Attention deficit and hyperactivity symptoms in children with asthma

Omalizumab in combination with subcutaneous immunotherapy for the treatment of multiple allergies associated with attention-deficit/hyperactivity disorder: a case report and a literature review

We describe the case of a 10-year-old boy with asthma (AS), accompanied by allergic rhinitis (AR), food allergy (FA), and combined attention-deficit/hyperactivity disorder (ADHD), who was treated at Shanghai Renji Hospital on 11 July 2020. The efficiency of the previous treatment with salmeterol/ticlosone was poor. Treatment with montelukast sodium resulted in development of neurological symptoms. Treatment with omalizumab in combination with subcutaneous immunotherapy (SCIT) was then initiated in our department based on anti-asthmatic therapy. Symptoms of asthma were completely controlled, and FA and AR symptoms improved. The treatment regimen led to a significant improvement in ADHD symptoms and the overall quality of life of the patient. The literature search was done in the PubMed database using "attention deficit/hyperactivity disorder/ADHD" and "asthma" as keywords, and we identified 47 relevant articles. In conclusion, our results show that treating asthma with omalizumab in combination with salmeterol/ticlosone and SCIT is efficient in controlling symptoms of multiple allergies and may lead to the improvement in ADHD symptoms and the overall quality of life of pediatric patients with ADHD. While current studies suggest that allergic diseases are closely related to ADHD, there is still a lack of studies or case reports of complete treatment protocols to provide clinical clues for management of the disease.

Childhood Physical Health and Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis of Modifiable Factors

Although neurobiologic and genetic factors figure prominently in the development of attention deficit/hyperactivity disorder (ADHD), adverse physical health experiences and conditions encountered during childhood may also play a role. Poor health is known to impact the developing brain with potential lifelong implications for behavioral issues. In attempt to better understand the relationship between childhood physical health and the onset and presence of ADHD symptoms, we summarized international peer-reviewed articles documenting relationships between a select group of childhood diseases or health events (e.g., illnesses, injuries, syndromes) and subsequent ADHD outcomes among children ages 0-17 years. Drawing on a larger two-phase systematic review, 57 longitudinal or retrospective observational studies (1978-2021) of childhood allergies, asthma, eczema, head injury, infection, or sleep problems and later ADHD diagnosis or symptomatology were identified and subjected to meta-analysis. Significant associations were documented between childhood head injuries, infections, and sleep problems with both dichotomous and continuous measures of ADHD, and between allergies with dichotomous measures of ADHD. We did not observe significant associations between asthma or eczema with ADHD outcomes. Heterogeneity detected for multiple associations, primarily among continuously measured outcomes, underscores the potential value of future subgroup analyses and individual studies. Collectively, these findings shed light on the importance of physical health in understanding childhood ADHD. Possible etiologic links between physical health factors and ADHD are discussed, as are implications for prevention efforts by providers, systems, and communities.

The Relationship Between Pediatric Attention-Deficit/Hyperactivity Disorder Symptoms and Asthma Management

PURPOSE

Children with comorbid Attention-Deficit/Hyperactivity Disorder (ADHD) and asthma are at an increased risk for adverse health outcomes and reduced quality of life. The objective of these analyses was to examine if self-reported ADHD symptoms in children with asthma are associated with asthma control, asthma controller medication adherence, quick relief medication use, pulmonary function, and acute healthcare utilization.

METHODS

We analyzed data from a larger study testing a behavioral intervention for Black and Latinx children with asthma aged 10-17 years and their caregivers. Participants completed the Conners-3AI self-report assessment for ADHD symptoms. Asthma medication usage data were collected for 3 weeks following baseline via electronic devices fitted to participants' asthma medications. Other outcome measures included the Asthma Control Test, self-reported healthcare utilization, and pulmonary function measured by spirometry testing.

RESULTS

The study sample consisted of 302 pediatric participants with an average age of 12.8 years. Increased ADHD symptoms were directly associated with reduced adherence to controller medications, but no evidence of mediation was observed. Direct effects of ADHD symptoms on quick-relief medication use, health care utilization, asthma control, or pulmonary function were not observed. However, the effect of ADHD symptoms on emergency room visits was mediated by controller medication adherence.

DISCUSSION

ADHD symptoms were associated with significantly reduced asthma controller medication adherence and indirectly with emergency room visits. There are significant potential clinical implications to these findings, including the need for the development of interventions for pediatric asthma patients with ADHD.

