Preschool onset attention-deficit/hyperactivity disorder: course and predictors of stability over 24 months

Maternal emotional availability and perinatal depressive symptoms as predictors of early childhood executive function

BACKGROUND

The interconnected effects of maternal perinatal depression and the early mother-infant relational quality on children's executive function development are crucial yet understudied. This study addresses this gap, focusing on how perinatal depressive symptoms and emotional availability at 6 months predict child executive function performance at age four, with an emphasis on the moderating role of emotional availability.

METHOD

This study included 282 mother-infant pairs recruited from the Mercy Pregnancy and Emotional Wellbeing Study, utilising repeated Edinburgh Postnatal Depression Scale measurement over the perinatal period, Emotional Availability Scales, and child executive function assessments (Shape School, NEPSY-II, Preschool Age Psychiatric Assessment, Attention Deficit Hyperactivity scale, inattentive subscale). Latent growth curve analysis incorporated controls for socioeconomic status and maternal cognitive abilities, and moderation effects were examined through multiplicative interaction terms.

RESULTS

We found that emotional availability influences children's executive function, specifically switching, motor inhibition, and inattentive symptoms, irrespective of maternal depressive symptom changes. This effect is further nuanced by emotional availability's moderating role in the association between depressive symptom change and switching.

LIMITATIONS

The study's limitations include a relatively small sample size for moderation analysis and the exclusion of paternal influences.

CONCLUSION

This study is a significant step in understanding the profound influence of maternal emotional availability in infancy on child executive function development, offering new avenues for research and, if replicated, a foundation for innovative intervention approaches.

Behavioral characteristics of toddlers later identified with an autism diagnosis, ADHD symptoms, or combined autism and ADHD symptoms

BACKGROUND

Autism commonly co-occurs with attention-deficit/hyperactivity disorder (ADHD), but less is known regarding how ADHD symptoms impact the early presentation of autism. This study examined early behavioral characteristics of a community sample of toddlers later identified with autism diagnosis, ADHD symptoms, combined autism and ADHD symptoms, or neither condition.

METHODS

Participants were 506 toddlers who were part of a longitudinal study of children's behavioral development. Parents completed questionnaires about their children's behavior at two time points. Four groups were identified based on study measures or medical record: autism diagnosis (n = 45), elevated ADHD symptoms (n = 70), autism and ADHD symptoms (n = 30), or neurotypical development (n = 361). Relationships between early parent report of autism- and ADHD-related behaviors, social-emotional and behavioral functioning, and caregiver experience and subsequent group designation were evaluated with adjusted linear regression models controlling for sex.

RESULTS

Significant group differences were found in measures of autism-related behaviors, ADHD-related behaviors, externalizing and internalizing behaviors, and parent support needs (p < .0001). Pairwise comparisons indicated toddlers later identified with combined autism diagnosis and ADHD symptoms had higher levels of autism-related behaviors, externalizing and internalizing behaviors, and autism-related parent support needs compared to the other groups. Toddlers with subsequent elevated ADHD symptoms or combined autism diagnosis and ADHD symptoms exhibited similar levels of ADHD-related behaviors, while both groups displayed more ADHD-related behaviors than toddlers subsequently identified with autism or those with neither condition.

CONCLUSIONS

In this community sample, toddlers for whom combined autism diagnosis and ADHD symptoms were subsequently identified showed a distinct presentation characterized by higher early autism-related behaviors, broader behavioral concerns, and higher parent support needs. Presence of ADHD symptoms (alone or in combination with autism) was associated with higher parent-reported ADHD-related behaviors during toddlerhood. Results indicate that ADHD-related behaviors are manifest by toddlerhood, supporting screening for both autism and ADHD during early childhood.

Behavior Management Training for Parents of Children with Preschool ADHD Based on Parent-Child Interactions: A Multicenter Randomized Controlled, Follow-Up Study

Objective

There is a need to develop optimized, evidence-based parent training programs tailored for preschoolers with attention deficit hyperactivity disorder (ADHD). The objective of this study was to explore a behavioral management training program aimed at the parents of preschool children with ADHD, which directly analyzes parent-child interaction from the perspective of system theory, and the intervention effect on ADHD in preschool children.

Methods

A multicenter randomized controlled study was conducted using system-based group therapy with 62 parents of preschool children with ADHD aged four to six years. ADHD symptoms, behavioral and emotional problems, and social functioning were compared with 61 control children whose parents did not receive training by applying the ADHD Rating Scale (ADHD-RS), Strengths and Difficulties Questionnaire (SDQ), and Questionnaire-Children with Difficulties (QCD) at the time of subject entry and at two and six months of entry, respectively.

Results

The results of the ADHD-RS assessment showed that children in the intervention group had significantly lower factor scores for attention deficit, hyperactivity, and impulsivity than the children in the control group after parental training and at follow-up (P < 0.05). Total scores on the SDQ scale, as well as character problems, hyperactivity, and peer interaction scores, significantly decreased with statistically significant differences (all P < 0.05), and emotional symptoms and prosocial behavior did not notable decline (P > 0.05). Compared with the control group, the total scores of the QCD scale and the scores of each factor in the intervention group remained significantly higher at the follow-up (P < 0.05).

Conclusion

After continuous intervention for eight weeks, parents were able to help the children with preschool ADHD to improve their ADHD symptoms and emotional behavioral and social functioning significantly, and the efficacy was maintained at the four-month follow-up; the systemic-based parent training in behavior management (PTBM) is applicable to the treatment of preschool ADHD and is worth promoting.

