Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry

Effect of CYP2D6 genetic variation on patient-reported symptom improvement and side effects among children and adolescents treated with amphetamines

OBJECTIVES

Amphetamine-based medications are recommended as a first-line pharmacotherapy for the treatment of attention-deficit/hyperactivity disorder in children and adolescents. However, the efficacy and tolerability of these medications vary across individuals, which could be related to interindividual differences in amphetamine metabolism. This study examined if genotype-predicted phenotypes of the cytochrome P450 isozyme CYP2D6 were associated with self-reported side effects and symptom improvement in youth treated with amphetamines.

METHODS

Two hundred fourteen participants aged 6-24 who had a history of past or current amphetamine treatment were enrolled from Western Canada. Amphetamine dose and duration information was collected from the participants along with questions regarding adherence, concomitant medications, symptom improvement and side effects. DNA was extracted from saliva samples and genotyped for CYP2D6 . Binomial logistic regression models were used to determine the effect of CYP2D6 metabolizer phenotype with and without correction for phenoconversion on self-reported symptom improvement and side effects.

RESULTS

Genotype-predicted CYP2D6 poor metabolizers had significantly higher odds of reporting symptom improvement when compared to intermediate metabolizers (OR = 3.67, 95% CI = 1.15-11.7, P  = 0.029) after correction for phenoconversion and adjusting for sex, age, dose, duration, and adherence. There was no association between CYP2D6 metabolizer phenotype and self-reported side effects.

CONCLUSION

Our findings indicate that phenoconverted and genotype-predicted CYP2D6 poor metabolizer phenotype is significantly associated with higher odds of symptom improvement in children and adolescents treated with amphetamine. If replicated, these results could inform the development of future dosing guidelines for amphetamine treatment in children and adolescents.

Expected changes in parenting after an online parent training for ADHD

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in children and adolescents. Treatments for this population should be multidisciplinary and must be initiated as early as possible. Non-pharmacological interventions for ADHD include psychoeducation, parent behavioural training programs and school interventions and accommodations. In response to the COVID-19 pandemic, we developed an online version of a combined psychoeducation and behavioural training program to facilitate access to mental health treatment and ensure continuity of care.

OBJECTIVE

The study assessed the acceptability of this online parent training program, among parents and caretakers of children and adolescents with ADHD.

METHODS

The program consisted of ten online sessions over the course of two consecutive days (five sessions a day). Satisfaction, usefulness and general comments about the program were assessed with open-ended questions and visual-analogous scales. Parents/caretakers' use of strategies to manage behavioural problems was assessed using the Parenting and Family Adjustment Scales.

RESULTS

A total of 206 parents participated in the online program 175 of whom completed the evaluation. Participants were satisfied with the content of the program. More than half of participants had already started using strategies included in the program. The engagement was high and no major obstacles were identified other than some internet connection issues.

DISCUSSION

In our survey, online delivery was described as more convenient, and participants were satisfied with the content of the program finding it beneficial for their child. Despite this, some difficulties in implementing new strategies were observed. Online BTP increased access to the BTP programs while being effective on ADHD symptoms and behavioural disturbances.

CONCLUSIONS

With these measures, we hope to improve engagement in online psychoeducation and behavioural therapy programs. Future research evaluating online behavioural training programs should focus on ways to make them more accessible and adaptable to families' obstacles.