Is Histamine and Not Acetylcholine the Missing Link between ADHD and Allergies? Speer Allergic Tension Fatigue Syndrome Re-Visited

Speer allergic tension-fatigue syndrome (SATFS) is a classic allergy syndrome characterized by allergy-like symptoms, muscle tension, headaches, chronic fatigue, and other particular behaviors that were initially described in the fifties. The particular behaviors displayed include symptoms such as hyperkinesis, hyperesthesia (i.e., insomnia), restlessness, and distractibility, among others. Interestingly, these symptoms are very similar to descriptions of attention deficit hyperactivity disorder (ADHD), the most prevalent neurodevelopmental disorder worldwide, which is characterized by inattention, hyperactivity, and impulsivity. The clinical description of SATFS precedes the nomination of ADHD in 1960 by Stella Chess. In this conceptual paper, we stress that there is a gap in the research on the relationship between ADHD and allergic pathologies. The hypotheses of this conceptual paper are (1) SATFS is probably one of the first and best historical descriptions of ADHD alongside a common comorbidity (allergy) displayed by these patients; (2) SATFS (ADHD) is a systemic disease that includes both somatic and behavioral manifestations that may influence each other in a bidirectional manner; (3) The role of neuroinflammation and histamine is key for understanding the pathophysiology of ADHD and its frequent somatic comorbidities; (4) The deficiency of the diamine oxidase (DAO) enzyme, which metabolizes histamine extracellularly, may play a role in the pathophysiology of ADHD. Decreased DAO activity may lead to an accumulation of histamine, which could contribute to core ADHD symptoms and comorbid disorders. Further empirical studies are needed to confirm our hypotheses.

Evaluation of the frequency of attention deficit hyperactivity disorder in patients with asthma

BACKGROUND

Asthma is the most prevalent respiratory disease caused by chronic airway inflammation. Attention Deficit Hyperactivity Disorder (ADHD) is children's most common psychological and neurodevelopmental disorder. Increased risk for ADHD in patients with inflammatory and autoimmune diseases supports the role of inflammatory mechanisms in the occurrence of ADHD. However, the association between asthma and ADHD remains unclear.

OBJECTIVE

This study was designed to evaluate the prevalence of ADHD in patients with asthma who were referred to the clinic of allergy and clinical immunology.

METHODS

This cross-sectional study was conducted on children aged 6 to 18 with asthma at Imam Ali hospital, Karaj, Iran. The patient's demographic data, history of childbirth delivery type, premature birth, hospital admission, family income, birth rate, and family history information related to the patient's asthma and medicines were recorded. ADHD diagnosis was made using the Persian version of Conners Parent Behavioral Problems Rating Scale (CPRS-26).

RESULTS

In this study, 677 asthmatic patients were enrolled; 46 patients (6.8%) had ADHD. The probability of ADHD in asthmatic patients inhabited in a rural area, males, and patients with a history of food allergy, allergic rhinitis, urticaria, and eczema was significantly higher (p < 0.05). In addition, our result demonstrated that the likelihood of ADHD in patients with asthma and a history of PICU admission was significantly higher (p < 0.05).

CONCLUSIONS

The present study showed that severe asthma, was the risk factor for ADHD in patients with asthma. Physicians should be aware of this co-morbidity to refer asthmatic patients who have the symptoms of ADHD to a psychologist.

Lung function and cognitive ability in children: a UK birth cohort study

BACKGROUND

Decreased adult lung function is associated with subsequent impairment in cognition. A similar relationship in early life could be of great policy importance, since childhood cognitive ability determines key adult outcomes, including socioeconomic status and mortality. We aimed to expand the very limited data available on this relationship in children, and hypothesised that reduced lung function would be longitudinally associated with decreased cognitive ability.

METHODS

Lung function was measured at age 8 (forced expiratory volume in one second (FEV₁), forced vital capacity (FVC); % predicted), and cognitive ability was measured at ages 8 (Wechsler Intelligence Scale for Children, third edition) and 15 (Wechsler Abbreviated Scale of Intelligence), in the Avon Longitudinal Study of Parents and Children. Potential confounders were identified as preterm birth, birth weight, breastfeeding duration, prenatal maternal smoking, childhood environmental tobacco smoke exposure, socioeconomic status and prenatal/childhood air pollution exposure. Univariable and multivariable linear models (n range=2332-6672) were fitted to assess the cross-sectional and longitudinal associations of lung function with cognitive ability, and change in cognitive ability between ages 8 and 15.

RESULTS

In univariate analyses, both FEV₁ and FVC at age 8 were associated with cognitive ability at both ages, but after adjustment, only FVC was associated with full-scale IQ (FSIQ) at ages 8 (β=0.09 (95% CI 0.05 to 0.12; p<0.001)) and 15 (β=0.06 (0.03 to 0.10; p=0.001)). We did not find evidence of an association between either lung function parameter and interval change in standardised FSIQ.

DISCUSSION

Reduced FVC, but not FEV₁, is independently associated with decreased cognitive ability in children. This low-magnitude association attenuates between ages 8 and 15, while no association is evident with longitudinal change in cognitive ability. Our results support a link between FVC and cognition across the life course, possibly due to shared genetic or environmental risk, rather than causation.

