Comorbidity in ADHD: implications for research, practice, and DSM-V

Associations Between Child and Parent Characteristics and Parenting Stress in Japanese Mothers of Children With Attention Deficit Hyperactivity Disorder (ADHD)

OBJECTIVE

Parents of children with attention deficit hyperactivity disorder (ADHD) experience elevated levels of stress in their parenting role. Understanding what contributes to such stress is important for its management.

METHODS

We assessed associations between child and parent characteristics and parenting stress in Japanese mothers of 6-12-year-old children with ADHD recruited through the community (n = 51) and hospital child psychiatry/pediatric clinics (n = 124). Hierarchical multiple regression analyses assessed the extent to which child symptom severity (ADHD and ODD), parenting efficacy, depression, and maternal ADHD symptoms explained variance in both child-domain and parent-domain parenting stress.

RESULTS

Child symptom severity and maternal depression accounted for significant variance in child-domain parenting stress. Child ODD, parenting efficacy, depression, and maternal ADHD (clinic sample) explained significant variance in parent-domain parenting stress. Exploratory cross-sectional mediational analyses highlight the inter-relatedness of the associations between parenting-efficacy, maternal depression and parent-domain parenting stress. The association between maternal ADHD and parent-domain parenting stress is statistically fully mediated by maternal depression.

CONCLUSION

The pattern of associations between child and parent characteristics and parenting stress in Japanese mothers of children with ADHD are consistent with Abidin's model of parenting stress with implications for clinical management.

A novel approach to ADHD classification based on severity and emotional impairment: Findings from artificial intelligence analysis

Attention Deficit Hyperactivity Disorder (ADHD) is a disorder characterized by symptoms of inattention and executive dysfunction, although there is not always agreement on the onset, course and long-term stability of the diagnosis. This study aims to detect differences in the cognitive profile according to the subtype of ADHD following a professional diagnosis and to propose an alternative classification. The scores obtained for each cognitive construct were compared using the Student's t-test. In order to explore different diagnostic categories based on groupings made by Artificial Intelligence (AI) subjects were grouped based on their performance through the K-means clustering technique. The results obtained by Artificial Intelligence (AI) identified groups based on the severity of the cognitive profile and the presence of emotional impairment. Difficulties in perceived planning within family and school environments were highlighted as major risk factors in the severity of ADHD in children. Emotional disturbances perceived by both parents, such as depressive symptoms, anxiety, and somatization, were observed subsequently. In accordance with the results, an alternative way to classify ADHD is possible, involving categorization according to the presence or absence of emotional impairment, along with the severity of impairment in attentional and executive functions.

Oppositional Defiant Disorder in Autism and ADHD

Our study compared oppositional defiant disorder (ODD) in children with autism to ADHD-Combined presentation and ADHD-Inattentive presentation. Mothers of 2,400 children 3-17 years old with autism and/or ADHD completed the Pediatric Behavior Scale. ADHD-Combined was most strongly associated with ODD, with an ODD prevalence of 53% in children with ADHD-Combined only. When autism was added to ADHD-Combined, prevalence increased to 62% and the ODD score increased significantly. Autism+ADHD-Inattentive, Autism Only, and ADHD-Inattentive Only had ODD prevalences of 28%, 24% and 14%. In each diagnostic group, ODD had the same two factors (irritable/angry and oppositional/defiant); demographic differences between children with and without ODD were few; and correlations between ODD and conduct problems were large, correlations with depression were medium, and correlations with anxiety were small. However, ODD scores differed significantly between groups (Autism+ADHD-Combined > ADHD-Combined Only > Autism+ADHD-Inattentive and Autism Only > ADHD-Inattentive Only). The irritable/angry ODD component was greater in Autism+ADHD-Combined than in ADHD-Combined Only, whereas the oppositional/defiant component did not differ between the two groups. Autism was a significant independent risk factor for ODD, particularly the irritable/angry ODD component, but ADHD-Combined was the strongest risk factor. Therefore, the high co-occurrence of ADHD-Combined in autism (80% in our study) largely explains the high prevalence of ODD in autism. ADHD-Combined, autism, and ODD are highly comorbid (55-90%). Clinicians should assess all three disorders in referred children and provide evidence-based interventions to improve current functioning and outcomes for children with these disorders and reduce family and caretaker stress.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Process evaluation of a Structured E-parenting Support (STEPS) in the OPTIMA randomised controlled trial: a protocol

INTRODUCTION

Structured E-parenting Support (STEPS) is a digital application (app) designed to help parents manage behaviour of their children who are referred to mental health services and are waiting for an assessment or treatment. STEPS is currently being evaluated in the Online Parent Training for the Initial Management of Attention-Deficit/Hyperactivity Disorder randomised controlled trial. Alongside the examination of STEPS' clinical and cost-effectiveness, we are conducting a process evaluation to better understand the contextual factors that may influence study outcomes. The purpose of this protocol is to describe the aims, objectives and methodology of the process evaluation prior to it taking place to add to the fidelity and rigour of the trial process and outcomes. Our goal is to adapt STEPS to optimise its benefits in future applications.

METHODS

In line with the Medical Research Council guidelines for evaluating complex interventions, the process evaluation will adopt a mixed method design using qualitative data collected from clinicians and parent interviews and app usage data from participants assigned to the intervention arm.

ANALYSIS

Qualitative data from semistructured interviews and free text box responses included in trial questionnaires will be analysed thematically using framework analysis to better understand how parents use STEPS, how it works and key factors that could aid or hinder its effective implementation in routine clinical practice.

ETHICS

The application for ethical approval for the study was submitted to the North West-Liverpool Central Research Ethics Committee and received a favourable opinion on further information on 26 November 2021, reference number 21/NW/0319.

DISSEMINATION

The process evaluation aims to explore how a digital app might support parents in managing their child's behaviour. Implications for policy and research will be explored and the clinical implications of offering the app to a wider audience to address the lack of support to parents as highlighted in this paper. We plan to publish findings in international, peer-reviewed journals as well as present at conferences.

TRIAL REGISTRATION NUMBER

The trial has been prospectively registered on 18 November 2021; ISRCTN816523503. https://www.isrctn.com/ISRCTN16523503.

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

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

Prevalence of somatic diseases in adults with attention deficit hyperactivity disorder in Japan is highest in people aged ≥40 years with mental disorders: a cross-sectional study of a Japanese health insurance claims database

Introduction

Studies have reported an association between attention deficit hyperactivity disorder (ADHD) and somatic diseases; however, the correlation of mental disorders with the association between ADHD and somatic diseases remains uninvestigated. This study investigated and compared the prevalence of somatic diseases among adults with/without ADHD, stratified by the presence or absence of mental disorders.

Methods

This cross-sectional study (October 2020-September 2021), using data (June 2013-September 2021) from a Japanese health insurance claims database, included adult participants with a medical record of and receiving medication for ADHD (ADHD group); the control group (matched 1:5 by age/sex) comprised participants without ADHD. The prevalence and odds ratio (OR; ADHD versus control) of type 2 diabetes mellitus (T2DM), diabetes complications, hypertension, cardiovascular disease (CVD), dyslipidemia, gout and hyperuricemia, chronic obstructive pulmonary disease (COPD), non-alcoholic fatty liver disease/non-alcoholic steatohepatitis (NAFLD/NASH), and atopic dermatitis were investigated. Pooled ORs for stratified analysis were calculated using the Mantel-Haenszel method.