Sex, hormones and cerebrovascular function: from development to disorder

Proper cerebrovascular development and neurogliovascular unit assembly are essential for brain growth and function throughout life, ensuring the continuous supply of nutrients and oxygen. This involves crucial events during pre- and postnatal stages through key pathways, including vascular endothelial growth factor (VEGF) and Wnt signaling. These pathways are pivotal for brain vascular growth, expansion, and blood-brain barrier (BBB) maturation. Interestingly, during fetal and neonatal life, cerebrovascular formation coincides with the early peak activity of the hypothalamic-pituitary-gonadal axis, supporting the idea of sex hormonal influence on cerebrovascular development and barriergenesis.Sex hormonal dysregulation in early development has been implicated in neurodevelopmental disorders with highly sexually dimorphic features, such as autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). Both disorders show higher prevalence in men, with varying symptoms between sexes, with boys exhibiting more externalizing behaviors, such as aggressivity or hyperactivity, and girls displaying higher internalizing behaviors, including anxiety, depression, or attention disorders. Indeed, ASD and ADHD are linked to high prenatal testosterone exposure and reduced aromatase expression, potentially explaining sex differences in prevalence and symptomatology. In line with this, high estrogen levels seem to attenuate ADHD symptoms. At the cerebrovascular level, sex- and region-specific variations of cerebral blood flow perfusion have been reported in both conditions, indicating an impact of gonadal hormones on the brain vascular system, disrupting its ability to respond to neuronal demands.This review aims to provide an overview of the existing knowledge concerning the impact of sex hormones on cerebrovascular formation and maturation, as well as the onset of neurodevelopmental disorders. Here, we explore the concept of gonadal hormone interactions with brain vascular and BBB development to function, with a particular focus on the modulation of VEGF and Wnt signaling. We outline how these pathways may be involved in the underpinnings of ASD and ADHD. Outstanding questions and potential avenues for future research are highlighted, as uncovering sex-specific physiological and pathological aspects of brain vascular development might lead to innovative therapeutic approaches in the context of ASD, ADHD and beyond.

Burden of Attention Deficit Hyperactivity Disorder (ADHD) in Indian Children: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine the pooled prevalence of attention deficit hyperactivity disorder (ADHD) in Indian children.

METHODS

The searching of published literature was conducted in different databases (PubMed, Ovid SP, and EMBASE). The authors also tried to acquire information from the unpublished literature about the prevalence of ADHD. A screening was done to include eligible original studies, community or school-based, cross-sectional or cohort, reporting the prevalence of ADHD in children aged ≤ 18 y in India. Retrieved data were analyzed using STATA MP12 (Texas College station).

RESULTS

Of 729 studies retrieved by searching different databases, 183 studies were removed as duplicates, and 546 titles and abstracts were screened. After screening, 19 studies were included for quantitative analysis. Subgroup analysis was conducted with respect to their setting (school-based/community-based). Fifteen studies performed in a school-based setting showed 75.1 (95% CI 56.0-94.1) pooled prevalence of ADHD per 1000 children of 4-19 y of age. In community-based settings, the pooled prevalence per 1000 children surveyed was 18.6 (95% CI 8.8-28.4). The overall pooled prevalence of ADHD was observed as 63.2 (95% CI 49.2-77.1) in 1000 children surveyed. Significant heterogeneity was observed in the systemic review.

CONCLUSIONS

ADHD accounts for a significant health burden, and understanding its burden is crucial for effective health policy-making for educational intervention and rehabilitation.

Harmonized Phenotypes for Anxiety, Depression, and Attention-Deficit Hyperactivity Disorder (ADHD)

In multi-cohort consortia, the problem often arises that a phenotype is measured using different questionnaires. This study aimed to harmonize scores based on the Child Behaviour Check List (CBCL) and the Strength and Difficulties Questionnaire (SDQ) for anxiety/depression and ADHD. To link the scales, we used parent reports on 1330 children aged 10–11.5 years from the Raine study on both SDQ and CBCL. Harmonization was done based on Item Response Theory. We started from existing CBCL and SDQ scales related to anxiety/depression and ADHD (theoretical approach). Next, we conducted a data-driven approach using factor analysis to validate the theoretical approach. Both approaches yielded similar scales, validating the combination of existing scales. In addition, we studied the impact of harmonized (IRT-based) scores on the statistical power of the results in meta-analytic gene-finding studies. The results showed that the IRT-based harmonized scores increased the statistical power of the results compared to sum scores, even with an equal sample size. These findings can help future researchers to harmonize data from different samples and/or different questionnaires that measure anxiety, depression, and ADHD, in order to obtain the larger sample sizes, to compare research results across subpopulations or to increase generalizability, the validity or statistical power of research results. We recommend using our item parameters to estimate harmonized scores that represent commensurate phenotypes across cohorts, and we explained in detail how other researchers can use our results to harmonize data in their studies.

Attitudes and practices in the management of attention deficit hyperactivity disorder among Brazilian pediatric neurologists who responded to a national survey: a cross-sectional study

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) has a prevalence of 5.3% among children and adolescents. It is characterized by attention deficit, hyperactivity, and impulsivity.

OBJECTIVE

We aimed to conduct a survey involving pediatric neurologists in the management of ADHD and compare the results with the current literature and guidelines.