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

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

Increased attention deficit/hyperactivity and oppositional defiance symptoms of 6-12 years old Chinese children with atopic dermatitis

Atopic dermatitis (AD), a prevalent chronic skin disease in children, has been associated with psychosocial illness and reduced quality of life because of severe itching and sleep deprivation. Previous studies have found a consistent association between AD and attention deficit hyperactivity disorder (ADHD). However, little is known about this relationship in Chinese children with AD.To investigate co-occurrence of ADHD symptoms, oppositional defiant disorder (ODD) symptoms, and the relevant risk factors of AD, as well as its impact on the quality of life in Chinese school-aged children with AD.Outpatients aged 6 to 12 years with confirmed AD and healthy controls matched for age were randomly included in this study from October 2018 to October 2019. AD severity was evaluated using the Severity Scoring of Atopic Dermatitis scale (SCORAD). Inattention, hyperactivity, and oppositional defiant symptoms were evaluated by using the Swanson, Nolan and Pelham IV Teacher and Parent 26-Item Rating Scale (SNAP-IV) questionnaires and quality of life was evaluated using the Children's Dermatology Life Quality Index (CDLQI).The study included 89 AD patients and 184 healthy controls. AD patients were more likely to have ADHD symptoms (10.1% vs. 3.8%; P = .04) and ODD symptoms (5.6% vs 0%; P < .001) than controls, especially hyperactive/impulsive (P = .03). The severity of itching and sleep loss in AD patients were positively correlated with inattention (P = .03; P < .001), hyperactivity/impulsiveness (P = .01; P = .03), and oppositional defiance scores (P < .01; P = .04). Sleep loss in AD patients was independently associated with an increased risk of ADHD symptoms (OR, 1.78; 95% CI, 1.07-2.98; P = .03). The mean CDLQI scores of AD patients were 6.98 ± 5.02, and CDLQI scores were significantly higher in AD patients with ADHD symptoms than in those without ADHD symptoms (11.44 vs. 6.48; P = .01).AD is a prevalent chronic condition associated with an increased likelihood of ADHD symptoms and ODD symptoms in school-aged children. Sleep deprivation caused by AD may be a risk factor for ADHD. AD affects quality of life, especially in patients with ADHD symptoms. AD patients with symptoms of inattention and hyperactivity should be evaluated for ADHD.

Reduced Attention in Former Smokers with and without COPD

BACKGROUND

Attention difficulties are often reported by patients with chronic obstructive pulmonary disease (COPD); however, limited research exists using objective tests designed specifically to measure attention in this population. This study aimed to (1) identify specific attention deficits in COPD and (2) determine which demographic/clinical characteristics are associated with reduced attention.

METHODS

Eighty-four former smokers (53 COPD, 31 no COPD) completed questionnaires, pulmonary function testing, and the Conner's Continuous Performance Test II (CPT-II). Participants with and without COPD were compared on CPT-II measures of inattention, impulsivity, and vigilance. CPT-II measures that differed significantly between the two groups were further examined using hierarchical regression modeling. Demographic/clinical characteristics were entered into models with attention as the dependent variable.

RESULTS

Participants with COPD performed worse than those without COPD on CPT measures of inattention and impulsivity (i.e., detectability [discrimination of target from non-target stimuli], perseverations [reaction time under 100 ms], omissions [target stimuli response failures], and commissions [responses to non-target stimuli]). More severe COPD (measured by greater airflow limitation) was associated with poorer ability to detect targets vs. foils and perseverative responding after adjusting for age and other covariates in the model.

CONCLUSION

Former smokers with COPD experience problems with attention that go beyond slowed processing speed, including aspects of inattention and impulsivity. Clinicians should be aware that greater airflow limitation and older age are associated with attention difficulties, as this may impact functioning.

Antenatal active maternal asthma and other atopic disorders is associated with ADHD behaviors among school-aged children

BACKGROUND

Identifying modifiable risk factors for neuropsychological correlates of attention deficit hyperactivity disorder (ADHD) in early childhood can inform prevention strategies. Prenatal inflammatory states, such as maternal asthma and other atopic disorders, have been increasingly linked to enhanced risk for neurobehavioral disorders in children, with some studies suggesting sex-specific effects.

OBJECTIVES

To assess the association between maternal active asthma and/or atopy in the antenatal period and child symptoms of ADHD during mid-childhood and, given the male-bias in ADHD prevalence, to examine modifying effects of child sex.

STUDY DESIGN

The study sample includes 250 maternal-child pairs enrolled in the Boston-based Asthma Coalition on Community, Environment and Social Stress (ACCESS) pregnancy cohort. We defined antenatal active atopy based on maternal report of current asthma, allergic rhinitis or atopic dermatitis during and/or in the year before pregnancy. When children were approximately 6 years old, mothers completed a battery of standardized child behavior rating scales designed for evaluating symptoms of ADHD. We used multivariable quantile regression to assess the relations between maternal antenatal atopy and symptoms of ADHD among children.