Classifying Young Children with Attention-Deficit/Hyperactivity Disorder Based on Child, Parent, and Family Characteristics: A Cross-Validation Study

We aimed to identify subgroups of young children with differential risks for ADHD, and cross-validate these subgroups with an independent sample of children. All children in Study 1 (N = 120) underwent psychological assessments and were diagnosed with ADHD before age 7. Latent class analysis (LCA) classified children into risk subgroups. Study 2 (N = 168) included an independent sample of children under age 7. A predictive model from Study 1 was applied to Study 2. The latent class analyses in Study 1 indicated preference of a 3-class solution (BIC = 3807.70, p < 0.001). Maternal education, income-to-needs ratio, and family history of psychopathology, defined class membership more strongly than child factors. An almost identical LCA structure from Study 1 was replicated in Study 2 (BIC = 5108.01, p < 0.001). Indices of sensitivity (0.913, 95% C.I. 0.814−0.964) and specificity (0.788, 95% C.I. 0.692−0.861) were high across studies. It is concluded that the classifications represent valid combinations of child, parent, and family characteristics that are predictive of ADHD in young children.

The Developmental Course of Teacher-Rated ADHD Symptom Levels in an Early Childhood Community Sample

OBJECTIVE

This study examined trajectories of inattention and hyperactivity/impulsivity symptom levels across one preschool year and explored variation in trajectories by age, sex, and end-of-year impairment.

METHOD

Participants were 261 preschoolers (87% Head Start; 59% Caucasian; 53% boys; M_age = 3.97 years). Teachers rated ADHD symptom levels four times throughout one academic year.

RESULTS

Results showed a course of increasing inattention that decelerated over time and steadily increasing hyperactivity/impulsivity. Group-based finite mixture modeling revealed three trajectories of inattention: stable low (57%), change (32%), and stable high (11%), as well as three trajectories of hyperactivity/impulsivity: stable low (63%), increasing (26%), and stable high (11%). Compared to children with increasing or changing symptoms levels, children with stable high levels were more impaired and children with stable low symptom levels were less impaired.

CONCLUSION

Findings suggest a "wait and see" approach to treatment may miss an important opportunity for early intervention.

Resting-state EEG Connectivity in Young Children with ADHD

Objective: Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent and impairing neurodevelopmental disorder. While early childhood is a crucial time for early intervention, it is characterized by instability of ADHD diagnosis. Neural correlates of ADHD have potential to improve diagnostic accuracy; however, minimal research has focused on early childhood. Research indicates that disrupted neural connectivity is associated with ADHD in older children. Here, we explore network connectivity as a potential neural correlate of ADHD diagnosis in early childhood.Method: We collected EEG data in 52 medication-naïve children with ADHD and in 77 typically developing controls (3-7 years). Data was collected with the EGI 128 HydroCel Sensor Net System, but to optimize the ICA, the data was down sampled to the 10-10 system. Connectivity was measured as the synchronization of the time series of each pair of electrodes. Subsequent analyses utilized graph theoretical methods to further characterize network connectivity.Results: Increased global efficiency, which measures the efficiency of information transfer across the entire brain, was associated with increased inattentive symptom severity. Further, this association was robust to controls for age, IQ, SES, and internalizing psychopathology.Conclusions: Overall, our findings indicate that increased global efficiency, which suggests a hyper-connected neural network, is associated with elevated ADHD symptom severity. These findings extend previous work reporting disruption of neural network connectivity in older children with ADHD into early childhood.

The 5-HTTLPR-rs25531 S-A-S-A Haplotype and Chronic Stress Moderate the Association Between Acute Stress and Internalizing Mental Disorders Among HIV+ Children and Adolescents in Uganda

Background: Internalizing mental disorders (IMDs) among HIV-positive (HIV+) children and adolescents are associated with poor disease outcomes, such as faster HIV disease progression. Although it has been suggested that the development of IMDs is moderated by interaction of stressful life events and vulnerability factors, the underlying etiology is largely unknown. Serotonin transporter gene [solute carrier family 6 member A4 (SLC6A4)] and human tryptophan hydroxylase 2 gene (TPH2) polymorphisms have been implicated in the development of IMDs. This study investigated the association between acute stress and IMDs, and moderation by chronic stress and genetic variants in SLC6A4 and TPH2. Hypothesis: Acute stress acts through genetic and environmental vulnerability factors to increase the risk of developing IMDs. Methods: Polymorphisms in SLC6A4 (5-HTTLPR, rs25531, 5-HTTLPR-rs25531, and STin2 VNTR) and TPH2 (rs1843809, rs1386494, rs4570625, and rs34517220) were genotyped in 368 HIV+ children and adolescents (aged 5-17 years) with any internalizing mental disorder (depression, anxiety disorders, or posttraumatic stress disorder), and 368 age- and sex-matched controls, who were also HIV+. Chronic and acute stress categories were derived by hierarchical cluster analysis. Logistic regression analysis was used to assess the independent moderating effect of chronic stress and each selected polymorphism on the association between acute stress and IMDs. Results: We observed a statistically significant association between severe acute stress and IMDs (p = 0.001). Children and adolescents who experienced severe acute stress were twice as likely to develop IMDs, compared to children and adolescents who experienced mild acute stress (p = 0.001). Chronic stress interacted with severe acute stress to increase the risk of IMDs (p = 0.033). Acute stress was found to interact with 5-HTTLPR-rs25531 S-A-S-A haplotype to increase the risk for IMDs among Ugandan HIV+ children and adolescents (p = 0.049). We found no evidence for a combined interaction of acute stress, chronic stress, and 5-HTTLPR-rs25531 on IMDs. Conclusion: The odds of having an internalizing mental disorder (IMD) were higher among HIV+ children and adolescents who experienced severe acute stress compared to HIV+ children and adolescents who experienced mild acute stress. Chronic stress and 5-HTTLPR-rs25531 independently moderated the association between acute stress and IMDs.