DESIGN AND SETTING

Descriptive analytical study of a virtual environment, was used Test of equality of proportions for comparison between two groups of pediatric neurologists (working as specialists for > 6 versus ≤ 6 years), with a significance level of P = 0.05.

METHODS

This cross-sectional study used a virtual questionnaire covering the steps in the diagnosis and treatment of children with ADHD. The inclusion criteria were professionals who had completed their residency/specialization in pediatric neurology and clinical neurologists working in pediatric neurology.

RESULTS

Among the 548 electronic invitations sent, 128 were considered valid. For all participants, the diagnosis was clinically based on the disease classification manuals. Combination treatment promotes improvement of symptoms (96.9%). Among psychostimulants, short-acting methylphenidate was the most commonly prescribed medication (85.2%). Headache was the most common side effect (77.3%). Altogether, 73.4% of the participants requested laboratory tests, 71.1% requested an electrocardiogram, and 42.2% requested an electroencephalogram. Pediatric neurologists working as specialists for ≤ 6 years had more frequent referrals to psycho-pedagogists for diagnosis (P = 0.03).

CONCLUSIONS

The participants complied with clinical guidelines, emphasizing the relevance of diagnostic manuals and treatment guidelines for an eminently clinical situation and enabling uniformity in quality treatment.

Reliability, Criterion and Concurrent Validity of the Farsi Translation of DIVA-5: A Semi-Structured Diagnostic Interview for Adults With ADHD

Objectives: This study evaluated the psychometrics of the Farsi translation of diagnostic interview for attention-deficit hyperactivity disorder (ADHD) in adults (DIVA-5) based on DSM-5 criteria. Methods: Referrals to a psychiatric outpatient clinic (N = 120, 61.7% males, mean age 34.35 ± 9.84 years) presenting for an adult ADHD (AADHD) diagnosis, were evaluated using the structured clinical interviews for DSM-5 (SCID-5 & SCID-5-PD) and the DIVA-5. The participants completed Conner's Adult ADHD Rating Scale-Self Report-Screening Version (CAARS-S-SV). Results: According to the SCID-5 and DIVA-5 diagnoses, 55% and 38% of the participants had ADHD, respectively. Diagnostic agreement was 81.66% between DIVA-5/SCID-5 diagnoses, 80% between SCID-5/CAARS-S-SV, and 71.66% between DIVA-5/CAARS-S-SV. Test-retest and inter-rater reliability results for the DIVA-5 were good to excellent. Conclusion: Findings support the validity and reliability of the Farsi translation of DIVA-5 among the Farsi-speaking adult outpatient population.

A Virtual Reality Game (The Secret Trail of Moon) for Treating Attention-Deficit/Hyperactivity Disorder: Development and Usability Study

Background

Attention-deficit/hyperactivity disorder (ADHD) affects between 4% and 8% of children worldwide. The treatment of choice is multimodal treatment. Multimodal interventions for ADHD may be improved by incorporating new treatments, such as treatment via serious video games. The Secret Trail of Moon (TSTM) is a virtual reality serious video game that was designed for cognitive training related to core ADHD symptoms and executive dysfunction.

Objective

We aimed to describe the development and usability of TSTM.

Methods

The usability study included 37 children and adolescents who tested TSTM during the early usability stage (preinclusion) of a randomized controlled clinical trial for testing the effectiveness of TSTM. Chi-square tests were performed to compare patients with ADHD (ADHD combined subtype vs inattentive subtype) and to compare frequent and infrequent video game players in the second study. We used SPSS version 20 for Macintosh (IBM Corporation).

Results

A total of 31/37 (86%) and 30/37 (83%) of participants liked playing TSTM and wanted to continue playing TSTM, respectively. Further, 5/37 (14%) of participants reported that they experienced either perceived dizziness or virtual reality motion sickness. We found no statistically significant differences after comparing the ADHD combined subtype to the inattentive subtype and frequent video game players to infrequent video game players.

Conclusions

Serious video games, such as TSTM, may complement the current multimodal approach for treating ADHD.