RESULTS

In adjusted models, maternal atopy was significantly associated with greater risk for ADHD behaviors, as indicated by scores on the Conners' Parent Rating Scale-Revised ADHD index (β = 3.32, 95% CI: 0.33, 6.32). In sex-stratified models this association was stronger among girls (5.96, 95% CI = 0.95, 10.96) compared to boys (-2.14, 95% CI = -5.75, 1.45, p-interaction = 0.01). Among girls, we observed a similar finding for the Behavior Assessment System for Children 2nd Edition Parent Rating Scale Attention Problems subscale (β = 7.77, 95% CI = 1.57, 13.97). Results from other outcome subscales were similar in magnitude and direction, however, associations did not reach statistical significance at the p = 0.05 level.

CONCLUSIONS

Maternal antenatal active atopy may be a risk factor for the development of ADHD-like symptoms, especially among girls.

Medical and Psychiatric Comorbidities in Korean Children and Adolescents with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) is associated with a high rate of comorbid disorders. We aimed to investigate the medical and psychiatric comorbidities of Korean children and adolescents with ADHD.

METHODS

Data were obtained from Korean National Health Insurance Review and Assessment Service-National Patient Sample (HI-RA-NPS) for 2011. We included 2,140 (mean age, 10.9±3.1 years; boys, 1,710) and 219,410 (non-ADHD; mean age, 12.4±3.7 years; boys, 113,704) children and adolescents with and without ADHD, respectively. We compared medical and psychiatric comorbidities between the groups, and performed weighted logistic regression analyses to obtain odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Most medical comorbidities were more likely in patients with ADHD and included nervous system disease (OR, 2.59; 95% CI, 2.52-2.66); endocrine, nutritional, and metabolic disease (OR, 2.09; 95% CI, 2.04-2.15); and congenital malformations, deformations, and chromosomal abnormalities (OR, 2.00; 95% CI, 1.90-2.11). Oppositional defiant disorder and conduct disorder were more prevalent in patients with ADHD (OR, 81.88; 95% CI, 79.00-84.86), followed by learning (OR, 75.61; 95% CI, 69.69-82.04), and depressive disorders (OR, 55.76; 95% CI, 54.44-57.11).

CONCLUSION

Our results suggest that Korean children and adolescents with ADHD are more likely to suffer medical and psychiatric comorbidities than those without ADHD.

Poor Executive Functions among Children with Moderate-into-Severe Asthma: Evidence from WCST Performance

Executive functions (EFs) measures of 27 asthmatic children, with general learning difficulties, were tested by using the Wisconsin card sorting test (WCST), and were compared to the performances of 30 non-asthmatic children with general learning difficulties. The results revealed that the asthmatic group has poor performance through all the WCST psychometric parameters and especially the perseverative errors one. The results were discussed in light of the postulation that poor EFs could be associated with the learning difficulties of asthmatic children. Neurophysiological framework has been suggested to explain the etiology of poor EFs among children with moderate into severe asthma.

Impact of asthma medication and familial factors on the association between childhood asthma and attention-deficit/hyperactivity disorder: a combined twin- and register-based study: Epidemiology of Allergic Disease

BACKGROUND

Asthma and attention-deficit/hyperactivity disorder (ADHD) are prevalent in childhood and may cause functional impairment and stress in families. Previous research supports an association between asthma and ADHD in children, but several aspects of this relationship are unclear.

OBJECTIVE

Our aim was to study whether the association between asthma and ADHD is restricted to either the inattentive or the hyperactive/impulsive symptoms of ADHD, to explore the impact of asthma severity and asthma medication and the contribution of shared genetic and environmental risk factors on the asthma-ADHD relationship.

METHODS

Data on asthma, ADHD, zygosity and possible confounders were collected from parental questionnaires at 9 or 12 years on 20 072 twins through the Swedish Twin Register, linked to the Swedish Medical Birth Register, the National Patient Register and the Prescribed Drug Register. The association between asthma and ADHD, the impact of asthma severity and medication, was assessed by generalized estimating equations. Cross-twin-cross-trait correlations (CTCT) were estimated to explore the relative importance of genes and environment for the association.

RESULTS

Asthmatic children had a higher risk of also having ADHD [odds ratio (OR) 1.53, 95% confidence interval (CI): 1.16-2.02]. The association was not restricted to either of the two dimensions of ADHD. The magnitude of the association increased with asthma severity (OR 2.84, 95% CI: 1.86-4.35) for ≥ 4 asthma attacks in the last 12 months and was not affected by asthma treatment. The CTCTs possibly indicate that the genetic component in overlap of the disorders is weak.

CONCLUSIONS AND CLINICAL RELEVANCE

Childhood asthma, especially severe asthma, is associated with ADHD. Asthma medication seems not to increase the risk of ADHD. Clinicians should be aware of the potential of ADHD in asthma. Optimal asthma care needs to be integrated with effective evaluation and treatment of ADHD in children with co-existing disorders.