The Association between Residential Green Space in Childhood and Development of Attention Deficit Hyperactivity Disorder: A Population-Based Cohort Study

BACKGROUND

Access to green space has been hypothesized to have a beneficial impact on children's mental well-being and cognitive development. The underlying mechanisms of the mental health benefits of green space are not fully understood, but different pathways have been suggested, such as the psychologically restoring capacities of green space, the ability to facilitate physical activity and social cohesion, and the mitigation of exposure to air pollution.

OBJECTIVES

In this nationwide cohort study, we investigated associations between residential green space in early childhood and a clinical diagnosis of attention deficit hyperactivity disorder (ADHD).

METHODS

The cohort included individuals, who were born in Denmark between 1992 and 2007 (n=814,689) and followed for a diagnosis of ADHD from age 5, during the period 1997-2016. We used the normalized difference vegetation index (NDVI) as a measure of vegetation greenness surrounding each residential address in a quadratic area of 210m×210m in which the residence was located in the center of the quadrate. Individual exposure to green space was calculated as the average of NDVI surrounding each individual's residential address (or addresses if more than one) between birth and the fifth birthday. Multilevel modeling was used to estimate the incidence rate ratios (IRRs) with 95% confidence intervals (CI) for ADHD, according to exposure level and adjusted for calendar time, age, sex, parental socioeconomic status, neighborhood level socioeconomic status, and urbanicity.

RESULTS

Individuals living in areas defined by sparse green vegetation (lowest decile of NDVI) had an increased risk of developing ADHD, compared with individuals living in areas within the highest decile of NDVI (IRR=1.55; 95% CI: 1.46, 1.65). Adjusting for the known confounders attenuated the result, but the association remained (IRR=1.20; 95% CI: 1.13, 1.28).

CONCLUSION

Our findings suggest that lower levels of green space in residential surroundings, during early childhood, may be associated with a higher risk of developing ADHD. https://doi.org/10.1289/EHP6729.

Early Predictors of ADHD: Evidence from a Prospective Birth Cohort

Objective: To identify preschool predictors of registered ADHD diagnoses and compare two ADHD rating scales, Child Behavior Checklist (CBCL) and Conners' Parent Rating Scale (CPRS-R:S). Method: The Norwegian Mother and Child Cohort study (MoBa) is a prospective population-based cohort study. The sample were singletons whose mothers responded to MoBa questionnaires at child age 3 years (n = 57,986) and 5 years (n = 32,377). ADHD diagnoses were obtained from the Norwegian Patient Register. Predictors were child gender, development and symptoms, and maternal ADHD symptoms. We used Cox proportional hazard regression analyses. Results: In all final models, ADHD symptoms at age 3 and 5 years predicted later ADHD: Age 3, CBCL: hazard ratio (HR) = 3.23 (CI [2.59, 4.02]); age 5, CBCL: HR = 10.30 (CI [7.44, 14.26]); and age 5 CPRS-R:S: HR = 5.92 (CI [4.95, 7.07]). Conclusion: The findings underline the importance of taking early parent-reported symptoms seriously. Both rating scales were useful for predicting ADHD.

Neuroimaging-Based Deep Learning in Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder

Deep learning (DL) is a kind of machine learning technique that uses artificial intelligence to identify the characteristics of given data and efficiently analyze large amounts of information to perform tasks such as classification and prediction. In the field of neuroimaging of neurodevelopmental disorders, various biomarkers for diagnosis, classification, prognosis prediction, and treatment response prediction have been examined; however, they have not been efficiently combined to produce meaningful results. DL can be applied to overcome these limitations and produce clinically helpful results. Here, we review studies that combine neurodevelopmental disorder neuroimaging and DL techniques to explore the strengths, limitations, and future directions of this research area.

Diagnosis and Treatment Options for Preschoolers with Attention-Deficit/Hyperactivity Disorder

Objective: The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), classifies attention-deficit/hyperactivity disorder (ADHD) as a neurodevelopmental disorder, with symptoms becoming apparent as early as the preschool years. Early recognition can lead to interventions such as parent/teacher-administered behavior therapy, the recommended first-line treatment for preschool patients. There are few data, however, to inform the use of second-line, pharmacotherapy options in this population. In this review, we identified recent literature on the diagnosis and treatment of ADHD in preschool children. Methods: A PubMed and clinicaltrials.gov search was conducted for trials assessing efficacy or safety of ADHD medications in children aged <6 years. Diagnostic methods and criteria focusing on recognition of ADHD in preschool children were also surveyed. Results: The DSM-5 describes different manifestations of ADHD in preschool versus school-aged children, but does not list separate criteria by age group. Importantly, behaviors indicative of ADHD in older children may be developmentally appropriate in preschool children. Several behavioral rating scales have been validated in children younger than 6 years of age for assessing ADHD. The Preschool ADHD Treatment Study (PATS) has provided the most extensive efficacy and safety data on methylphenidate (MPH) for ADHD in preschoolers to date, with significant improvement in ADHD symptoms observed with MPH compared with placebo, although adverse event-related discontinuation was higher in PATS compared with studies of MPH for ADHD in school-aged children. Since PATS was conducted, few studies designed to assess ADHD medication effectiveness in preschool children have been published. One article reported significant improvement in ADHD symptoms with MPH (immediate release) versus placebo, two studies showed no difference between MPH and risperidone or MPH plus risperidone in relief of ADHD symptoms, and one study demonstrated the efficacy of atomoxetine versus placebo for ADHD symptoms in preschoolers. Conclusions: Further research is needed on pharmacotherapy for preschool children with ADHD.

Internalizing Mental Disorders and Accelerated Cellular Aging Among Perinatally HIV-Infected Youth in Uganda

Introduction: Internalizing mental disorders (IMDs) in HIV+ children and adolescents are associated with impaired quality of life and non-adherence to anti-retroviral treatment. Telomere length is a biomarker of cellular aging, and shorter telomere length has been associated with IMDs. However, the nature of this association has yet to be elucidated.