Trial Registration

ClinicalTrials.gov NCT04355065; https://clinicaltrials.gov/ct2/show/NCT04355065

Research protocol for a pragmatic randomized controlled effectiveness and cost effectiveness study of Well Parent Japan (WPJ) for Japanese mothers of children with ADHD: The TRaining And Nurturing Support FOR Mothers TRANSFORM study (Preprint)

Background

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder associated with numerous functional deficits and poor long-term outcomes. Internationally, behavioral interventions are recommended as part of a multimodal treatment approach for children with ADHD. Currently, in Japan, there are limited interventions available to target ADHD. Well Parent Japan (WPJ), a new hybrid parent-training program, provides a culturally acceptable and effective way to help support Japanese children with ADHD and their parents.

Objective

This pragmatic multicenter randomized controlled trial aims to provide preliminary evidence about the effectiveness and cost-effectiveness of WPJ evaluated against treatment as usual (TAU) within routine Japanese mental health services.

Methods

Mothers of children (aged 6-12 years) diagnosed with ADHD were recruited from child and adolescent mental health care services at three hospital sites across Japan (Fukui, Fukuoka, and Okinawa). The mothers were randomized to receive immediate treatment or TAU. The effectiveness and cost-effectiveness of WPJ over TAU at the end of the intervention and at 3-month follow-up will be evaluated. The primary outcome is maternal parent domain stress in the parenting role. The following secondary outcomes will be explored: child behavior, including severity of ADHD symptoms; parenting practices; emotional well-being; and the parent-child relationship and maternal child domain parenting stress. Data analysis will follow intention-to-treat principles with treatment effects quantified through analysis of covariance using multilevel modeling. An incremental cost-effectiveness ratio will be used to analyze the cost-effectiveness of the WPJ intervention.

Results

Study funding was secured through a proof-of-concept grant in July 2018. Approval by the institutional review board for the data collection sites was obtained between 2017 and 2019. Data collection began in August 2019 and was completed in April 2022. Participant recruitment (N=124) was completed in May 2021. Effectiveness and cost-effectiveness analyses are expected to be completed by July 2022 and December 2022, respectively. These timelines are subject to change owing to the COVID-19 pandemic.

Conclusions

This is the first multisite pragmatic trial of WPJ based on the recruitment of children referred directly to routine clinical services in Japan. This multisite randomized trial tests the effectiveness of WPJ in children and families by comparing WPJ directly with the usual clinical care offered for children diagnosed with ADHD in Japan. We also seek to assess and compare the cost-effectiveness of WPJ with TAU in Japan.

Trial Registration

International Standard Randomised Controlled Trial Number ISRCTN66978270; https://www.isrctn.com/ISRCTN66978270

International Registered Report Identifier (IRRID)

DERR1-10.2196/32693

Effects of biological determinist and interactionist causal explanations on undergraduate students' stigma of children with attention deficits hyperactivity disorders: An experimental investigation

This experimental study examined the effects of biological explanations on individuals' stigma against children with ADHD. We randomly assigned 174 undergraduate students to read one of the three fictitious articles: the first article focused on the determining role of biology in affecting children's ADHD symptoms (biological determinist), the second article highlighted the interplay between biological and environmental factors (interactionist), and the third article was unrelated to ADHD (control). Analyses of variance showed that participants who read the biological determinist message, relative to the control group, were (a) less likely to blame the children for their problems, but (b) more likely to endorse fixed beliefs about the nature of ADHD (entity beliefs). Thus, the overall direct effect of biological determinist message on desire for social distance was not significant. By contrast, participants who read the interactionist message showed (a) less blame attribution and (b) lower levels of entity beliefs, which contributed to less desire for social distance. These findings suggest that (a) presenting biological information regarding ADHD in a deterministic way may not be an effective way to reduce stigma, whereas (b) providing an interactionist account of ADHD may undermine the potential negative effect of an exclusively biological explanation.

Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women

BACKGROUND

There is evidence to suggest that the broad discrepancy in the ratio of males to females with diagnosed ADHD is due, at least in part, to lack of recognition and/or referral bias in females. Studies suggest that females with ADHD present with differences in their profile of symptoms, comorbidity and associated functioning compared with males. This consensus aims to provide a better understanding of females with ADHD in order to improve recognition and referral. Comprehensive assessment and appropriate treatment is hoped to enhance longer-term clinical outcomes and patient wellbeing for females with ADHD.

METHODS

The United Kingdom ADHD Partnership hosted a meeting of experts to discuss symptom presentation, triggers for referral, assessment, treatment and multi-agency liaison for females with ADHD across the lifespan.