Risk Factors for Attention and Behavioral Issues in Pediatric Sickle Cell Disease

BACKGROUND

Children with sickle cell disease have an increased risk of neurodevelopmental disorders such as attention deficit hyperactivity disorder, intellectual disability, and specific learning disabilities. Little research has been done to characterize the sickle cell disease-related characteristics associated with neurodevelopmental disorders in the sickle cell disease population.

METHODS

This study was a retrospective chart review involving the outpatient records of 2 medical centers, Kennedy Krieger Institute and Johns Hopkins Hospital. Participants in the study included 59 children with sickle cell disease with a documented neurodevelopmental diagnosis, specifically attention deficit hyperactivity disorder, attention issues, behavioral issues, executive dysfunction, specific learning disabilities in math, reading, and reading comprehension, intellectual disabilities, developmental delay, fine motor disorders, language disorders, or autism spectrum disorders.

RESULTS

Children with sickle cell disease type hemoglobin S-β thalassemia plus had significantly higher odds of attention issues than children with sickle cell disease type hemoglobin SS (OR = 17.0, 95% CI = 1.99-145.00, P < .02). Children with sickle cell disease and a reported history of asthma had significantly higher odds of behavioral issues than children with sickle cell disease without a history of asthma, after adjustment for gender and sickle cell disease type (exact OR = 19.53, 95% CI = 1.16-1369.72, P < .04).

CONCLUSION

Children with sickle cell disease may have increased risk for certain neurodevelopmental diagnoses based on their disease characteristics and associated comorbidities. These preliminary study results should be explored in a larger database.

Child Allergic Symptoms and Well-Being at School: Findings from ALSPAC, a UK Cohort Study

Background

Eczema and asthma are common conditions in childhood that can influence children’s mental health. Despite this, little is known about how these conditions affect the well-being of children in school. This study examines whether symptoms of eczema or asthma are associated with poorer social and mental well-being in school as reported by children and their teachers at age 8 years.

Methods

Participants were from the Avon Longitudinal Study of Parents and Children. Measures of child well-being in school were child-reported (n = 6626) and teacher reported (n = 4366): children reported on their enjoyment of school and relationships with peers via a self-complete questionnaire; teachers reported child mental well-being using the Strengths and Difficulties Questionnaire [binary outcomes were high ‘internalizing’ (anxious/depressive) and ‘externalizing’ (oppositional/hyperactive) problems (high was >90th percentile)]. Child rash and wheeze status were maternally reported and symptoms categorised as: ‘none’; ‘early onset transient’ (infancy/preschool only); ‘persistent’ (infancy/preschool and at school age); and ‘late onset’ (school age only).

Results

Children with persistent (OR 1.29, 95% CI 1.02 to 1.63) and late onset (OR 1.48, 95% CI 1.02 to 2.14) rash were more likely to report being bullied, and children with persistent wheeze to feel left out (OR 1.42, 95% CI 1.10 to 1.84). Late onset rash was associated with high teacher-reported internalising behaviours (OR 1.61, 95% CI 1.02 to 2.54), and persistent rash with high externalising behaviours (OR 1.37, 95% CI 1.02 to 1.84). Child sleep and maternal mental health explained some of the associations with teacher-reported mental well-being.

Conclusion

Symptoms of eczema or asthma can adversely affect a child’s social and mental well-being at primary school. This suggests interventions, such as additional support or education of peers, should begin at early stages in schooling.

Cognitive outcomes following arterial ischemic stroke in infants and children

This study sought to investigate cognitive outcomes following pediatric arterial ischemic stroke and explore predictors. Participants included 36 children with perinatal or childhood arterial ischemic stroke and a comparison group of 15 children with asthma. Outcomes included cognitive ability, executive functions, and neurological function (Pediatric Stroke Outcome Measure). Magnetic resonance imaging measured lesion location and volume. Mean cognitive scores were at the low end of the average range. Children with arterial ischemic stroke performed significantly below normative populations and significantly below the asthma group on inhibitory control (Cohen's d = .68). Both the Pediatric Stroke Outcome Measure and lesion volume were negatively correlated with cognitive outcome (Spearman r = -.01 to -.42 Pediatric Stroke Outcome Measure; r =-.14 to -.32 Volume). Following arterial ischemic stroke, children performed at the low end of the average range on measures of cognitive functioning. Cognitive outcomes depend on a variety of factors.

