Clinical Usefulness of Observational Assessment in the Diagnosis of DBD and ADHD in Preschoolers

Towards an Objective Measurement Tool for ADHD-like Traits in Family Dogs: A Comprehensive Test Battery

Family dogs exhibit neuropsychological deficits similar to attention-deficit/hyperactivity disorder (ADHD) symptoms in humans. Questionnaire methods have mostly been used to assess ADHD-like behaviours in dogs. In addition to our validated questionnaire (Dog ADHD and Functionality Rating Scale-DAFRS; 2024), we developed a simple behavioural test battery covering the ADHD symptom domains (i.e., inattention, hyperactivity, and impulsivity) in dogs. Our main aim was (i) to provide a final external validation step to the DAFRS by examining its associations with the test variables (N = 59); and (ii) to compare owner- and trainer-rated factor scores' associations with the test variables (n = 38). We developed four tests covering the ADHD symptom domains: the attention test (inattention), the plush dog test (impulsivity), the leash test, and the sit test (hyperactivity). All four behavioural variables correlated with their respective questionnaire scores, i.e., the strongest for hyperactivity, and the least strong for inattention. Both owner- and trainer-rated scores (n = 38) correlated with the relevant test variables in an expected direction. Dogs' training status was linked only to the sit test results. Test-retest analyses (n = 34) indicated moderate-to-excellent agreement across all behavioural variables. Our findings support the validity of our novel human-analogue questionnaire for dogs as the behavioural tests strongly correlate with the relevant questionnaire scores, indicating that the two constructs together can effectively assess inattention, hyperactivity, and impulsivity in dogs.

Trajectories of Executive Functions and ADHD Symptoms in Preschoolers and the Role of Negative Parental Discipline

In the present study, we investigated whether the longitudinal growth trajectories of executive functions (EF) and Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms are related. In addition, we investigated whether negative discipline moderated these longitudinal relations. The sample consisted of predominantly clinically referred preschoolers (N = 248, age 42-66 months at Time 1; 79.0% boys). Assessment occurred three times: at baseline, at 9 months, and at 18 months. EF was assessed with five EF tasks. ADHD symptoms (Child Behavior Checklist 1.5-5) were reported by parents. Groups of medium to high and low negative discipline were based on mother- and father-reports (Parenting Practices Inventory). Growth curve models showed that EF generally increased and ADHD symptoms generally decreased over time. Parallel process models showed that there was no relation between the change in EF and the change in ADHD symptoms over time, suggesting no co-development. However, higher EF at baseline was related to lower ADHD symptoms at baseline. This was irrespective of whether children were exposed to high or low negative discipline. Overall, the results suggest that, while EF and ADHD symptoms are related, they develop independently across the preschool years.

A two arm randomized controlled trial comparing the short and long term effects of an elimination diet and a healthy diet in children with ADHD (TRACE study). Rationale, study design and methods

BACKGROUND

Food may trigger Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms. Therefore, an elimination diet (ED) might be an effective treatment for children with ADHD. However, earlier studies were criticized for the nature of the control group, potential confounders explaining the observed effects, unsatisfactory blinding, potential risks of nutritional deficiencies and unknown long term and cost-effectiveness. To address these issues, this paper describes the rationale, study design and methods of an ongoing two arm randomized controlled trial (RCT) comparing the short (5 week) and long term (1 year) effects of an elimination diet and a healthy diet compared with care as usual (CAU) in children with ADHD.

METHODS

A total of N = 162 children (5-12 years) with ADHD will be randomized to either an ED or a healthy diet. A comparator arm including N = 60 children being solely treated with CAU (e.g. medication) is used to compare the effects found in both dietary groups. The two armed RCT is performed in two youth psychiatry centers in the Netherlands, with randomization within each participating center. The primary outcome measure is response to treatment defined as a ≥ 30% reduction on an ADHD DSM-5 rating scale (SWAN) and/or on an emotion dysregulation rating scale (SDQ: dysregulation profile). This is assessed after 5 weeks of dietary treatment, after which participants continue the diet or not. Secondary outcome measures include the Disruptive Behavior Diagnostic Observational Schedule (DB-DOS), parent and teacher ratings of comorbid symptoms, cognitive assessment (e.g. executive functions), school functioning, physical measurements (e.g. weight), motor activity, sleep pattern, food consumption, nutritional quality of the diet, adherence, parental wellbeing, use of health care resources and cost-effectiveness. Assessments take place at the start of the study (T0), after five weeks (T1), four months (T2), eight months (T3) and 12 months of treatment (T4). T0, T1 and T4 assessments take place at one of the psychiatric centers. T2 and T3 assessments consist of filling out online questionnaires by the parents only.

DISCUSSION

This RCT will likely contribute significantly to clinical practice for ADHD by offering insight into the feasibility, nutritional quality, (cost-)effectiveness and long term effects of dietary treatments for ADHD.

TRIAL REGISTRATION

www.trialregister.nl, NTR5434. Registered at October 11th, 2015.

A Review of the Clinical Utility of Systematic Behavioral Observations in Attention Deficit Hyperactivity Disorder (ADHD)

This review evaluates the clinical utility of tools for systematic behavioral observation in different settings for children and adolescents with ADHD. A comprehensive search yielded 135 relevant results since 1990. Observations from naturalistic settings were grouped into observations of classroom behavior (n = 58) and of social interactions (n = 25). Laboratory observations were subdivided into four contexts: independent play (n = 9), test session (n = 27), parent interaction (n = 11), and peer interaction (n = 5). Clinically relevant aspects of reliability and validity of employed instruments are reviewed. The results confirm the usefulness of systematic observations. However, no procedure can be recommended as a stand-alone diagnostic method. Psychometric properties are often unsatisfactory, which reduces the validity of observational methods, particularly for measuring treatment outcome. Further efforts are needed to improve the specificity of observational methods with regard to the discrimination of comorbidities and other disorders.