Objective: We determined the longitudinal association between IMDs and relative telomere length (rTL) and the influence of chronic stress among Ugandan perinatally HIV-infected youth (PHIY).

Methods: IMDs (depressive disorders, anxiety disorders, and post-traumatic stress disorder) and IMDs were assessed using the locally adapted Child and Adolescent Symptom Inventory-5. In 368 PHIY with any IMD and 368 age- and sex-matched PHIY controls without any psychiatric disorder, rTL was assessed using quantitative polymerase chain reaction. Hierarchical cluster analysis was used to generate the three chronic stress classes (mild, moderate, and severe). t-tests were used to assess the difference between baseline and 12 month rTL and the mean difference in rTL between cases and controls both at baseline and at 12 months. Linear regression analysis was used to model the effects of chronic stress on the association between IMDs and rTL, controlling for age and sex.

Results: We observed longer rTL among cases of IMDs compared with controls (p < 0.001). We also observed a statistically significant reduction in rTL between baseline and 12 months in the combined sample of cases and controls (p < 0.001). The same statistical difference was observed when cases and controls were individually analyzed (p < 0.001). We found no significant difference in rTL between cases and controls at 12 months (p = 0.117). We found no significant influence of chronic stress on the association between IMDs and rTL at both baseline and 12 months.

Conclusion: rTL is longer among cases of IMDs compared with age- and sex-matched controls. We observed a significant attrition in rTL over 12 months, which seems to be driven by the presence of any IMDs. There is a need for future longitudinal and experimental studies to understand the mechanisms driving our findings.

The role of effortful control in the development of ADHD, ODD, and CD symptoms

Many adolescents have difficulty regulating their impulses and become prone to externalizing problems (e.g., attention-deficit/hyperactivity disorder [ADHD], oppositional defiant disorder [ODD], and conduct disorder [CD]) and other adverse consequences. Using multimethod data from a longitudinal study of Mexican-origin youth (N = 674), assessed annually from age 10 to 16, we examined the relations between effortful control and ADHD, ODD, and CD symptoms over time. Bivariate latent growth curve models showed negative correlations between the trajectories of effortful control and ADHD, ODD, and CD, indicating that steeper decreases in effortful control were related to steeper increases in ADHD, ODD, and CD symptoms. Using a novel statistical technique, the factor of curves model (FOCUS), we found that ADHD, ODD, and CD share a common "externalizing" trajectory during adolescence. Although effortful control was strongly associated with this common trajectory, it had few unique associations with the individual disorder trajectories, above and beyond their shared trajectory. When we extended the FOCUS model to include the effortful control trajectory as an indicator, we found that ADHD and ODD had strong loadings, whereas effortful control and CD had comparatively weak loadings on the shared developmental trajectory. Follow-up analyses showed that a two-factor solution, with externalizing symptom trajectories on one factor and the effortful control facet trajectories on a separate factor, was a better fit to the data than a one-factor solution. Finally, parent ASPD symptoms were related to increases in CD, but had no significant influence on effortful control, ADHD, or ODD. We discuss the implications for personality and externalizing problem development. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Maternal Thyroid Function During Pregnancy or Neonatal Thyroid Function and Attention Deficit Hyperactivity Disorder: A Systematic Review

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder in children, yet its etiology is poorly understood. Early thyroid hormone disruption may contribute to the development of ADHD. Disrupted maternal thyroid hormone function has been associated with adverse neurodevelopmental outcomes in children. Among newborns, early-treated congenital hypothyroidism has been consistently associated with later cognitive deficits.

METHODS

We systematically reviewed literature on the association between maternal or neonatal thyroid hormones and ADHD diagnosis or symptoms. We searched Embase, Pubmed, Cinahl, PsycInfo, ERIC, Medline, Scopus, and Web of Science for articles published or available ahead of print as of April 2018.

RESULTS

We identified 28 eligible articles: 16 studies of maternal thyroid hormones, seven studies of early-treated congenital hypothyroidism, and five studies of neonatal thyroid hormones. The studies provide moderate evidence for an association between maternal thyroid hormone levels and offspring ADHD, some evidence for an association between early-treated congenital hypothyroidism and ADHD, and little evidence for an association between neonatal thyroid hormone levels and later ADHD.

CONCLUSIONS

The reviewed articles suggest an association between maternal thyroid function and ADHD, and possibly between early-treated congenital hypothyroidism and ADHD. Study limitations, however, weaken the conclusions in our systematic review, underlining the need for more research. Importantly, there was much variation in the measurement of thyroid hormone function and of ADHD symptoms. Recommendations for future research include using population-based designs, attending to measurement issues for thyroid hormones and ADHD, considering biologically relevant covariates (e.g., iodine intake), and assessing nonlinear dose-responses.

A National Profile of Attention-Deficit Hyperactivity Disorder Diagnosis and Treatment Among US Children Aged 2 to 5 Years

OBJECTIVE

Clinical guidelines provide recommendations for diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD), with specific guidance on caring for children younger than 6 years. This exploratory study describes ADHD diagnosis and treatment patterns among young children in the United States using 2 nationally representative parent surveys.

METHODS

The National Survey of Children's Health (2007-2008, 2011-2012) was used to produce weighted prevalence estimates of current ADHD and ADHD medication treatment among US children aged 2 to 5 years. The National Survey of Children with Special Health Care Needs (2009-2010) provided additional estimates on types of medication treatment and receipt of behavioral treatment among young children with special health care needs (CSHCN) with ADHD.