Nutrition, immunological mechanisms and dietary immunomodulation in ADHD

Attention-deficit hyperactivity disorder (ADHD) etiology is not completely understood, but common comorbid dysfunction of the gastrointestinal and immune system suggests that these systems may be affected by a common genetic background and molecular mechanisms. For example, increased levels of specific cytokines were observed in ADHD. Moreover, ADHD has a high comorbidity with both Th1- and Th2-mediated disorders like ear infections, eczema and asthma. A common pathophysiological mechanism was suggested to underlie both asthma and ADHD, while several genes that are linked to ADHD have immune functions. Furthermore, immunological recognition of food provoking ADHD-like behavior was suggested. An immune imbalance, probably requiring a predisposing genetic background, is therefore suggested to contribute to ADHD etiology, with immune dysregulation being more likely than a single subcellular defect. However, next to allergic mechanisms, also pharmacological mechanisms (especially in case of food additives) might be involved. In addition, though cellular (cytokine-related) rather than antibody-mediated immune mechanisms seem involved, specific immune-inflammatory markers other than antibodies have not been systematically studied in ADHD. Substantial alterations implicated in ADHD apparently occur in the immune system and epigenetic regulation of gene expression. As a result, chronic inflammation and oxidative stress could develop, which can lead to ADHD symptoms, for example by chronic T-cell-mediated neuroinflammation. If immune pathways contribute to ADHD, both its diagnosis and treatment should be reconsidered. Modulation of immune system activity might have potential in ADHD treatment, for example by nutritional approaches providing safe and low-cost ADHD therapy, but further research in these fields is implicated.

Communication about ADHD and its treatment during pediatric asthma visits

The objectives of the study were to examine provider-family communication about attention deficit disorder during pediatric asthma visits. Children with asthma, aged 8 through 16 and their parents were recruited at five pediatric practices. All medical visits were audio-taped. There were 296 asthmatic children enrolled into the study and 67 of them also had attention deficit hyperactivity disorder (ADHD). ADHD communication elements suggested by national guidelines were discussed infrequently. Providers were more likely to discuss, educate, and ask one or more questions about ADHD medications if the visit was non-asthma related. Providers included child input into the ADHD treatment regimen during 3% of visits and they included parent input during 4.5% of visits. Only one child and three parents asked questions about ADHD. Providers may neglect essential aspects of good ADHD management and communication in children who have ADHD plus another chronic condition such as asthma. Providers should set appropriate treatment expectations, establish target symptoms, and encourage children and parents to ask questions so mutual decision-making can occur.

Asthma and attention-deficit/hyperactivity disorder: a nationwide population-based prospective cohort study

BACKGROUND

Previous cross-sectional studies have suggested an association between asthma and attention-deficit/hyperactivity disorder (ADHD), but the temporal relationship was not determined. Using a nationwide population-based prospective case-control cohort study (1:4, age-/gender-matched), we hypothesized that asthma in infanthood or early childhood would increase the risk of ADHD in later life.

METHODS

In all, 2,294 children with asthma and 9,176 controls aged between 0 and 3 years in 2000 were included in our study. Cases of ADHD that occurred to the end of follow-up (31 December 2010) were identified.

RESULTS

Children with asthma had a higher incidence of developing ADHD (7% vs. 4.6%, p < .001) than control cohort during the follow-up period. After adjusting for age at enrollment, gender, level of urbanization, and comorbid allergic diseases (allergic rhinitis and atopic dermatitis), children with asthma had an elevated risk (HR: 1.31, 95% CI: 1.07-1.59) of developing ADHD compared with control group.

DISCUSSION

Our prospective study supported a temporal relationship between asthma and ADHD. Asthma in very early life increased the risk of developing ADHD during the school years. Further studies are required to investigate whether the prompt treatment of asthma and comorbid allergic diseases could prevent the development of ADHD or decrease ADHD symptoms.

Obesity and asthma at school entry: co-morbidities and temporal trends

AIM

A decline in asthma prevalence from 2000 to 2005 was reported previously. The objective is to examine the temporal trends for the prevalence of obesity and other childhood disorders and consider the extent to which associations between asthma and other co-morbidities can be accounted for by body mass index.

METHODS

Serial cross-sectional surveys of primary school entrants (n = 18,999) in the Australian Capital Territory between 2001 and 2005 were used. Asthma, recent respiratory symptoms and diabetes data were extracted from parental reports. Anthropometric measurements were obtained from health assessments by school nurses. Child obesity was defined using the age and sex-specific Cole criteria. Time trends for the prevalence of obesity and other disorders, and the association between 'current asthma' and co-morbidities were analysed using multiple logistic regression and other analyses.

RESULTS

Obesity prevalence was 5.24% in 2001 decreasing to 3.60% in 2005 (test of linear trend P = 0.02). Overweight (adjusted odds ratio (AOR) 1.30 (95% confidence interval (CI) 1.16, 1.46), P < 0.001) and obese (AOR 1.36 (95% CI 1.13, 1.62), P = 0.001) children were more likely to report 'asthma ever'. Children with diabetes (AOR 9.35 (95% CI 3.11, 28.12, P < 0.001)) and attention deficit (AOR 3.39 (95% CI 2.04, 5.64), P < 0.001) were more likely to report 'current asthma'.

CONCLUSIONS

The pattern of association with co-morbidities was different for asthma and obesity. The temporal decline/plateau effect in 'current asthma' could not be explained by concurrent body mass index changes. The decline in obesity was largely driven by the 2005 findings. Longer term trends need to be evaluated further.