Mother-Child Interactions and Externalizing Behavior Problems in Preschoolers over Time: Inhibitory Control as a Mediator

Previous research has shown links between parenting and externalizing behavior problems in young children over time. Associations between inhibitory control, one of the executive functions, and externalizing behavior problems are widely established as well. Yet, the role of inhibitory control in the maintenance and change of externalizing behavior problems over time remains unclear. We examined whether inhibitory control could explain the link between mother-child interactions measured on a moment-to-moment timescale and preschoolers’ externalizing behavior problems as reported by teachers. With a sample of 173 predominantly clinically referred preschoolers (76.9% boys) we tested a longitudinal model proposing that affective dyadic flexibility and maternal negative affect predict as well as interact in predicting hyperactive/impulsive behavior and aggressive behavior, with preschoolers’ inhibitory control as a mediator. Our results provide support for this model for preschoolers’ hyperactive/impulsive behavior, but not for aggressive behavior. Hence, inhibitory control is identified as a mechanism linking the content and structure of mother-child interactions to preschoolers’ hyperactivity and impulsivity over time.

Autism spectrum disorder and attention-deficit/hyperactivity disorder in early childhood: A review of unique and shared characteristics and developmental antecedents

Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) have overlapping characteristics and etiological factors, but to which extent this applies to infant- and preschool age is less well understood. Comparing the pathways to ASD and ADHD from the earliest possible stages is crucial for understanding how phenotypic overlap emerges and develops. Ultimately, these insights may guide preventative and therapeutic interventions. Here, we review the literature on the core symptoms, temperament and executive function in ASD and ADHD from infancy through preschool age, and draw several conclusions: (1) the co-occurrence of ASD and ADHD increases with age, severity of symptoms and lower IQ, (2) attention problems form a linking pin between early ASD and ADHD, but the behavioral, cognitive and sensory correlates of these attention problems partly diverge between the two conditions, (3) ASD and ADHD share high levels of negative affect, although the underlying motivational and behavioral tendencies seem to differ, and (4) ASD and ADHD share difficulties with control and shifting, but partly opposite behaviors seem to be involved.

Contextual variation in young children's observed disruptive behavior on the DB-DOS: implications for early identification

BACKGROUND

Contextual variation in child disruptive behavior is well documented but remains poorly understood. We first examine how variation in observed disruptive behavior across interactional contexts is associated with maternal reports of contextual variation in oppositional-defiant behavior and functional impairment. Second, we test whether child inhibitory control explains the magnitude of contextual variation in observed disruptive behavior.

METHODS

Participants are 497 young children (mean age = 4 years, 11 months) from a subsample of the MAPS, a sociodemographically diverse pediatric sample, enriched for risk of disruptive behavior. Observed anger modulation and behavioral regulation problems were coded on the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS) during interactions with parent and examiner. Oppositional-defiant behavior, and impairment in relationships, with parents and nonparental adults, were measured with the Preschool Age Psychiatric Assessment (PAPA) interview with the mother. Functional impairment in the home and out-and-about was assessed with the Family Life Impairment Scale (FLIS), and expulsion from child care/school was measured with the baseline survey and FLIS.

RESULTS

Observed disruptive behavior on the DB-DOS Parent Context was associated with oppositional-defiant behavior with parents, and with impairment at home and out-and-about. Observed disruptive behavior with the Examiner was associated with oppositional-defiant behavior with both parents and nonparental adults, impairment in relationships with nonparental adults, and child care/school expulsion. Differences in observed disruptive behavior in the Parent versus Examiner Contexts was related to the differences in maternal reports of oppositional-defiant behavior with parents versus nonparental adults. Children with larger decreases in disruptive behavior from Parent to Examiner Context had better inhibitory control and fewer attention-deficit/hyperactivity disorder symptoms.

CONCLUSIONS

The DB-DOS showed clinical utility in a community sample for identifying contextual variation that maps onto reported oppositional-defiant behavior and functioning across contexts. Elucidating the implications of contextual variation for early identification and targeted prevention is an important area for future research.

The Child Behavior Checklist Dysregulation Profile in Preschool Children: A Broad Dysregulation Syndrome

OBJECTIVE

Children with concurrent impairments in regulating affect, behavior, and cognition can be identified with the Anxious/Depressed, Aggressive Behavior, and Attention Problems scales (or AAA scales) of the Child Behavior Checklist (CBCL). Jointly, these scales form the Dysregulation Profile (DP). Despite persuasive evidence that DP is a marker for severe developmental problems, no consensus exists on the preferred conceptualization and operationalization of DP in preschool years. We addressed this concern by testing and validating the factor structure of DP in a group of predominantly clinically referred preschool children.

METHOD

Participants were 247 children (195 boys and 52 girls), aged 3.5 to 5.5 years. Children were assessed at baseline and 18 months later, using parent and teacher reports, a clinical interview with parents, behavioral observations, and neuropsychological tasks.

RESULTS

Confirmatory factor analysis showed that a bifactor model, with a general DP factor and 3 specific factors representing the AAA scales, fitted the data better than a second-order model and a one-factor model for both parent-reported and teacher-reported child problem behavior. Criterion validity analyses showed that the DP factor was concurrently and longitudinally associated with markers of dysregulation and clinically relevant criteria, whereas the specific factors representing the AAA scales were more differentially related to those criteria.

CONCLUSION

DP is best conceptualized as a broad syndrome of dysregulation that exists in addition to the specific syndromes as represented by the AAA scales. Implications for researchers and clinicians are discussed.