Results

In the matched analysis sets, the ORs for all somatic diseases were significantly higher for the ADHD group (n=15,028) versus the control group (n=74,796). On stratified analysis, the Mantel-Haenszel ORs were significant for NAFLD/NASH (1.53; 95% confidence interval [CI]: 1.34, 1.73), diabetes complications (1.39; 95% CI: 1.09, 1.77), and gout and hyperuricemia (1.34; 95% CI: 1.19, 1.51). Furthermore, the stratum-specific ORs for T2DM, hypertension, and dyslipidemia were >1 and <1 in the presence and absence of mental disorders, respectively. The prevalence of all somatic diseases except atopic dermatitis increased with age. For participants aged ≥40 years, the Mantel-Haenszel ORs were significant for all somatic diseases except CVD, COPD, and atopic dermatitis.

Conclusions

The prevalence of several somatic diseases, including chronic disorders, was high among adults with ADHD, particularly in those aged ≥40 years and those with mental disorders.

Remote Recruitment Strategy and Structured E-Parenting Support (STEPS) App: Feasibility and Usability Study

BACKGROUND

The Structured E-Parenting Support (STEPS) app provides support for parents of children with elevated hyperactivity, impulsivity, inattention, and conduct problems who are awaiting clinical assessment. STEPS will be evaluated in a randomized controlled trial (RCT) within the Online Parent Training for the Initial Management of ADHD Referrals (OPTIMA) research program in the United Kingdom. Phase 1 of the OPTIMA tested the feasibility of participants' recruitment and the app's usability.

OBJECTIVE

This study aimed to adapt a digital routine clinical monitoring system, myHealthE, for research purposes to facilitate waitlist recruitment; test using remote methods to screen and identify participants quickly and systematically; pilot the acceptability of the recruitment and assessment protocol; and explore the usability of STEPS.

METHODS

myHealthE was adapted to screen patients' data. Parents' and clinicians' feedback on myHealthE was collected, and information governance reviews were conducted in clinical services planning to host the RCT. Potential participants for the observational feasibility study were identified from new referrals using myHealthE and non-myHealthE methods. Descriptive statistics were used to summarize the demographic and outcome variables. We estimated whether the recruitment rate would meet the planned RCT sample size requirement (n=352). In addition to the feasibility study participants, another group of parents was recruited to assess the STEPS usability. They completed the adapted System Usability Scale and responded to open-ended questions about the app, which were coded using the Enlight quality construct template.

RESULTS

Overall, 124 potential participants were identified as eligible: 121 (97.6%) via myHealthE and 3 (2.4%) via non-myHealthE methods. In total, 107 parents were contacted, and 48 (44.9%) consented and were asked if, hypothetically, they would be willing to participate in the OPTIMA RCT. Of the 28 feasibility study participants who provided demographic data, 21 (75%) identified as White. Their children had an average age of 8.4 (SD 1.7) years and 65% (31/48) were male. During the primary recruitment period (June to July 2021) when 45 participants had consented, 38 (84%) participants agreed hypothetically to take part in the RCT (rate of 19/mo, 95% CI 13.5-26.1), meeting the stop-go criterion of 18 participants per month to proceed with the RCT. All parents were satisfied or very satisfied with the study procedures. Parents (n=12) recruited to assess STEPS' usability described it as easy to navigate and use and as having an attractive combination of colors and visual design. They described the content as useful, pitched at the right level, and sensitively presented. Suggested improvements included adding captions to videos or making the recorded reflections editable.

CONCLUSIONS

Remote recruitment and study procedures for testing a parenting intervention app are feasible and acceptable for parents. The parents felt that STEPS was a useful and easy-to-use digital parenting support tool.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s40814-021-00959-0.

Latent structure of working memory and emotion regulation in pediatric ADHD

Working memory is a key cognitive function that is often implicated in ADHD and may represent an underlying cognitive endophenotype of the disorder. Working memory is related to emotion regulation, which is a common area of impairment in children with ADHD. Given the high rate of comorbid diagnoses with ADHD, children with comorbid internalizing, externalizing, and developmental disorders may present with variable working memory profiles and subsequent emotion regulation deficits. This study aimed to adequately characterize the latent structure of working memory impairments and emotional regulation outcomes in a clinical sample of children ages 6-16 with ADHD. This study also examined the interplay between the identified working memory/emotion regulation patterns, demographic characteristics, and the role of comorbid diagnoses. Results highlighted two distinct, invariant, unrestricted classes of working memory/emotion regulation. Class 1 (Average; 62% of the sample) had significantly lower digit-span scores, and generally persevered emotion regulation functioning per parent/teacher report. Class 2 (Emotionally Dysregulated) had average working memory scores, and elevated emotion regulation problems. The working memory indicators had small correlations with parents (and not teacher) measures of emotion regulation. Finally, latent class membership did not differ by comorbid diagnosis, age, gender, or verbal IQ. Findings elucidate heterogeneity in common domains affected by ADHD and suggest that this heterogeneity may not be due to demographic/comorbidity factors. The role of varying information reports is discussed, and potential assessment and treatment implications are highlighted.

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

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

Mechanism-based groups of children with ADHD are associated with distinct domains of impairment

Person-oriented analyses are commonly used to identify subgroups of children with mental health conditions in the hopes that they will meaningfully inform the taxonomy, assessment, and treatment of psychological disorder. However, whether these data-driven groups are demonstrably better at predicting important aspects of adaptive functioning than standard DSM taxonomy has not been established. Using Attention-Deficit-Hyperactivity-Disorder (ADHD) as a model condition, we utilized dimensions of personality and cognitive ability to identify person-centered profiles of school-aged children (N=246) and evaluated the association of these profiles with critical areas of adaptive functioning. A single profile ("Conscientious") represented non-ADHD controls and was characterized by faster drift rate and higher executive functioning scores. Three profiles ("Disagreeable," "Negative Emotionality," and "Extraverted") were identified for children with ADHD. Drift rate, but not executive functioning, distinguished among ADHD profiles, which were also distinctly associated with comorbid externalizing and internalizing psychopathology, social skills, and academic achievement. In contrast, the Diagnostic and Statistical Manual (DSM) presentations were not informative and showed similar patterns of impairment across domains. Person-centered profiles of children with ADHD are associated with distinct adaptive functioning deficits and may be useful in informing clinical practice.