Allergic disease in the first year of life is associated with differences in subsequent neurodevelopment and behaviour

BACKGROUND

Recent trials suggest a link between neuropsychological function, atopy and allergic disease particularly in early childhood; however the nature of this association remains unclear.

AIMS

To investigate the relationship between early allergic disease and sensitisation at 12 months of age and neurodevelopmental outcomes at 18 months.

STUDY DESIGN

Linear or binary logistic regression analysis was used to determine whether allergic diseases or sensitization at 12 months of age was a significant predictor of neurodevelopmental test scores at the 18 months.

SUBJECTS

Infants with a maternal history of allergic disease (n=324).

OUTCOME MEASURES

Allergic outcomes at 12 months of age included allergen sensitisation, eczema, IgE-mediated and food allergy, and neurodevelopmental outcomes at 18 included the Bayley Scales of Infant Toddler Development III Edition, the Achenbach Child Behaviour Checklist and the Macarthur Scales of Infant Toddler Development.

RESULTS

Children with any diagnosed allergic disease at 12 months had evidence of reduced motor scores (p=.016), and this was most apparent for a diagnosis of eczema (p=.007). Non-IgE mediated food allergy was significantly positively associated with problem Internalising Behaviours (p=.010), along with a trend for effects on the Social-Emotional composite score for IgE-Mediated food allergies (p=.052). Allergic sensitisation was not independently associated with any effects on neurodevelopmental outcomes.

CONCLUSION

This study provides evidence that an allergic phenotype in infancy is associated with effects on neurodevelopment. Further research is required to investigate the nature of this relationship.

Describing and quantifying asthma comorbidity [corrected]: a population study

Background

Asthma comorbidity has been correlated with poor asthma control, increased health services use, and decreased quality of life. Managing it improves these outcomes. Little is known about the amount of different types of comorbidity associated with asthma and how they vary by age.

Methodology/Principal Findings

The authors conducted a population study using health administrative data on all individuals living in Ontario, Canada (population 12 million). Types of asthma comorbidity were quantified by comparing physician health care claims between individuals with and without asthma in each of 14 major disease categories; results were adjusted for demographic factors and other comorbidity and stratified by age. Compared to those without asthma, individuals with asthma had higher rates of comorbidity in most major disease categories. Most notably, they had about fifty percent or more physician health care claims for respiratory disease (other than asthma) in all age groups; psychiatric disorders in individuals age four and under and age 18 to 44; perinatal disorders in individuals 17 years and under, and metabolic and immunity, and hematologic disorders in children four years and under.

Conclusion/Significance

Asthma appears to be associated with significant rates of various types of comorbidity that vary according to age. These results can be used to develop strategies to recognize and address asthma comorbidity to improve the overall health of individuals with asthma.

Association between childhood asthma and ADHD symptoms in adolescence--a prospective population-based twin study

BACKGROUND

Cross-sectional studies report a relationship between childhood asthma and attention-deficit hyperactivity disorder (ADHD) symptoms, but the mechanisms are yet unclear. Our objective was to investigate the longitudinal link between childhood asthma and the two dimensions of ADHD (hyperactivity-impulsivity, HI, and inattention, IN) in adolescence. We also aimed to explore the genetic and environmental contributions and the impact of asthma medication.

METHODS

Data on asthma, HI and IN, birth weight, socioeconomic status, zygosity, and medication were collected from the Swedish Medical Birth Register and through parental questionnaires at ages 8-9 and 13-14 years on 1480 Swedish twin pairs born 1985-1986. The association between asthma at age 8-9 and ADHD symptoms at age 13-14 was assessed with generalized estimating equations, and twin analyses to assess the genetic or environmental determinants were performed.

RESULTS

Children with asthma at age 8-9 had an almost twofold increased risk of having one or more symptom of HI (OR 1.88, 95% CI 1.18-3.00) and a more than twofold increased risk to have three symptoms or more of HI (OR 2.73, 95% CI 1.49-5.00) at age 13-14, independent of asthma medication. For IN, no significant relationship was seen. Results from twin modeling indicate that 68% of the phenotypic correlation between asthma and HI (r=0.23, 0.04-0.37) was because of genetic influences.

CONCLUSIONS

Our findings suggest that childhood asthma is associated with subsequent development of HI in early adolescence, which could be partly explained by genetic influences. Early strategies to identify children at risk may reduce burden of the disease in adolescence.

Common behavioral problems among children with asthma: is there a role of asthma treatment?

BACKGROUND

An increased prevalence of behavioral problems has been described among children with asthma.

OBJECTIVE

To investigate those associations between common behavioral problems and asthma, with an emphasis on the roles of medications used for asthma.

METHOD

We studied 409 children who had been followed-up in pediatric allergy clinics and 157 age-matched healthy controls. A diagnostic and statistical manual disorder-referenced symptom inventory was used to assess "attention deficit-hyperactivity disorder" (ADHD), "attention deficit" (AD), "hyperactivity and impulsivity" (HI), and "oppositional defiant disorder" (ODD) behavioral problems.