RESULTS

In 2011 to 2012, 1.5% of young children (approximately 237,000) had current ADHD compared to 1.0% in 2007 to 2008. In 2011 to 2012, 43.7% of young children with current ADHD were taking medication for ADHD (approximately 104,000). In young CSHCN with ADHD, central nervous system stimulants were the most common medication type used to treat ADHD, and 52.8% of young CSHCN with current ADHD had received behavioral treatment for ADHD in the past year.

CONCLUSION

Nearly a quarter million In young CSHCN have current ADHD, with a prevalence that has increased by 57% from 2007 to 2008 to 2011 to 2012. The demographic patterns of diagnosis and treatment described in this study can serve as a benchmark to monitor service use patterns of young children diagnosed with ADHD over time.

Co-Occurrence of ODD and CD in Preschool Children With Symptoms of ADHD

OBJECTIVE

Patterns of co-occurrence between ADHD, Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD) were examined in a sample of non-referred preschool children. ADHD subtypes and sex differences were also explored.

METHOD

Children aged 3.5 years ( n = 1,048) with high scores on ADHD characteristics were recruited from the Norwegian Mother and Child Cohort Study and clinically assessed, including a semi-structured psychiatric interview.

RESULTS

In children with ADHD, concurrent ODD was present more often than CD (31% vs. 10%), but having ADHD gave higher increase in the odds of CD than of ODD (ODD: odds ratio [OR] = 6.7, 95% confidence interval [CI] = [4.2, 10.8]; CD: OR = 17.6, 95% CI = [5.9, 52.9]). We found a greater proportion of children having the combined ADHD subtype as well as more severe inattentiveness among children with co-occurring CD compared with ODD. Sex differences were minor.

CONCLUSION

There are important differences in co-occurring patterns of ODD and CD in preschool children with ADHD.

Attention Deficit Hyperactivity Disorder in Preschool-Age Children

Attention deficit hyperactivity disorder is a neurodevelopmental disorder marked by age-inappropriate deficits in attention or hyperactivity/impulsivity that interfere with functioning or development. It is highly correlated with other disorders, such as oppositional defiant disorder, conduct disorder, and mood symptoms. The etiology is multifactorial, and neuroimaging findings are nonspecific. Although assessment tools exist, there is variability among them, and historically, parent-teacher agreement has not been consistent. Treatment algorithm for attention deficit hyperactivity disorder in preschoolers includes behavioral interventions first followed by psychopharmacologic treatment when behavioral therapies fail. Other nonpharmacologic and nonbehavioral interventions are discussed including the role of exercise and nutrition.

Early development of comorbidity between symptoms of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD)

Attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are among the most common childhood disorders and frequently co-occur. The present study sought to advance our understanding of how comorbidity between ADHD and ODD develops during the preschool years by testing a cross-lagged model that integrates 2 prominent models: the developmental precursor model and the correlated risk factors model. Participants were 199 children (107 boys) who took part in a longitudinal study of preschoolers with behavior problems. Parent reports of ADHD and ODD symptoms were collected annually from ages 3 to 6 and a family history interview was administered at age 3. In support of the developmental precursors model, ADHD symptoms predicted later argumentative/defiant symptoms. In support of the correlated risk factors model, family histories of ADHD and ODD/CD symptoms were correlated risk factors that uniquely predicted ADHD and anger/irritable symptoms in children. Results suggest that the correlated risk factors model may best explain the development of comorbidity between symptoms of ADHD and anger/irritability, whereas the developmental precursors model may better explain the development of comorbidity between symptoms of ADHD and argumentative/defiance.

Temperamental predictors of developmental trajectories of inattention and hyperactivity-impulsivity problems in schoolchildren

Background

The current study aimed to examine the temperamental predictors of developmental trajectory subgroups of children's inattention and hyperactivity–impulsivity problems through a short-term longitudinal study.

Methods

Children (n = 1344) were divided into younger (age 6–8 years) and older (age 9–11 years) groups in order to observe changes in inattention and hyperactivity–impulsivity problems. Inattention and hyperactivity–impulsivity problems were measured three times at 5-month intervals and Cloninger's four temperaments (novelty seeking, harm avoidance, reward dependence, and persistence) were examined on the first occasion only. A cohort sequential design and growth mixture model were used for investigating trajectory subgroups and multiple logistic regression analysis to examine the temperamental predictors.

Results

Developmental trajectories of inattention and hyperactivity–impulsivity showed different subgroupings depending on the age group of children. Temperament (high score on novelty seeking and low score on persistence as well as high score on reward dependence) and gender predicted the likelihood of belonging to high-risk versus low-risk subgroups.

Conclusion

Suggestions taking into account the predictors of developmental trajectories in inattention and hyperactivity–impulsivity problems for future research are discussed along with the limitations of the current study.

Preschool hyperactivity specifically elevates long-term mental health risks more strongly in males than females: a prospective longitudinal study through to young adulthood

Evidence of continuities between preschool hyperactivity and adult mental health problems highlights the potential value of targeting early identification and intervention strategies. However, specific risk factors are currently unclear. This large-scale prospective longitudinal study aimed to identify which hyperactive preschoolers are at the greatest long-term risk of poor mental health. One hundred and seventy children (89 females) rated as hyperactive by their parents, and 88 non-hyperactive controls (48 females) were identified from a community sample of 4215 3-year-olds. Baseline data relating to behavioral/emotional problems and background characteristics were collected. Follow-up mental health and functional impairment outcomes were collected between 14 and 25 years of age. At age 3 years, males and females in the hyperactive group had similarly raised levels of hyperactivity and other behavior problems. In adolescence/young adulthood, these individuals showed elevated symptoms of ADHD, conduct disorder, mood disorder, anxiety and autism, as well as functional impairment. Preschool hyperactivity was strongly predictive of poor adolescent/adult outcomes for males across domains with effects being specifically driven by hyperactivity. For females, the effects of preschool hyperactivity were smaller and dropped to non-significant levels when other preschool problems were taken into account. Environmental risk factors also differed between the sexes, although these may also have been mediated by genetic risk. In conclusion, these results demonstrate marked sex differences in preschool predictors of later adolescent/adult mental health problems. Future research should include a measure of preschool inattention as well as hyperactivity. The findings highlight the potential value of tailored approaches to early identification strategies.