RESULTS

A consensus was reached offering practical guidance to support medical and mental health practitioners working with females with ADHD. The potential challenges of working with this patient group were identified, as well as specific barriers that may hinder recognition. These included symptomatic differences, gender biases, comorbidities and the compensatory strategies that may mask or overshadow underlying symptoms of ADHD. Furthermore, we determined the broader needs of these patients and considered how multi-agency liaison may provide the support to meet them.

CONCLUSIONS

This practical approach based upon expert consensus will inform effective identification, treatment and support of girls and women with ADHD. It is important to move away from the prevalent perspective that ADHD is a behavioural disorder and attend to the more subtle and/or internalised presentation that is common in females. It is essential to adopt a lifespan model of care to support the complex transitions experienced by females that occur in parallel to change in clinical presentation and social circumstances. Treatment with pharmacological and psychological interventions is expected to have a positive impact leading to increased productivity, decreased resource utilization and most importantly, improved long-term outcomes for girls and women.

Teacher reports of ADHD symptoms in Italian children at the end of first grade

Objective:

To determine the prevalence of teacher-rated ADHD symptoms in Italian first-graders.

Method:

1891 first-graders aged 6.6–7.4 years were evaluated using a 34-item DSM-IV-referenced ADHD teacher rating questionnaire which included all the 18 DSM-IV ADHD diagnostic criteria, some Oppositional-Defiant Disorder (ODD), Conduct Disorder (CD), depression and anxiety symptoms, and questions about the child's social and scholastic impairment.

Results:

Criteria for ADHD were met in 7.1% (n = 135) of the subjects (10.4% males and 3.8% females), 3.5% with the Inattentive subtype, 2.3% with the Hyperactive/Impulsive subtype and 1.3% with a Combined subtype. Internalizing (depression and/or anxiety) symptoms were reported in 25.9% of the subjects with ADHD symptoms, 17% showed externalizing symptoms (ODD or CD), and 12.6% showed both. Comorbid symptoms were 10 times more frequent than in subjects without ADHD symptoms. Inattentive subtype and scholastic impairment were more frequent in females, Hyperactive/Impulsive subtype and social impairment were more frequent in males.

Conclusions:

Even though the real prevalence of ADHD in first graders is presumably lower than that found in the present study, this screening procedure might allow detecting those children who could benefit from referral for more comprehensive assessments.

Stereoacuity, Fusional Vergence Amplitudes, and Refractive Errors Prior to Treatment in Patients with Attention-Deficit Hyperactivity Disorder

Objectives:

To evaluate stereoacuity, fusional vergence amplitudes, and refractive errors in patients with attention-deficit hyperactivity disorder (ADHD).

Materials and Methods:

Twenty-three patients who were newly diagnosed as having ADHD and had not started medication, and 48 children without ADHD were included. Retrospective data analysis of comprehensive eye examination, stereoacuity, and fusional vergence amplitudes of the patients were performed.

Results:

The mean age at ADHD diagnosis was 10.68±2.34 (7-16) years in the ADHD group (14 male, 9 female) and 12.23±2.16 (7-15) years in the control group (25 male, 23 female) patients (p=0.605). The mean stereoacuity was 142.14±152.65 (15-480) sec/arc in patients with ADHD and 46.3±44.11 (15-240) sec/arc in the control group (p<0.001). For ADHD patients, the mean convergence and divergence amplitudes at distance were 19.87±8.40 (6 to 38) prism diopter (PD) and -9.09±-4.34 (-4 to -25) PD, and 37.30±12.81 (14 to 70) PD and -13.13±-3.45 (-4 to -20) PD at near, respectively. The mean cycloplegic spherical equivalent was 1.06±1.13 (-1 to 4.63) diopter in ADHD patients, with 6 patients having significant refractive errors (hyperopia in 4 patients, astigmatism in 2 patients). There were no significant differences between groups in terms of spherical equivalents (p=0.358) or convergence and divergence amplitudes at distance (p=0.289 and p=0.492, respectively) or near (p=0.452 and p=0.127, respectively).

Conclusion:

Fusional vergence amplitudes did not present significant difference, while the mean value of stereoacuity was significantly lower in newly diagnosed ADHD patients prior to treatment.

