all studies on adaptive emotion regulation were conducted with youth samples.

CONCLUSIONS

Sleep loss compromises optimal affective functioning, though the magnitude of effects varies across components. Findings underscore the importance of sleep for healthy affective outcomes.

A mixed methods study examining neighborhood disadvantage and childhood behavior problems in Montevideo, Uruguay

BACKGROUND

Neighborhood disadvantage (ND) is a risk factor for child behavior problems (CBPs), but is understudied outside the United States and Europe. Our mixed methods study aims to (1) create a culturally meaningful measure of ND, (2) test cross-sectional associations between ND and CBPs and (3) qualitatively explore life in the neighborhoods of families participating in the Salud Ambiental Montevideo (SAM) study.

METHODS

The quantitative study (Study 1) comprised 272, ~7-year-old children with geolocation and complete data on twelve behavioral outcomes (Conner's Teachers Rating Scale - Revised Short Form: CTRS-R:S and Behavioral Rating Inventory of Executive Functioning: BRIEF). A ND factor was created at the census segment level (1,055 segments) with 19 potential indicators of ND downloaded from the Municipality of Montevideo Geographic Services. Children were assigned ND scores based on the location of their household within a census segment. Multilevel models tested associations between ND and all CBP scales, controlling for confounders at the individual level. The qualitative study (Study 2) comprised 10 SAM caregivers. Photovoice alongside semi-structured interviews in Spanish were used to foster conversations about neighborhood quality, activities, and raising children. Thematic analysis with inductive coding was used to summarize qualitative study findings.

RESULTS

The ND factor consisted of 12 census-based indicators related to education, employment, ethnicity, housing quality, and age characteristics, but unrelated to home ownership and some ethnicity variables. In multivariable models, ND was associated with greater conduct problems (β = 1.37, p < .05), poor shifting (β = 1.56, p < .01) and emotional control problems (β = 2.36, p < .001). Photovoice and semi-structured interviews yielded four themes: physical disorder, recreation, safety and crime, and community resources. Residents discussed improving waste management and transportation, updating playgrounds, and ensuring neighborhood safety.

CONCLUSIONS

ND in Montevideo comprised a unique set of census indicators. ND was primarily related to behavioral regulation problems. Hypothesized pathways whereby ND affects CBPs are discussed.

Predictors of Behavioral Changes After Adenotonsillectomy in Pediatric Obstructive Sleep Apnea: A Secondary Analysis of a Randomized Clinical Trial

Importance

Adenotonsillectomy (AT) is associated with improved behavior in children with obstructive sleep apnea (OSA). However, it is unknown whether polysomnographic parameters are superior to the parent-reported severity of sleep-disordered breathing (SDB) in predicting behavioral changes after AT.

Objective

To ascertain whether polysomnographic parameters vs parent-reported severity of SDB are better predictors of treatment-related behavioral changes in children with OSA.

Design, Setting, and Participants

This ad hoc secondary analysis of the Childhood Adenotonsillectomy Trial (CHAT) downloaded and analyzed data from January 1 to January 31, 2020. Children aged 5 to 9 years with a polysomnographic diagnosis of OSA were enrolled in the CHAT and subsequently randomized to undergo either early AT or watchful waiting with supportive care. All outcome measures were obtained at baseline and at follow-up (7 months after randomization).

Interventions

Early AT vs watchful waiting with supportive care.

Main Outcomes and Measures

Postrandomization changes between the baseline and follow-up periods were derived from (1) T scores in 4 validated behavioral assessments (Conners Global Index parent and teacher versions, Behavior Rating Inventory of Executive Function metacognition index, and Child Behavior Checklist of total, internalizing, and externalizing behavior subscales); (2) 8 aggregated polysomnographic parameters representing the severity of obstruction, hypoxemia, sleep quality, and structure; and (3) the parent-reported severity of SDB measured by the Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder (PSQ-SRBD) scale. The treatment-related changes in each of the behavioral outcomes attributable to changes in SDB severity (represented by the subjective PSQ-SRBD score and objective polysomnographic parameters) were measured and compared using mediation analysis.

Results

A total of 453 children were assessed at baseline, of whom 234 were girls (52%) and the mean (SD) age was 6.6 (1.4) years. The postrandomization changes in 7 of 8 behavioral outcome measures between the baseline and follow-up periods were partially mediated by the changes in PSQ-SRBD scores (range of nonzero causally mediated effects, 2.4-3.5), without contribution from any of the polysomnographic parameters.

Conclusions and Relevance

This secondary analysis of a national randomized clinical trial found that most treatment-related behavioral changes in children with OSA were mediated by the changes in parent-reported SDB severity alone. These findings suggest that polysomnographic parameters provide clinicians with limited means to predict the improvement in neurobehavioral morbidity in OSA.

Trial Registration

ClinicalTrials.gov Identifier: NCT00560859.

Cumulative exposure to ADHD medication is inversely related to hippocampus subregional volume in children

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Cumulative exposure to ADHD medication characterized as the product of lifetime duration and dose.

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Medication effects investigated on 51 subregional volumes.

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Smaller hippocampus CA1 volumes associated with higher medication exposure.

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Effects remained when correcting for age and ADHD symptom severity.

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No global effects of medication on cortical thickness or surface area detected.

Background

Although there is some evidence for a normalization of brain structure following exposure to ADHD medication, literature on the effects of duration and dose of continued use on the brain is scarce. Here, we investigated the association between cumulative exposure to medication (range 1 week to 4.69 years) and cortical structures and subcortical volumes in a clinical sample of children with ADHD taking medication (n = 109). To the best of our knowledge, this is the first structural MRI study investigating the effects of cumulative exposure to medication on subregional volumes in children treated for ADHD.

Methods

Cumulative exposure to ADHD medication (CEM) was defined as the product of duration on medication (days) and dose (mg/day), yielding the area under the curve (total mg). Cortical thickness and surface area measurements (CIVET-1.1.12), and subcortical volumes in 51 regions (MAGeT-Brain) were analyzed using general linear modelling.

Results

Significant effects of CEM were found in two subregions of the left hippocampus, the CA1 (df = 95; q = 0.003) and the strata radiatum/lacunosum/moleculare (df = 95; q = 0.003). Specifically, higher CEM was associated with smaller volumes within these subregions. No effects of medication exposure were detected on cortical thickness or surface area.

Conclusions

Although this study is cross-sectional, the results found within this sample of children show that prolonged ADHD medication use at higher doses is significantly associated with smaller hippocampus volumes in specific subregions. More research is required to determine whether these results are reproduced in other samples of children of ADHD, and further, whether these are beneficial or off-target effects of the medication.

Efficacy of the parenting support program on child behavior problems

The study aimed to examine the efficacy of the Parenting Support Program (PSP) for reducing problem behaviors and increasing adaptive behaviors in young children aged 3 to 6. The PSP focuses on effective parenting skills and building positive interactions between parents and their children. Parents of children (n = 18 mothers and 11 fathers) were randomly assigned to an experiment group (EG) and a wait-list (WL) group. The EG attended a total of 12 individually delivered sessions. Data was gathered via parent and teacher report measures, observation and semi-structured interviews. The PSP was effective in increasing adaptive behaviors and decreasing behavior problems in children. The change in the children's score which fulfills the Reliable Change Index criteria in the EG was found to be higher than the WL group. However, fathers reported fewer improvements than mothers in the EG. Qualitative data supported the experimental study results demonstrating the efficacy of the PSP, and met the expectations of parents. Consequently, the PSP could be used as an intervention tool to decrease behavior problems and increase adaptive behaviors in young children.