Characterizing Youth-Caregiver Concordance and Discrepancies in Psychopathology Symptoms in a US Community Sample

Evidence shows that reports of psychopathology symptoms by youth and their caregiver informants differ. To quantify youth-caregiver discrepancies in psychopathology symptoms and factors associated with such discrepancies, we investigated differences in how youth and their caregivers rated psychopathology symptoms. The sample (N = 5094) was extracted from the Philadelphia Neurodevelopmental Cohort, a community-based sample of youth and included participants ages 11-17 years old with both youth and caregiver reported symptom scores. Across psychopathology symptoms, youth-caregiver concordance was poor to fair (Cohens kappa for symptom items ranged between 0.03-0.41). Psychosis symptoms had the lowest concordance-Cohen's kappa ranged from 0.03 to 0.17 across psychosis symptoms. Discrepancies between youth and caregiver symptom reports were greater than average for Black youth and for youth of low socioeconomic status; discrepancies were also higher than average in youth with any psychiatric disorder when compared to typically developing youth. Network analysis of difference scores obtained by subtracting youth symptom scores from caregiver reported symptom scores showed that network connectivity (i.e., correlated difference scores) was sparsest for psychosis spectrum compared to other psychiatric disorders. Using a large sample, we show that youth and their caregiver informants tend to report psychopathology symptoms differently. Youth-caregiver discrepancies were the most pronounced for Black youth and youth of low socio-economic status. Race and socioeconomic status contribute to significant differences in how youth and their caregivers report such symptoms and are important factors that should be accounted for to facilitate accurate mental health symptom assessment and evaluation.

A systematic review of the use of atomoxetine for management of comorbid anxiety disorders in children and adolescents with attention-deficit hyperactivity disorder

BACKGROUND

Anxiety disorders are among the most common comorbid mental disorders in children and adolescents with attention-deficit hyperactivity disorder (ADHD). While the role of atomoxetine, a non-stimulant medication, is well-established in the management of ADHD symptoms since two decades, there is a dearth of evidence regarding its efficacy in the management of anxiety disorders in children and adolescents with ADHD.

AIMS

We aimed to provide insights into (1) the comparative efficacy of atomoxetine in children and adolescents with comorbid ADHD and anxiety disorders, (2) change in severity of anxiety symptoms based on patients', parents', and clinicians' ratings, (3) tolerability and side effects.

METHODS

We searched PubMed, EMBASE, and PsycINFO for clinical trials that addressed the efficacy of atomoxetine for anxiety symptoms in children and adolescents with ADHD. All published literature was systematically reviewed.

RESULTS

We included four studies, out of which two specifically addressed comorbid ADHD and anxiety disorder. The studies suggested that atomoxetine did not exacerbate and in fact reduced anxiety symptoms in young patients with comorbid ADHD.

CONCLUSIONS AND IMPLICATIONS

Overall, atomoxetine demonstrates good efficacy in improving anxiety symptoms in children and adolescents with ADHD. Further studies are needed to shed light on atomoxetine's efficacy for anxiety subtypes in ADHD.

Why mental disorders are brain disorders. And why they are not: ADHD and the challenges of heterogeneity and reification

Scientific attempts to identify biomarkers to reliably diagnose mental disorders have thus far been unsuccessful. This has inspired the Research Domain Criteria (RDoC) approach which decomposes mental disorders into behavioral, emotional, and cognitive domains. This perspective article argues that the search for biomarkers in psychiatry presupposes that the present mental health categories reflect certain (neuro-) biological features, that is, that these categories are reified as biological states or processes. I present two arguments to show that this assumption is very unlikely: First, the heterogeneity (both within and between subjects) of mental disorders is grossly underestimated, which is particularly salient for an example like Attention Deficit/Hyperactivity Disorder (ADHD). Second, even the search for the biological basis of psychologically more basic categories (cognitive and emotional processes) than the symptom descriptions commonly used in mental disorder classifications has thus far been inconclusive. While philosophers have discussed this as the problem of mind-body-reductionism for ages, Turkheimer presented a theoretical framework comparing weak and strong biologism which is more useful for empirical research. This perspective article concludes that mental disorders are brain disorders in the sense of weak, but not strong biologism. This has important implications for psychiatric research: The search for reliable biomarkers for mental disorder categories we know is unlikely to ever be successful. This implies that biology is not the suitable taxonomic basis for psychiatry, but also psychology at large.

A systematic review of interventions to support adults with ADHD at work—Implications from the paucity of context-specific research for theory and practice

Attention Deficit Hyperactivity Disorder (ADHD) is estimated to affect 3.5% of the global workforce. Despite the high prevalence rate, little is known about how best to support adults with ADHD (ADHDers) at work. Relevant research is dispersed across different disciplines such as medicine, health studies and psychology. Therefore, it is important to synthesize interventions aimed at ADHDers to examine what learning can be gleaned for effective workplace support. We conducted a systematic review of relevant interventions framed by realist evaluation and the Context-Intervention-Mechanism-Outcome classification to identify key mechanisms of effectiveness for workplace interventions. We searched 10 databases including a range of journals from medical science to business management applying predetermined inclusion criteria and quality appraisal through a risk of bias assessment for quantitative and qualitative methods. We synthesized 143 studies with realist evaluation. Most studies evaluated the effectiveness of pharmacological interventions highlighting the dominance of the medical approach to supporting ADHDers. Key mechanisms of effectiveness were identified from psychosocial interventions including group therapy, involvement of people in the ADHDers network, and the importance of the client-patient relationship. Overall, there is limited research that examines the effectiveness of workplace interventions for ADHDers. Furthermore, much of the existing research evaluates pharmacological interventions which is difficult to transfer to the workplace context. It is recommended that future research and practice consider the key mechanisms identified in this review when designing interventions as well as barriers to accessing support such as disclosure and self-awareness.

Does Child Anxiety Exacerbate or Protect Against Parent–Child Relationship Difficulties in Children with Elevated ADHD Symptoms?

Pediatric ADHD is associated with parent–child relationship difficulties. However, the extent to which these relations are attributable to specific ADHD symptom clusters (i.e., inattentive vs. hyperactive/impulsive), and the extent to which child anxiety symptoms may exacerbate or protect against these difficulties, remains unclear. To address these gaps in the literature, the current study combined multi-informant measures (parent, teacher, child) with a clinically-evaluated and carefully-phenotyped sample of 188 children with and without ADHD and anxiety (ages 8–13; 63 girls). Results indicated that child-reported anxiety (β = .46) and teacher-reported inattentive (β = .71) symptoms, and their interaction (β = -1.06), along with child age and IQ (β = -.14 to -.15), predict the extent to which parents perceive themselves as confident and competent parents (all p < .05). In contrast, only comorbid oppositional-defiant disorder conferred risk for increased parent-reported relational frustration, and we were unable to detect any reliable child-level demographic, diagnostic, or behavioral predictors of parent-reported discipline practices. These findings were robust to control for child demographic characteristics, clinical diagnoses, and intellectual functioning, with sensitivity analyses highlighting the importance of assessing ADHD inattentive vs. hyperactive/impulsive symptoms separately for understanding parenting outcomes. Taken together, the current findings suggest that child ADHD and anxiety symptoms may influence specific rather than broad-based aspects of the parent–child relationship, and produce differently valenced outcomes in the presence vs. absence of the other condition. Interestingly, it appears that the combination of greater child inattention and anxiety, rather than elevations in either symptom domain independently, predict adverse parenting outcomes in terms of reduced parental confidence.

Effect of Maternal Anxiety on Parenting Stress of Fathers of Children With ADHD

BACKGROUND

Hyperactivity, inattention, and impulsivity of children with attention deficit hyperactivity disorder (ADHD) increase parenting stress and familial conflict. Among parent-related factors, maternal mental health has been studied in-depth, but studies on paternal factors in this context are scarce. This cross-sectional study was conducted of children with ADHD and their parents in South Korea. We investigated the relationships between ADHD symptom severity of children and the mental health of their mothers and fathers.