ADHD pathogenesis in the immune, endocrine and nervous systems of juvenile and maturating SHR and WKY rats

RATIONALE

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioural disorders with morphological and functional brain abnormalities. However, there is a growing body of evidence that abnormalities in the immune and endocrine systems may also account for the ADHD pathogenesis.

OBJECTIVES

To test ADHD pathogenesis in neurological, immune and endocrine systems, this study examined the concentrations of cytokines, chemokines, oxidative stress markers, metabolic parameters, steroid hormones and steroidogenic enzymes in the serum and/or tissues of spontaneously hypertensive rats (SHRs, animal model of ADHD) and Wistar Kyoto rats (WKYs, control animals). Moreover, the volume of the medial prefrontal cortex (mPFC) as well as the density of dopamine 2 (D2) receptor-expressing cells and tyrosine hydroxylase (TH)-positive nerve fibres in it was also elucidated.

METHODS

Peripheral blood, spleen and adrenal gland samples, as well as brain sections collected on day 35 (juvenile) and day 70 (maturating) from SHRs and WKYs, were processed by ELISA and immunohistochemistry, respectively.

RESULTS

The results show significant increases of serum and/or tissue concentrations of cytokines, chemokines and oxidative stress markers in juvenile SHRs when compared to the age-matched WKYs. These increases were accompanied by a lowered volume of the mPFC and up-regulation of D2 in this brain region. In maturating SHRs, the levels of inflammatory and oxidative stress markers were normalised and accompanied by elevated contents of steroid hormones.

CONCLUSIONS

Significant elevations of serum and/or tissue contents of cytokines, chemokines and oxidative stress markers as well as volumetric and neurochemical alterations in the mPFC of juvenile SHRs may suggest the cooperation of neurological and immune systems in the ADHD pathogenesis. Elevated levels of steroid hormones in maturating SHRs may be a compensatory effect involved in reducing inflammation and ADHD symptoms.

The Impact of Adult ADHD in the Quality of Life Profile

OBJECTIVE

In this multicenter, cross-sectional study, we aimed to investigate the quality of life (QoL) and the neuropsychological and clinical characteristics of adults with ADHD with different developmental pathways.

METHOD

Our study sample included 25 control (healthy) participants, 31 patients with newly diagnosed ADHD without comorbidities (ADHD-C-D), 31 with newly diagnosed ADHD with comorbidities (ADHD+C-D), and 29 with previously diagnosed ADHD with comorbidities (ADHD+C+D).

RESULTS

Compared with controls, ADHDs had little differences in the attentional performance but showed higher impulsivity, more severe symptoms of depression and anxiety, and lower QoL. The ADHD+C-D group showed more severe symptoms of depression and anxiety than the ADHD+C+D group ( p = .037 and p = .008, respectively), and poorer QoL in the psychological health sphere ( p = .003).

CONCLUSION

Differences between ADHD and control subjects were particularly remarkable in mood symptoms and QoL. Previous diagnosis might have a positive impact on mood symptoms and QoL in ADHD adults.

Depression in Maltreated Children and Adolescents

Maltreatment affects 9.1 to 17.1 of every 1000 US children and adolescents. Maltreated youth are at high risk for depression. Clinicians should screen young patients for maltreatment history. Depressed maltreated youth are at high risk for treatment resistance. Combination treatment with selective serotonin reuptake inhibitors and cognitive behavior therapy (CBT) with a trauma-informed approach should be considered for depressed maltreated youth. Behavioral management can be integrated with trauma-focused CBT to treat the externalizing disorders that commonly occur in maltreated depressed youth. If one approach is unsuccessful, a change to another medication or type of evidence-based psychotherapy or intervention is indicated.

Characterizing the unmet mental health needs of urban adolescents

BACKGROUND

Untreated mental illness among adolescents is a serious public health concern. This study offers a classification tool for mental illness based on severity and identifies a starting point for needed interventions.

METHODS

We assessed the prevalence and severity of serious emotional disturbances (SED)/serious mental illnesses (SMI) among transition-aged adolescents in an urban primary care practice and identified those with unmet needs. Medical records were abstracted for 16-22 year-old patients with at least one International Classification of Diseases (ICD)-9 diagnosis of serious emotional disturbances (SED)/serious mental illnesses (SMI) seen between May 1, 2014 and July 31, 2015. The primary outcome was whether 16-22 year-old patients with serious emotional disturbances (SED)/serious mental illnesses (SMI) diagnoses were connected to mental health care and associated factors including severity of mental illness, provider referral and psychotropic medication use.