RESULTS

The study group consisted of 409 patients (male: 251, female: 158), with a mean age of 9.0 ± 2.67 years, and the control group consisted of 157 children (male: 75, female: 82), with a mean age of 9.0 ± 2.86 years. Prevalences of AD, hyperactivity, ADHD, and ODD were not significantly different between the study and control groups. Among those patients receiving leukotriene antagonist (LA) drugs adjunctive to inhaled corticosteroids (ICS), duration of treatment was correlated with total scores calculated for hyperactivity (P = .035, r = 0.432), AD (P = .044, r = 0.414), ADHD (P = .042, r = 0.418), and ODD (P = .032, r = 0.439). Among patients with asthma, children with ODD had a significantly longer duration of LA+ICS use (P = .024) compared with those with no ODD. Patients with hyperactivity had a longer duration of ICS+LA use compared with those with no hyperactivity (P = .009). Patients with asthma receiving LA+ICS treatment had a higher risk for oppositional behavior (4.282 times compared with the control group [P = .042, confidence interval (CI): 1.542-15.949]) and 8.3 times compared with patients with asthma not using any drug (P = .021, CI: 1.419-48.543).

CONCLUSION

Rather than asthma itself, adjunctive use of ICS+LA therapy appears to be related with symptoms of common behavioral problems, including hyperactivity, AD, ADHD, and ODD and to increase the risk of ODD.

Is atopic disease a risk factor for attention-deficit/hyperactivity disorder? A systematic review

The increase in prevalence and burden of atopic diseases, i.e. eczema, rhinitis, and asthma over the past decades was paralleled by a worldwide increase in attention-deficit/hyperactivity disorder (ADHD) diagnoses. We systematically reviewed epidemiologic studies investigating the relationship between atopic diseases and ADHD. Electronic literature search in PubMed and PsycINFO (until 02/2010) supplemented by handsearch yielded 20 relevant studies totaling 170,175 individuals. Relevant data were abstracted independently by two reviewers. Six studies consistently reported a positive association between eczema and ADHD with one study suggesting effect modification by sleeping problems. Twelve studies consistently found a positive association between asthma and ADHD, which, however, appeared to be at least partly explained (confounded) by concurrent or previous eczema. Rhinitis and serum-IgE level were not related to ADHD symptomatology. We conclude that not atopic disease in general, but rather that eczema appears to be independently related to ADHD. Conclusions about temporality and whether the observed association constitutes a causal relationship are impossible, as most studies were cross-sectional (n = 14; 70%) or case-control studies without incident exposure measurement (n = 5; 25%). Another methodological concern is that the criteria to define atopic disease and ADHD were inadequate in most studies. A failure to adjust for confounders in the majority of studies was an additional limitation so that meta-analysis was not indicated. Future interdisciplinary high-quality prospective research is needed to better understand the mechanisms underlying the relationship between eczema and ADHD and to eventually establish targeted preventive and treatment strategies.

The association between symptomatic asthma and neurobehavioral comorbidities among children

BACKGROUND

Asthma affects millions of children in the United States. The extent to which asthma and other medical conditions coexist, however, is largely unknown.

OBJECTIVE

This study aimed to determine associations between symptomatic asthma and neurobehavioral comorbidities among children in rural United States.

METHODS

This cross-sectional study used data from 406 parents/caregivers of children aged 16 or younger, who completed survey questionnaires assessing their child's health status. Symptomatic asthma was defined as parents'/caregivers' report of physician diagnosed asthma and presence of night-time asthma symptoms in their children. The dependent variables were parents'/caregivers' reported comorbidities in children.

RESULTS

Symptomatic asthma was present in 9% of the sample. Approximately 26% parents/caregivers reported their child had one or more mental health problems and 13% reported one or more neurological problems. In multivariable logistic regression analyses, a statistically nonsignificant 50% elevated odds of one or more mental health problems were observed for children with symptomatic asthma (adjusted odds ratio [OR] = 1.5, 95% confidence interval [CI] = 0.6-3.5). Of the individual comorbidities included in the mental health construct, more than 2-fold elevated odds of anxiety problems (adjusted OR = 2.6, 95% CI = 0.8-8.6) and attentional problems (adjusted OR = 2.4, 95% CI = 1.0-5.8) were observed for symptomatic asthma. The odds of reporting one or more neurological problems were 4-fold elevated (adjusted OR = 4.0, 95% CI = 1.6-10.0) for symptomatic asthma. Of the individual comorbidities included in the neurological construct a significantly elevated odds of hearing impairment or deafness was observed among children with symptomatic asthma (adjusted OR = 8.2, 95% CI = 1.5-45.3) as compared to the no asthma/no symptoms reference group.

CONCLUSION

These data suggest significant associations between symptomatic asthma and neurological comorbidities.