METHODS

The study included 70 children with ADHD and their 140 married heterosexual parents (70 fathers and 70 mothers). Children completed the Child Depression Inventory and State-Anxiety Inventory for children, and their parents completed the Korean ADHD rating scale-IV, Adult ADHD self-report scale, State-Anxiety Inventory, Patient Health Questionnaire-9, and Parental Stress Scale.

RESULTS

There was a significant positive correlation between children's ADHD symptoms and maternal anxiety symptom severity, whereby more severe ADHD symptoms were associated with more severe maternal anxiety symptoms. There was also a significant positive correlation between maternal anxiety symptom severity and paternal parenting stress severity, whereby more severe maternal anxiety was associated with more severe paternal parenting stress. A mediation model showed that paternal parenting stress severity was not directly related to children's ADHD symptoms, but the severity of maternal anxiety mediated this relationship.

CONCLUSION

The present study found the importance of mental health in mothers of children with ADHD and the interrelatedness of mental health within families. Future assessments and treatment of children with ADHD should include both the children and their parents.

Comorbidities Associated With Attention-Deficit/Hyperactivity Disorder in Children and Adolescents at a Tertiary Care Setting

Studies have revealed high rates of neurodevelopmental and psychiatric comorbid conditions among individuals diagnosed with attention-deficit/hyperactivity disorder (ADHD). However, research on this topic in the Arab world has been limited. This study evaluates the medical, neurodevelopmental, and psychiatric comorbidities in children and adolescents diagnosed with ADHD in Dubai, United Arab Emirates (UAE). A total of 428 pediatric patients diagnosed with ADHD were included. Children and adolescents with ADHD had high rates of comorbid disorders. Twenty comorbid conditions were identified. More than 3 quarters of the study sample had at least 1 comorbid disorder. The most common comorbidity among children was autism spectrum disorder, and among adolescents was anxiety disorders. Comprehensive assessments are highly warranted to identify and manage associated comorbid conditions. Further research is needed in exploring the biopsychosocial factors contributing to the elevated rate of comorbidity in children and adolescents with ADHD.

Does Anxiety Symptomatology Affect Bullying Behavior in Children and Adolescents with ADHD?

Background

Anxiety disorders are common comorbidities in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) who are also at a high risk of bullying behavior. However, little is known about the roles of anxiety symptomatology in the relationship between ADHD and bullying behavior.

Objective

This cross-sectional, clinic-based study aims to investigate the associations between anxiety symptomatology and bullying involvement in youth with ADHD.

Method

One hundred and eighty children and adolescents with ADHD aged 10–18 years participated in the study. The Screen for Child Anxiety-Related Emotional Disorders (SCARED) was self-rated, and the participants were interviewed with the Revised Olweus Bully/Victim Questionnaire to categorize bullying involvement. Data were analyzed through percentage, nonparametric statistics, chi-squared statistics, and logistic regression analysis.

Results

Sixty-nine percent of youth with ADHD reported involvement in bullying, of which 33.3%, 8.9%, and 27.2% were classified as victims, bullies, and bully-victims, respectively. The means and 95% confidence intervals of the total SCARED scores showed a significant difference among bullying behavior groups. The highest SCARED scores could be noticed in the victim and bully-victim groups, with the lowest scores observed in the bully group. Youth with ADHD who had comorbid anxiety were 3.51 times more likely to be bullied than those who did not have anxiety.

Conclusions

A differential effect of anxiety symptomatology on bullying behavior in youth with ADHD was evident. These results highlight the utility of including anxiety in the conceptualization of bullying problems in youth with ADHD to plan successful anti-bullying interventions.

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

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

The feasibility of a strategy for the remote recruitment, consenting and assessment of recent referrals: a protocol for phase 1 of the On-Line Parent Training for the Initial Management of ADHD referrals (OPTIMA)

BACKGROUND

In the UK, children with high levels of hyperactivity, impulsivity and inattention referred to clinical services with possible attention-deficit/hyperactivity disorder (ADHD) often wait a long time for specialist diagnostic assessment. Parent training (PT) has the potential to support parents during this difficult period, especially regarding the management of challenging and disruptive behaviours that often accompany ADHD. However, traditional face-to-face PT is costly and difficult to organise in a timely way. We have created a low-cost, easily accessible PT programme delivered via a phone app, Structured E-Parenting Support (STEPS), to address this problem. The overall OPTIMA programme will evaluate the efficacy and cost-effectiveness of STEPS as a way of helping parents manage their children behaviour while on the waitlist. To ensure the timely and efficient evaluation of STEPS in OPTIMA, we have worked with children's health services to implement a remote strategy for recruitment, screening and assessment of recently referred families. Part of this strategy is incorporated into routine clinical practice and part is OPTIMA specific. Here, we present the protocol for Phase 1 of OPTIMA-a study of the feasibility of this remote strategy, as a basis for a large-scale STEPS randomised controlled trial (RCT).

METHODS

This is a single arm observational feasibility study. Participants will be parents of up to 100 children aged 5-11 years with high levels of hyperactivity/impulsivity, inattention and challenging behaviour who are waiting for assessment in one of five UK child and adolescent mental health or behavioural services. Recruitment, consenting and data collection will occur remotely. The primary outcome will be the rate at which the families, who meet inclusion criteria, agree in principle to take part in a full STEPS RCT. Secondary outcomes include acceptability of remote consenting and online data collection procedures; the feasibility of collecting teacher data remotely within the required timeframe, and technical difficulties with completing online questionnaires. All parents in the study will receive access to STEPS.

DISCUSSION

Establishing the feasibility of our remote recruitment, consenting and assessment strategy is a pre-requisite for the full trial of OPTIMA. It can also provide a model for future trials conducted remotely.

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

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

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

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

Alexithymia Is Associated With Internalizing Disorders in a Clinical Adolescent Outpatient Sample

ABSTRACT

The aim of this study was to investigate alexithymic traits in an adolescent clinical sample with internalizing and externalizing disorders. The study group consisted of 125 adolescents aged between 12 and 17 years who applied at our outpatient unit and diagnosed with an internalizing or externalizing disorder. The healthy control group consisted of 53 adolescents with no psychiatric disorder. All subjects fulfilled the Alexithymia Questionnaire for Children (AQC). Total AQC scores were higher in the study group than in the control group. When we divided the study group into two groups as internalizing and externalizing disorders, total AQC scores, AQC-difficulty identifying feelings, and AQC-difficulty describing feelings were significantly higher in the internalizing disorder group than in the externalizing disorder group. AQC-externally oriented thinking scores were significantly higher in the externalizing disorder group than in the internalizing disorder group. In future research, it would be useful to further increase understanding of alexithymia and its association with psychiatric disorders in adolescence.