A Flow Chart of Behavior Management Strategies for Families of Children with Co-Occurring Attention-Deficit Hyperactivity Disorder and Conduct Problem Behavior

Behavioral parent training is an evidence-based treatment for problem behavior described as attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct disorder. However, adherence to treatment fidelity and parent performance of the management skills remains an obstacle to optimum outcome. One variable that may limit the effectiveness of the parent training is that demanding behavior management procedures can be deceptively complicated and difficult to perform. Based on outcome research for families of children with co-occurring ADHD and conduct problem behavior, an example of a visual behavior management flow chart is presented. The flow chart may be used to help teach specific behavior management skills to parents. The flow chart depicts a chain of behavior management strategies taught with explanation, modeling, and role-play with parents. The chained steps in the flow chart are elements common to well-known evidence-based behavior management strategies, and perhaps, this depiction well serve as a setting event for other behavior analysts to create flow charts for their own parent training, Details of the flow chart steps, as well as examples of specific applications and program modifications conclude.

The Development of Comorbid Conduct Problems in Children With ADHD: An Example of an Integrative Developmental Psychopathology Perspective

OBJECTIVE

We describe interactions among factors that contribute to the development of conduct problems among children with ADHD.

METHOD

An integrative developmental psychopathology analysis combines various approaches and posits one model of how diverse risk factors operate together to contribute to the development of conduct problems among children with ADHD.

RESULTS

Substantial genetic risk increases covariation between ADHD and conduct problems. Candidate genes are associated with CNS monoaminergic neurotransmission. Subsequent neurodevelopmental impairment interferes with executive function, with impaired verbal working memory playing an important role. Parent/child bi-directional influences exacerbate the risk for conduct problems when ADHD symptoms increase the likelihood of a coercive parenting style. Parent stress in reaction to child comorbid ADHD and conduct problems, and parent attribution for the child's conduct problem behavior, add to the potential for coercion and reduce constructive parent-child interaction that might otherwise enhance the development of verbal working memory.

CONCLUSION

In an integrated manner, these variables increase the risk that a child with ADHD will subsequently develop conduct problems.

The emergence and stability of attention deficit hyperactivity disorder in boys with fragile X syndrome

BACKGROUND

Children with fragile X syndrome (FXS) are at high risk for developing a range of behavioural disorders, including attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorders (ASD). However, very few studies have investigated the comorbid profile of FXS and ADHD and the possible dissociation from the FXS and ASD profile. The present study examined the relationship of childhood temperament characteristics of the Surgency facet (activity level, impulsivity, approach, shyness, and smiling and laughter) and the severity of ADHD and ASD features at two measurement time points in childhood, preschool (ages 3-4) and at school entry (ages 5-6).

METHODS

The study consisted of males with FXS measured at each time point (preschool and school entry), as well as comparison of typically developing (TD) boys at the preschool measurement time point. Parent reported measures of temperament and behavioural symptoms were collected at each time point. Multiple regression analyses were used to analyse obtained data.

RESULTS

Elevated activity level scores are associated with ADHD scores at preschool age and elevated shyness and decreased smiling and laughter are strongly associated with ADHD scores upon school entry. Impulsivity emerges as a strong indicator of elevated ADHD scores around school age, but even preschool impulsivity scores demonstrate some predictive value for higher ADHD scores later in school. Finally, no Surgency characteristic was significantly related to ASD scores at any age.

CONCLUSIONS

Impulsivity serves as an indicator of elevated ADHD symptoms across development periods in boys with FXS, while activity level is just indicative of higher ADHD scores at the preschool age. The Surgency facet of temperament at either age does not predict strong relationships of comorbid pathologies of ADHD and ASD in FXS. However, Surgency characteristics may serve as informative discriminative factors when studying behavioural outcomes in boys with FXS.

Comparison of the effects of methylphenidate and the combination of methylphenidate and risperidone in preschool children with attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is a common psychiatric disorder among preschool children but the number of controlled clinical trials regarding psychopharmacological treatment in this age group is limited. The aim of this study was to compare methylphenidate with the combination of methylphenidate and risperidone in preschool children with ADHD. Forty-two preschool children, aged 3–6 years, diagnosed with ADHD by a child and adolescent psychiatrist according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-Text Revision criteria, were enrolled in a 6-week, single-blind clinical trial and administered with methylphenidate (5–30 mg/dl) or the combination of methylphenidate and risperidone (0.25–2 mg/dl) in Iran. Treatment outcomes were assessed using the Conners' Rating Scale and Clinical Global Impression (CGI) Scale at baseline and 3 and 6 weeks after starting the drugs administration. Side effects were rated by a checklist and body weight was measured at each visit. There were no significant differences between the two protocols in Parent Conners' Rating Scale scores (P > 0.05) and CGI scores (P > 0.05). Both groups showed a significant improvement in ADHD symptoms over the 6 weeks of treatment for Parent Conners' Rating Scale (P < 0.001). The combination group used significantly lower doses of methylphenidate compared to the other group (P = 0.002). The most common adverse effects were anorexia (21.7%) and daytime drowsiness (17.4%) in combination treatment group and insomnia (33.3%) and anorexia (25%) in methylphenidate group. Risperidone and methylphenidate may be effective and well tolerated in preschool children with ADHD, and adding risperidone to methylphenidate may decrease the occurrence of some side effects of methylphenidate such as insomnia and anorexia and lower the dose of methylphenidate may be needed to control symptoms.