Genetically Informed Regression Analysis: Application to Aggression Prediction by Inattention and Hyperactivity in Children and Adults

We present a procedure to simultaneously fit a genetic covariance structure model and a regression model to multivariate data from mono- and dizygotic twin pairs to test for the prediction of a dependent trait by multiple correlated predictors. We applied the model to aggressive behavior as an outcome trait and investigated the prediction of aggression from inattention (InA) and hyperactivity (HA) in two age groups. Predictions were examined in twins with an average age of 10 years (11,345 pairs), and in adult twins with an average age of 30 years (7433 pairs). All phenotypes were assessed by the same, but age-appropriate, instruments in children and adults. Because of the different genetic architecture of aggression, InA and HA, a model was fitted to these data that specified additive and non-additive genetic factors (A and D) plus common and unique environmental (C and E) influences. Given appropriate identifying constraints, this ADCE model is identified in trivariate data. We obtained different results for the prediction of aggression in children, where HA was the more important predictor, and in adults, where InA was the more important predictor. In children, about 36% of the total aggression variance was explained by the genetic and environmental components of HA and InA. Most of this was explained by the genetic components of HA and InA, i.e., 29.7%, with 22.6% due to the genetic component of HA. In adults, about 21% of the aggression variance was explained. Most was this was again explained by the genetic components of InA and HA (16.2%), with 8.6% due to the genetic component of InA.

Emotion Regulation and Children With Attention-Deficit/Hyperactivity Disorder: The Effect of Varying Phonological Working Memory Demands

Objective: Findings from extant studies of the relationship between ADHD-related emotion regulation and working memory deficits have been equivocal, and their correlational designs preclude inferences about the functional relationship between working memory demands and emotion regulation. This study aimed to experimentally examine the functional relationship between varying working memory demands and ADHD-related emotion regulation deficits. Method: Overt emotion regulation behaviors were coded while children with and without ADHD completed experimental tasks that manipulated low and high working memory demands. Results: Compared with typically developing children, children with ADHD exhibited large-magnitude overall emotion expression deficits, disproportionately greater self-criticism during high working memory conditions, and disproportionately greater positive emotion expression during low working memory demand conditions. Conclusion: These findings suggest that working memory demands are functionally related to emotion regulation deficits exhibited by children with ADHD and may explicate variability of emotion regulation difficulties related to environmental demands.

Comorbidities and functional impairments in children with attention deficit hyperactivity disorder in China: a hospital-based retrospective cross-sectional study

OBJECTIVES

The aim of this study was to assess comorbidity patterns and functional impairment in children with and without attention deficit hyperactivity disorder (ADHD).

DESIGN

Hospital-based retrospective cross-sectional study; data collection occurred between 2016 and 2019.

SETTINGS AND PATIENTS

A total of 8256 children and adolescents, 6-17 years of age, with suspected ADHD agreed to participate in this hospital-based cross-sectional study over a 4-year period in China. Comorbidities and social functions were assessed according to the scales Vanderbilt ADHD Diagnostic Parent Rating Scale and Weiss Functional Impairment Rating Scale-Parent Form, which were completed by the parents of the study participants.

RESULTS

Of the 8256 children, 5640 were diagnosed with ADHD. Other 2616 children who did not meet the ADHD diagnostic criteria were classified as the N-ADHD group . The proportion of comorbidities (47.4%) and functional impairments (84.5%) in the ADHD group were higher than the N-ADHD group (p≤0.001). The functional impairment scores in all of the six domains, including family, academic, life skills, self-concept, social activities and risky activities, were significantly higher in the ADHD group than the N-ADHD group (p≤0.001). The functional impairment in ADHD group with comorbidities was more severe than those without comorbidities (p≤0.001). Comorbidities and core symptoms both can affect the functions of children with ADHD. Logistics regression analysis indicated that in all of the six functional domains, the effect of comorbidities on functional impairment exceeded the effects of ADHD core symptoms.

CONCLUSIONS

Comorbidities had the greatest influence on different areas of adaptive functioning in children with ADHD. Clinical management of children suspected to have ADHD should address multiple comorbidities and functional impairments assessment, as well as core symptom analysis.

Disentangling nature from nurture in examining the interplay between parent-child relationships, ADHD, and early academic attainment

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is highly heritable and is associated with lower educational attainment. ADHD is linked to family adversity, including hostile parenting. Questions remain regarding the role of genetic and environmental factors underlying processes through which ADHD symptoms develop and influence academic attainment.

METHOD

This study employed a parent-offspring adoption design (N = 345) to examine the interplay between genetic susceptibility to child attention problems (birth mother ADHD symptoms) and adoptive parent (mother and father) hostility on child lower academic outcomes, via child ADHD symptoms. Questionnaires assessed birth mother ADHD symptoms, adoptive parent (mother and father) hostility to child, early child impulsivity/activation, and child ADHD symptoms. The Woodcock-Johnson test was used to examine child reading and math aptitude.

RESULTS

Building on a previous study (Harold et al., 2013, Journal of Child Psychology and Psychiatry, 54(10), 1038-1046), heritable influences were found: birth mother ADHD symptoms predicted child impulsivity/activation. In turn, child impulsivity/activation (4.5 years) evoked maternal and paternal hostility, which was associated with children's ADHD continuity (6 years). Both maternal and paternal hostility (4.5 years) contributed to impairments in math but not reading (7 years), via impacts on ADHD symptoms (6 years).

CONCLUSION

Findings highlight the importance of early child behavior dysregulation evoking parent hostility in both mothers and fathers, with maternal and paternal hostility contributing to the continuation of ADHD symptoms and lower levels of later math ability. Early interventions may be important for the promotion of child math skills in those with ADHD symptoms, especially where children have high levels of early behavior dysregulation.

Poor Separation of Clinical Symptom Profiles by DSM-5 Disorder Criteria

Assessment of mental illness typically relies on a disorder classification system that is considered to be at odds with the vast disorder comorbidity and symptom heterogeneity that exists within and across patients. Patients with the same disorder diagnosis exhibit diverse symptom profiles and comorbidities creating numerous clinical and research challenges. Here we provide a quantitative analysis of the symptom heterogeneity and disorder comorbidity across a sample of 107,349 adult individuals (aged 18-85 years) from 8 English-speaking countries. Data were acquired using the Mental Health Quotient, an anonymous, online, self-report tool that comprehensively evaluates symptom profiles across 10 common mental health disorders. Dissimilarity of symptom profiles within and between disorders was then computed. We found a continuum of symptom prevalence rather than a clear separation of normal and disordered. While 58.7% of those with 5 or more clinically significant symptoms did not map to the diagnostic criteria of any of the 10 DSM-5 disorders studied, those with symptom profiles that mapped to at least one disorder had, on average, 20 clinically significant symptoms. Within this group, the heterogeneity of symptom profiles was almost as high within a disorder label as between 2 disorder labels and not separable from randomly selected groups of individuals with at least one of any of the 10 disorders. Overall, these results quantify the scale of misalignment between clinical symptom profiles and DSM-5 disorder labels and demonstrate that DSM-5 disorder criteria do not separate individuals from random when the complete mental health symptom profile of an individual is considered. Greater emphasis on empirical, disorder agnostic approaches to symptom profiling would help overcome existing challenges with heterogeneity and comorbidity, aiding clinical and research outcomes.