Klinische Diagnostik der ADHS im Vorschulalter

Die Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) ist eine der häufigsten psychischen Störungen des Kindes- und Jugendalters und weist negative Folgen für die Betroffenen und das nähere Umfeld auf. Eine frühzeitige Erkennung von ADHS wäre für die Planung von Präventivmaßnahmen sinnvoll, um langfristige Folgen zu vermeiden. Ziel des Überblickartikels ist eine Bestandsaufnahme über die verfügbaren Fragebögen und klinischen Interviews zur Diagnostik von ADHS im Vorschulalter (3–5 Jahre). Es werden für den deutschen und den internationalen Raum verfügbare Verfahren verglichen und kritisch bewertet. Die Bedeutung von Fragebögen und klinischen Interviews im Rahmen einer ADHS-Diagnostik wird diskutiert.

Risperidone Versus Methylphenidate in Treatment of Preschool Children With Attention-Deficit Hyperactivity Disorder

Background:

Attention Deficit Hyperactivity Disorder (ADHD) is a common psychiatric diagnosis among preschool children.

Objectives:

The aim of this study was to examine the Risperidone treatment compared to Methylphenidate (MPH) in preschool children with ADHD.

Patients and Methods:

Thirty three outpatient preschool children, aged 3-6 years, diagnosed with ADHD (The diagnosis of ADHD was established by two child and adolescent psychiatrists according to the DSM-IV-TR criteria), participated in a 6-week, double-blind clinical trial with risperidone (0.5-1.5 mg/d) and methylphenidate (5-20 mg/d), in two divided doses. Treatment outcomes were assessed using the Parent ADHD Rating Scale and Conners Rating Scale. Patients were assessed by a child psychiatrist at baseline, 2, 4 and 6 weeks after the medication started. Side effects were also rated by side effects questionnaire.

Results:

There were no significant differences between the two protocols on the Parent ADHD Rating Scale scores (P > 0.05) and Parent Conners Rating Scale scores (P > 0.05). Both groups showed a significant improvement in ADHD symptoms over the 6 weeks of treatment for parent ADHD Rating Scale (P < 0.001) and Parent Conners Rating Scale (P < 0.001). The most common adverse effects seen with risperidone were daytime drowsiness and anorexia (20%), and with methylphenidate it was anorexia (55%).

Conclusions:

Results of this study show that risperidone may be effective and well tolerated for ADHD in preschool children, but more researches are needed to clarify the potential benefits and adverse effects in long term use and comorbid conditions.

A clinical study of attention-deficit/hyperactivity disorder in preschool children--prevalence and differential diagnoses

OBJECTIVE

We aimed to examine (1) the prevalence and characteristics of ADHD in preschool children, and (2) differential diagnoses among children who display symptoms of inattention and hyperactivity-impulsivity in early childhood.

METHODS

The participants were children living in Kanie-cho, in Japan's Aichi Prefecture, who underwent their age 5 exams at the municipal health center between April 2009 and March 2011. We first extracted children who were observed to be inattentive or hyperactive-impulsive during their age 5 exams and considered as possibly having ADHD. We conducted follow-ups with these children using post-examination consultations, visits to preschools, and group rehabilitation. The results of the age 5 exams were combined with behavior observations and interview content obtained during subsequent follow-ups. A child psychiatrist and several clinical psychologists discussed these cases and made a diagnosis in accordance with the DSM-IV-TR.

RESULTS

91 (15.6%) of the 583 children selected were considered as possibly having ADHD; we were able to conduct follow-ups with 83 of the 91 children. Follow-up results showed that 34 children (5.8% of all participants) remained eligible for a diagnosis of ADHD. Diagnoses for the remaining children included: pervasive developmental disorders (six children, or 6.6% of suspected ADHD children), intellectual comprehension problems (four children, or 4.4%), anxiety disorders (seven children, or 7.7%), problems related to abuse or neglect (four children, or 4.4%), a suspended diagnosis for one child (1.1%), and unclear diagnoses for 29 children (31.9%).

CONCLUSIONS

ADHD tendencies in preschool children vary with changing situations and development, and the present study provides prevalence estimates that should prove useful in establishing a diagnostic baseline.

Attention-deficit/hyperactivity disorder in young children: predictors of diagnostic stability

OBJECTIVES

The goals of this study were (1) to provide estimates of diagnostic stability for a sample of young children diagnosed with attention-deficit/hyperactivity disorder (ADHD) after undergoing comprehensive multidisciplinary assessments and (2) to identify baseline child and family characteristics that predict diagnostic stability over time.

METHODS

Children aged 3 to 6 years, 11 months consecutively diagnosed with ADHD after multidisciplinary consultations at a tertiary care clinic between 2003 and 2008 were recontacted in 2012 and 2013 (N = 120). At follow-up, the primary outcome was the proportion of children who continued to meet diagnostic criteria for ADHD. To identify predictors of diagnostic stability, logistic regression models were used. In addition, a latent class model was used to independently classify subjects into distinct clusters.

RESULTS

In this cohort, 70.4% of the children contacted at follow-up continued to meet diagnostic criteria for ADHD. Predictors of diagnostic stability included externalizing and internalizing symptoms at baseline, parental history of psychopathology, and family socioeconomic status. The latent class model independently identified 3 distinct profiles: (1) children who no longer met ADHD criteria; (2) children with persistent ADHD and high parental psychopathology; and (3) children with persistent ADHD and low family socioeconomic status.

CONCLUSIONS

Young children who underwent comprehensive developmental and psychological assessments before receiving an ADHD diagnosis, had higher rates of diagnostic stability than in previous studies of community samples. Child and family factors that predict diagnostic stability have the potential to guide treatment planning for children diagnosed with ADHD before 7 years of age.