Clinical Subtypes in Children with Attention-Deficit Hyperactivity Disorder According to Their Child Behavior Checklist Profile

This study sought to identify subgroups of attention-deficit hyperactivity disorder (ADHD) defined by specific patterns of emotional and behavioral symptoms according to the parent-rated Child Behavior Checklist (CBCL). Our clinical sample comprised 314 children (aged 4 to 15 years) diagnosed with ADHD according to the DSM-5. In addition, comorbid psychiatric disorders, general functioning, and medication status were assessed. Cluster analysis was performed on the CBCL syndrome subscales and yielded a solution with four distinct subgroups. The "High internalizing/externalizing" group displayed an overlap between internalizing and externalizing problems in the CBCL profile. In addition, the "High internalizing/externalizing" group revealed a high rate of comorbid autism spectrum disorder and elevated autistic traits. The "Inattention and internalizing" group revealed a high rate of the predominantly inattentive presentation according to ADHD specifier from the DSM-5. The "Aggression and externalizing" group revealed a high rate of comorbid oppositional defiant disorder and conduct disorder. The "Less psychopathology" group scored low on all syndrome scales. Children with ADHD were subdivided into four distinct subgroups characterized by psychopathological patterns, with and without internalizing and externalizing problems. The overlap between internalizing and externalizing problems may be mediated with emotional dysregulation and associated neurobiological bases.

Reduced fronto-striatal volume in attention-deficit/hyperactivity disorder in two cohorts across the lifespan

Attention-Deficit/Hyperactivity Disorder (ADHD) has been associated with altered brain anatomy in neuroimaging studies. However, small and heterogeneous study samples, and the use of region-of-interest and tissue-specific analyses have limited the consistency and replicability of these effects. We used a data-driven multivariate approach to investigate neuroanatomical features associated with ADHD in two independent cohorts: the Dutch NeuroIMAGE cohort (n = 890, 17.2 years) and the Brazilian IMpACT cohort (n = 180, 44.2 years). Using independent component analysis of whole-brain morphometry images, 375 neuroanatomical components were assessed for association with ADHD. In both discovery (corrected-p = 0.0085) and replication (p = 0.032) cohorts, ADHD was associated with reduced volume in frontal lobes, striatum, and their interconnecting white-matter. Current results provide further evidence for the role of the fronto-striatal circuit in ADHD in children, and for the first time show its relevance to ADHD in adults. The fact that the cohorts are from different continents and comprise different age ranges highlights the robustness of the findings.

Striatal dynamics as determinants of reduced gambling vulnerability in the NHE rat model of ADHD

The Naples High-Excitability (NHE) is a validated rat strain to model for a mesocortical variant of Attention Deficit Hyperactivity Disorder (ADHD). NHE rats' brains have a tuned-down cortical and a potentiated limbic loop (Zoratto et al., 2017). ADHD and comorbid pathological gambling (PG) involve similar deficits of prefrontal-striatal dialogue. This work aimed to understand if NHE rats (compared to normal random-bred rats, NRB) can be a useful model for gambling vulnerability in ADHD. Experiment 1 evaluated gambling proneness in NHE rats, namely attraction/avoidance in nose-poking for a "Large & Luck-Linked" (LLL) reward (versus a "Small & Sure" one, SS), when the probability of LLL delivery was progressively reduced. Experiment 2 assessed (by phMRI) differential responsivity of ventral (vStr) versus dorsal (dStr) striatum following a methylphenidate (MPH, 4 mg/kg I.P.) challenge. In NHE rats, reduced attraction by secondary cues (associated with uncertain, rarefying LLL delivery) comes along with little or no activation of dStr and enhanced activation of vStr by MPH. Together, such evidences from NHE rats indicate distinctive roles of ventral (enhanced value given to actual primary reward) and dorsal (lower encoding of repeated stimulus-reward associations into a habit) striatum. In conclusion, the dynamics of reward systems could link an attention deficit with a decreased vulnerability to pathological gambling.

Comorbid anxiety and irritability symptoms and their association with cognitive functioning in children with ADHD

Anxiety and irritability symptoms frequently co-occur in children with Attention-Deficit/Hyperactivity Disorder (ADHD). This study aims to investigate whether irritability and anxiety are uniquely associated with performance on measures of cognitive functioning in children with ADHD and whether these associations hold when accounting for confounding variables. Baseline data was used from a randomised controlled trial of cognitive behavioural therapy for anxiety in children with ADHD (N = 219, 8-13 years). Anxiety was assessed using the child- and parent-reported Spence Children's Anxiety Scale, while irritability was assessed using the parent-reported Affective Reactivity Index. Children completed the National Institutes of Health Toolbox - Cognition Battery. Higher symptoms of anxiety were uniquely associated with performance on the Dimensional Card Change Sort Test (β = -2.75, confidence interval (CI) [-4.97, -.52], p = .02) and the List Sort Working Memory Test (β = -2.57, CI [-4.43, -.70], p = .01), while higher symptoms of irritability were negatively associated with Picture Vocabulary Test (β = -2.00, CI [-3.83, -.16], p = .03). These associations did not survive correction for multiple comparisons. There was little evidence of an association between anxiety or irritability symptoms and cognitive functioning. Frequent co-occurrence of anxiety and irritability suggests clinicians working with children with ADHD should assess co-morbid symptom profiles to inform the provision of optimum care.

Comorbidity and Behavior Characteristics of Russian Male Juvenile Delinquents With ADHD and Conduct Disorder

Objective: To test the previously suggested hypothesis that those with comorbid ADHD and Conduct Disorder (CD) diagnoses differ from other antisocially involved youth in terms of higher rates of violent behavior, impulsiveness, and psychopathic traits. Method: Three hundred eighty juvenile incarcerated delinquents from Northern Russia were assessed by means of semi-structured psychiatric interview and by student and teacher self-reports. Results: The study has demonstrated higher rates of psychiatric disorders and of comorbidity, as well as more complicated substance abuse and disruptive behaviors in those with combined ADHD-CD diagnosis, as compared with CD only, ADHD only, and no CD no ADHD groups. The results regarding psychopathic traits were inconclusive. Conclusion: The group with combined ADHD-CD diagnosis is more severely disturbed, both as concerns psychiatric comorbidity and more severe aggressive and disruptive behaviors. However, there is only limited evidence supporting a higher prevalence of psychopathic traits in this group.

Family and Maternal Characteristics of Children With Co-Occurring ADHD and Depression

Objective: This study examined differences between children with ADHD and comorbid depression (n = 26), ADHD only (n = 111), and a community control group (n = 130) on measures of family and maternal characteristics. Method: The present study utilized a large, community sample. Diagnoses required positive endorsements from multiple sources. ANOVAs and chi-square tests were conducted to determine group differences. Results: Compared with children with ADHD alone and community controls, mothers of depressed ADHD children reported decreased family cohesion, limited participation in social/recreational activities, increased maternal depressive symptoms, difficulty coping with parenting roles, and higher rates of bipolar and anxiety disorders. Mothers of children with ADHD (with or without comorbid depression) reported increased conflict, decreased cohesion, and poor maternal coping compared with community controls. Conclusion: Findings are consistent with prior literature suggesting that families of children with ADHD and depression demonstrate both similar and unique characteristics. Clinical implications are discussed.

Neurobehavioural characterisation and stratification of reinforcement-related behaviour

Reinforcement-related cognitive processes, such as reward processing, inhibitory control and social-emotional regulation are critical components of externalising and internalising behaviours. It is unclear to what extent the deficit in each of these processes contributes to individual behavioural symptoms, how their neural substrates give rise to distinct behavioural outcomes and whether neural activation profiles across different reinforcement-related processes might differentiate individual behaviours. We created a statistical framework that enabled us to directly compare functional brain activation during reward anticipation, motor inhibition and viewing emotional faces in the European IMAGEN cohort of 2,000 14-year-old adolescents. We observe significant correlations and modulation of reward anticipation and motor inhibition networks in hyperactivity, impulsivity, inattentive behaviour and conduct symptoms, and we describe neural signatures across cognitive tasks that differentiate these behaviours. We thus characterise shared and distinct functional brain activation patterns underling different externalising symptoms and identify neural stratification markers, while accounting for clinically observed comorbidity.

[Attention deficit hyperactivity disorder in childhood and adolescence : Current state of research]

BACKGROUND

Attention deficit hyperactivity disorder (ADHD), defined by the core symptoms impulsiveness, inattention and motor hyperactivity, is one of the most common neurodevelopmental disorders beginning in early childhood.

OBJECTIVE

This article reviews the current state of research on the epidemiology, etiology, diagnostics and therapeutic interventions for ADHD in children and adolescents.

METHODS

A selective literature search was carried out in PubMed with reference to the German S3 clinical guidelines on ADHD in children, adolescents and adults.

RESULTS AND CONCLUSION

The epidemiological prevalence of ADHD in children is estimated to be 5.3%. The etiology is complex and heterogeneous and a high percentage of the phenotypic variance can be explained by genetic influences. The challenge of ADHD diagnostics is to exclude differential diagnoses while simultaneously identifying common coexisting psychiatric conditions. Treatment recommendations depend on the severity of symptoms. In severe ADHD pharmacotherapy should be considered as the first line intervention. Psychostimulants (various methylphenidate and amphetamine preparations) and the non-stimulants atomoxetine and guanfacine are approved in Germany for treatment of ADHD in children and adolescents. In milder cases as well as in preschool children, psychosocial interventions (including behavioral psychotherapy) are often sufficient.

Attention Deficit Hyperactivity Disorder and Psychiatric Comorbidities

Aim: This study aims to obtain current information on the clinical features of attention deficit hyperactivity disorder cases, comorbid psychiatric disorders and psychiatric drug use. Methods: All patients between the ages of 6 and 18 years who were admitted to our outpatient clinic and diagnosed with attention deficit hyperactivity disorder were included in the study. The files of the patients were examined and their demographic characteristics, symptoms, psychiatric diagnoses and drug profiles were recorded. The pattern of the psychiatric disorders accompanied by attention deficit hyperactivity disorder cases and the differences according to age and gender were analyzed. The differences were determined in patients with psychiatric comorbidity compared to those without. Result: The mean age of the 777 patients included in the study was 11.1±2.94 and 76.6% were boys. 60.9% of attention deficit hyperactivity disorder patients had comorbid psychiatric disorders. The most common psychiatric comorbidities were specific learning disability (23.6%), oppositional defiant disorder (12.9%) and conduct disorder (12.1%). There was no difference between the genders in terms of the incidence of psychiatric comorbidities. The rate of psychiatric comorbidity was significantly higher in adolescents than in children. A psychotropic medication was used in 86.4% of the cases and psychotropic polypharmacy was present in 31.5%. The rate of polypharmacy was significantly higher in the group with psychiatric comorbidity. Conclusion: Attention deficit hyperactivity disorder is frequently accompanied by other psychiatric disorders and the psychiatric comorbidity leads to a more complicated clinical profile. Approximately one-third of attention deficit hyperactivity disorder patients have psychiatric polypharmacy and these patients should be carefully monitored. Primary care physicians who are frequently confronted with attention deficit hyperactivity disorder cases should be careful about psychiatric comorbidities. Keywords: Child psychiatry, attention deficit hyperactivity disorder, mental disorders, Family practice

Anxious-Irritable Children: A Distinct Subtype of Childhood Anxiety?

Children with anxiety disorders often present with other co-occurring symptom clusters, of which irritability is among the most highly co-occurring. Despite compelling clinical and pathophysiological evidence linking anxiety and irritability, little is known regarding the clinical presentation and associated impairment of children with both anxiety and irritability. In this study, our aims were to confirm the preponderance of irritability in clinically anxious children and compare clinically anxious children with irritability to those without irritability across sociodemographic, clinical, psychosocial, and family domains. Participants were 230 children with anxiety disorders (ages 6-14 years) and their mothers, and 91 healthy controls (ages 6-17 years) and their mothers. Of the clinically anxious children, 121 were anxious and irritable; 109 were anxious but not irritable. Irritability levels were significantly higher in the clinically anxious children compared with the healthy controls. Children with anxiety disorders and irritability presented with greater severity and impairment across clinical phenomenology, psychosocial, and family domains relative to anxious children without irritability. Regression analysis findings were convergent in that greater severity and impairment across these same domains predicted higher irritability levels in the children with anxiety disorders. Results support the meaningful distinction between anxious children with and without irritability. Implications of the findings are discussed particularly in regard to assessment and treatment and future research directions are delineated.

The role of ADHD symptoms in the relationship between academic achievement and psychopathological symptoms

BACKGROUND

Previous research results suggest that ADHD symptoms explain the relationship between specific learning disability and externalising psychopathology and between math disability and anxiety, but not between reading disability and anxiety. For depression, previous results are mixed.

AIMS

The current study aims to clarify this role of ADHD symptoms in the relationship between various areas of academic achievement (reading, writing, and math skills) and psychopathological symptoms (anxiety, depression, and conduct disorder).

METHODS AND PROCEDURES

We used linear regressions based on data from a general population sample (N = 3014) collected using online assessment of 3^rd and 4^th grade students in Germany, which included measures of academic achievement and parent-reported psychopathological symptoms.

OUTCOMES AND RESULTS

ADHD symptoms completely account for the relationship between reading/writing achievement and anxiety and between writing/math achievement and conduct problems. The negative relationship between academic achievement and depression was strongest for children with average or high ADHD symptom scores.

CONCLUSIONS AND IMPLICATIONS

ADHD symptoms play an important role in explaining the relationship between academic achievement and psychopathological symptoms in elementary school children. The nature and size of this role depend on the exact constructs under study. We discuss implications for the support of children with learning problems, ADHD, and/or psychopathological problems.

The Co-Occurrence of Autism Spectrum Disorder in Children With ADHD

Objective: Children with ADHD frequently present with autism spectrum disorder (ASD) symptomatology, yet there is a notable gap in the treatment needs of this subpopulation, including whether the presence of ASD may be associated with more severe ADHD symptoms. Method: Data from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome (n = 2,464) were used to compare children diagnosed with ADHD and ASD with children with ADHD, but not ASD. Children were classified as needing treatment if it was received or their parents reported it was needed, but not received. Results: Approximately one in eight children currently diagnosed with ADHD was also diagnosed with ASD. Children diagnosed with both disorders had greater treatment needs, more co-occurring conditions, and were more likely to have a combined hyperactive/impulsive and inattentive ADHD subtype. Conclusion: These findings highlight the complexity of children diagnosed with both ADHD and ASD.