ADHS im Vorschulalter

Aktivitäts- und Aufmerksamkeitsstörungen (ADHS) im Vorschulalter sind der ADHS im Grundschulalter bezüglich Erscheinungsbild und Komorbiditäten teils ähnlich und teils unähnlich. Zudem ergeben sich besondere Herausforderungen hinsichtlich der Diagnostik und Behandlung u. a. aufgrund altersabhängiger Diagnosekriterien, einer schwierigen Unterscheidung von altersadäquatem und abweichendem Verhalten und erhöhten Nebenwirkungen bei der medikamentösen Behandlung. Daher werden in diesem Übersichtsartikel Subtypen und Komorbiditäten von ADHS, für den klinischen Gebrauch geeignete Diagnostikinstrumente sowie gezielte Behandlungsansätze, insbesondere Elterntrainings und Medikation, genauer betrachtet.

Association between variation in neuropsychological development and trajectory of ADHD severity in early childhood

OBJECTIVE

This longitudinal study examined if changes in neuropsychological functioning were associated with the trajectory of symptoms related to attention deficit hyperactivity disorder (ADHD) and impairment between preschool and school age.

METHOD

The sample consisted of 3- and 4-year-old children (N=138) who were identified as being at risk for ADHD based on parent and teacher reports. Neuropsychological functioning was measured annually using the NEPSY at four time points (mean ages, 4.19, 5.36, 6.35, and 7.35 years). ADHD symptoms and impairment were assessed with semiannual parent and teacher reports using the ADHD Rating Scale-IV and the Children's Problems Checklist at 10 time points (mean ages at baseline and final assessment, 4.19 and 8.81 years, respectively). Hierarchical linear modeling was used to assess the trajectories of change in neuropsychological functioning and ADHD severity as well as the association of change in neuropsychological functioning with change in ADHD severity over time.

RESULTS

Baseline neuropsychological functioning was not significantly associated with the slope of change in ADHD severity. However, the magnitude of change in neuropsychological functioning was linearly associated with the trajectory of ADHD symptom severity and impairment, such that individuals with greater neuropsychological growth over time had a greater diminution of ADHD severity and impairment. Family socioeconomic status at baseline was significantly associated with initial ADHD severity and impairment, but not with change over time.

CONCLUSIONS

Interventions that enhance neuropsychological functioning at an early age may be beneficial in attenuating long-term ADHD severity and impairment.

Assessment of attention in preschoolers

In the past two decades, there has been an increased interest in the assessment and treatment of preschool children presenting with concerns about attention problems. This article reviews the research and clinical literature involving assessment of attention and related skills in the preschool years. While inattention among preschoolers is common, symptoms alone do not necessarily indicate a disorder, and most often represent a normal variation in typical preschool child development. Thus, accurate identification of "disordered" attention in preschoolers can be challenging, and development of appropriate, norm-referenced tests of attention for preschoolers is also difficult. The current review suggests that comprehensive assessment of attention and related functions in the preschool child should include thorough review of the child's history, planned observations, and formal psychometric testing. The three primary methods of psychometric assessment that have been used to characterize attentional functioning in preschool children include performance-based tests, structured caregiver interviews, and rating scales (parent, teacher, and clinician). Among performance-based methods for measurement of attention in the preschool years, tests have been developed to assess sustained attention, selective (focused) attention, span of attention (encoding/manipulation), and (top-down) controlled attention--including freedom from distractibility and set shifting. Many of these tests remain experimental in nature, and review of published methods yields relatively few commercially available, nationally normed tests of attention for preschoolers, and an overall dearth of reliability and validity studies on the available measures.

Parent-reported Attention Deficit/Hyperactivity symptomatology in preschool-aged children: factor structure, developmental change, and early risk factors

Although Attention Deficit/Hyperactivity Disorder (ADHD) has increasingly been studied in preschool-aged children, relatively few studies have provided a comprehensive evaluation of the factor structure and patterns of developmental changes in parent-reported ADHD symptomatology across the early childhood period. This study used confirmatory factor analyses to test for longitudinal measurement invariance of ADHD symptoms and semi-parametric finite mixture models to identify prototypic patterns of developmental changes in ADHD symptomatology from 3 to 5 years of age. Participants were 1155 children and their parents who participated in a prospective longitudinal study involving a representative sample of children who resided in six non-metropolitan counties in the United States. Results indicated that (1) ADHD symptomatology was best represented by a single latent factor that exhibited partial measurement invariance from 3 to 5 years of age, (2) 8.5 % of children exhibited sustained high levels of ADHD symptoms from age 3-5 years, and (3) a variety of risk factors differentiated children with sustained high from those with sustained low levels of ADHD, relatively few (most notably caregiver education) were able to differentiate children with sustained high levels of ADHD symptoms from all other groups. Children who exhibit persistent ADHD symptomatology across the early childhood period may define a clinically important group for etiologic research and/or early intervention efforts.

Moderators of working memory deficits in children with attention-deficit/hyperactivity disorder (ADHD): a meta-analytic review

Working memory has assumed a prominent role as a primary neurocognitive deficit or endophenotype in extant models of attention-deficit/hyperactivity disorder (ADHD). The current study updated previous reviews and employed meta-analytic techniques to examine a broad range of moderating variables of effect size heterogeneity across phonological and visuospatial working memory tasks. Collectively, results revealed large between-group effect sizes across both working memory domains. In addition, several sample (percent female) and task (number of experimental trials, recall vs. recognition tasks, and demands on the central executive) moderating variables explained significant effect size variability among phonological and visuospatial studies. These findings suggest that children with ADHD exhibit statistically significant, large magnitude working memory deficits relative to their typically developing peers.