Role of conduct problems in the relation between Attention-Deficit Hyperactivity disorder, substance use, and gaming

Known comorbidities for Attention-Deficit Hyperactivity Disorder (ADHD) include conduct problems, substance use disorder and gaming. Comorbidity with conduct problems may increase the risk for substance use disorder and gaming in individuals with ADHD. The aim of the study was to build a causal model of the relationships between ADHD and comorbid conduct problems, and alcohol, nicotine, and other substance use, and gaming habits, while accounting for age and sex. We used a state-of-the-art causal discovery algorithm to analyze a case-only sample of 362 ADHD-diagnosed individuals in the ages 12-24 years. We found that conduct problem severity mediates between ADHD severity and nicotine use, but not with more severe alcohol or substance use. More severe ADHD-inattentive symptoms lead to more severe gaming habits. Furthermore, our model suggests that ADHD severity has no influence on severity of alcohol or other drug use. Our findings suggest that ADHD severity is a risk factor for nicotine use, and that this effect is fully mediated by conduct problem severity. Finally, ADHD-inattentive severity was a risk factor for gaming, suggesting that gaming dependence has a different causal pathway than substance dependence and should be treated differently. By identifying these intervention points, our model can aid both researchers and clinicians.

Do Comorbid Oppositional Symptoms Predict ADHD Behavioral Treatment Outcomes?

Parent management training (PMT) is considered a best-practice for treating childhood ADHD. However, the magnitude of change in response to PMT differs across individuals. This study examined comorbid oppositional symptoms as a predictor of ADHD treatment outcomes. We predicted children with more severe baseline oppositionality would exhibit greater improvements in externalizing behaviors overall, including core ADHD symptoms. Participants consisted of 67 children aged 7-10 diagnosed with ADHD-Combined Type. Participants and their families received a manualized ten-session intervention, Family Skills Training for ADHD-Related Symptoms (Family STARS), combining PMT with a simultaneously occurring child skills training intervention. Pre- and post-treatment parent and teacher rating scales were collected to assess changes in ADHD and oppositional symptoms. Results demonstrated that children with more severe ratings of oppositional behaviors achieved commensurate ADHD symptom outcomes compared to those with less severe oppositionality. Implications are discussed with regard to the utilization of ADHD impairment-specific treatment targets.

Associations of ADHD Symptoms With Smoking and Alternative Tobacco Product Use Initiation During Adolescence

Objective

Recently, use of alternative tobacco products, such as electronic cigarettes (e-cigarettes) and hookah (water-pipe tobacco), has increased among adolescents. It is unknown whether attention-deficit hyperactivity disorder (ADHD) symptoms are associated with initiation of alternative tobacco product use.

Methods

Ninth grade high school students who never used any tobacco product at baseline (N = 1,921) participated in a longitudinal survey from 2014 to 2015. Overall symptomatology and inattention (IN) and hyperactivity-impulsivity (HI) ADHD subtypes were assessed at baseline. Past 6-month e-cigarette, hookah, and combustible cigarette use (yes/no) were reported at three semi-annual follow-ups. Repeated measures logistic regression models assessed the association of baseline ADHD symptoms with likelihood of tobacco product initiation across follow-ups.

Results

For ADHD main effect estimates, unadjusted odds of reporting e-cigarette, hookah, and combustible cigarette use pooled across follow-up time points were 45%, 33%, and 37% greater, respectively, with each increase in one SD-unit of baseline ADHD symptoms in baseline never-users of tobacco products. ADHD was not associated with hookah or combustible cigarette use after adjusting for other risk factors. After adjustment, e-cigarette use initiation remained associated with overall ADHD (odds ratio, OR [95%confidence interval, 95% CI] = 1.22 [1.04, 1.42]) and HI (OR [95% CI] = 1.26 [1.09, 1.47]) symptoms, but not IN symptoms (OR [95% CI] = 1.13 [0.97, 1.32]). ADHD × Time interactions were not significant, suggesting ADHD increased odds of e-cigarette use initiation but did not alter the shape of use trajectory across follow-up among initiators.

Conclusions

Understanding the psychosocial mechanisms underlying the pathway from ADHD to e-cigarette use may advance tobacco product use etiologic theory and prevention practice in the current era in which e-cigarette use is popular among youth.

Negative Parenting Moderates the Prospective Association of ADHD Symptoms and Youth Social Problems

Although ADHD and negative parenting are established predictors of youth outcomes, their independent and interactive effects on youth social functioning remain unclear. We tested childhood ADHD symptoms and negative parenting as independent and interactive predictors of prospective change in social problems across a four-year follow-up. At baseline, families of 221 (33% female) children with (n = 94) and without ADHD were rigorously assessed including observed positive and negative parenting behavior, youth ADHD symptoms, as well as multi-informant ratings of youth social problems at multiple occasions. Based on multiple regression with robust standard errors and full-information maximum likelihood procedures to address missing data, ADHD symptoms positively predicted social problems, even with control of observed parenting behavior, child age and sex, oppositional defiant disorder symptoms, and baseline social problems. Additionally, a child ADHD symptoms x negative parenting interaction uniquely predicted separate parent- and teacher-rated social problems where ADHD symptoms positively predicted social problems exclusively in the context of high (+1SD) and very high (+2 SD) negative parenting, respectively. When ADHD was separated into distinct dimensions (i.e., inattention, hyperactivity), an interaction between inattention symptoms and negative parenting approached significance such that inattention symptoms positively predicted parent-rated social problems in the context of high negative parenting. We discuss the interaction between parenting and ADHD symptoms in predictions of youth social problems and implications for intervention.

Attention deficit hyperactivity disorder and comorbidity: A review of literature

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with onset in early childhood. It is a clinically heterogenous condition with comorbidity posing a distinct challenge to diagnosing and managing these children and adolescents. This review aims to provide an overview of comorbidity with ADHD including other neurodevelopmental disorders, learning disorders, externalising and internalising disorders. Challenges in screening for, diagnosing and managing comorbidity with ADHD are summarised. Also, methodological challenges and future directions in research in this interesting field are highlighted.

Patterns and Predictors of Service Utilization Among Youth With ADHD-Predominantly Inattentive Presentation

Objective: This study examined rates and predictors of educational and mental health service utilization among youth with ADHD-predominantly inattentive presentation (ADHD-I). Method: Participants were 199 children with ADHD-I in Grades 2 to 5. Parents reported past-year child service utilization. Parents and teachers rated child ADHD and oppositional defiant disorder (ODD) symptom severity and functional impairment. Children completed an academic achievement test. Results: All children had impairment at school and home. Most received some sort of school service (79%), but only 23% received community-based services. ADHD symptom severity was unrelated to service utilization. However, higher parent-rated functional impairment predicted community service utilization. Academic underachievement and higher teacher-rated functional impairment predicted school service utilization. Conclusion: Many youth with ADHD-I experience impairment across domains without receiving adequate services for these problems. Functional impairment appears to be a stronger predictor of service utilization than ADHD symptom severity, demonstrating the importance of impairment in understanding service needs for ADHD-I.