RESULTS

We identified 546 patients with a mean age of 18.8 years [standard deviation (SD) ± 1.7]. Ninety percent were African American and 86% were publicly insured. Based on the illness severity criteria, 189 (35%) were categorized as "mild", 293 (54%) as "moderate" and 64 (12%) as "severe". The majority (n = 460, 84.3%) had a mental health referral, but only 219 (40%) were connected to care. Adolescents aged 18-22 had 48% fewer odds to be connected to care compared to those aged 16-17 (odds ratio, 0.52; 95% confidence interval, 0.34-0.80; p-value = 0.003).

CONCLUSIONS

There is a gap in mental health services among a sample of minority adolescents in an urban environment with mental health needs. The gap is especially prevalent among older adolescents aging out of the pediatric system. Primary care providers (PCPs) are central to ensuring access to treatment, though they may be unable to meet the needs of patients with severe forms of serious emotional disturbances (SED)/serious mental illnesses (SMI). Our study characterizes the mental health needs of minority adolescents by severity and offers direction for identifying those who would most benefit from additional resources and support.

Differences in serum steroid hormones concentrations in Spontaneously Hypertensive Rats (SHR) - an animal model of Attention-Deficit/Hyperactivity Disorder (ADHD)

Spontaneously hypertensive rats are the most common animal model used to study attention deficit hyperactivity disorder (ADHD). The present study investigated the levels of steroid hormones in the bloodstream of hypertensive rats and its normotensive control strain, Wistar-Kyoto rats, to check if there are any hormonal differences between both strains at the onset of ADHD. Plasma samples were collected from young (5-week-old) and mature (10-week-old) male hypertensive and normotensive rats to determine the serum level of testosterone, 17beta-estradiol, free estriol, progesterone, corticosterone and cortisol using ELISA kits. The results showed statistically significant increases in serum levels of testosterone and free estriol in 10-week-old hypertensive and normotensive rats when compared to 5-week-old animals. Moreover, the concentrations of progesterone, corticosterone and cortisol were significantly elevated in 10-week-old hypertensive rats when compared to 5-week-old animals of both strains as well as 10-week-old normotensive rats. Hormonal differences observed between 10-week-old hypertensive and normotensive rats were also accompanied by differences in the volumes of lateral ventricles as well as the third ventricle and cerebral aqueduct. In conclusion, elevated contents of progesterone, corticosterone and cortisol in hypertensive rats may be associated not only with ADHD but also with developing hypertension. This question needs further study.

The moderating roles of bedtime activities and anxiety/depression in the relationship between attention-deficit/hyperactivity disorder symptoms and sleep problems in children

BACKGROUND

Children with attention-deficit/hyperactivity disorder (ADHD) often experience sleep problems, but the comorbidity mechanism has not been sufficiently studied. This study aimed to determine the comorbidity of ADHD symptoms and sleep problems as well as the moderating effects of bedtime activities and depression/anxiety symptoms on the relationship between ADHD symptoms and sleep problems.

METHODS

We recruited 934 primary students from third to fifth grade and their parents by stratified random sampling from three primary schools in Shanghai, China. This study used parent-reported versions of the ADHD Rating Scale-IV, Children's Sleep Habits Questionnaire, and Achenbach Child Behavior Checklist. We used hierarchical linear regression analysis to clarify the moderating effects of bedtime activities and depression/anxiety symptoms.

RESULTS

We found that children with more ADHD symptoms had shorter sleep durations and more sleep problems on weekdays. Screen time before bedtime strengthened the relationship between ADHD symptoms and sleep-disordered breathing. Children with more screen time were more likely to have sleep onset delay, while those with less screen time had more sleep onset problems with increasing ADHD symptoms. The high bedtime eating group experienced more night waking with increasing ADHD symptoms compared with the low bedtime eating group. Anxiety/depression exacerbated total sleep problems and further interacted with ADHD symptoms to predict sleep length and sleep duration problems.

CONCLUSIONS

Bedtime activities and emotional problems had important moderating effects on the relationship between ADHD symptoms and sleep problems. These findings indicate that appropriate bedtime management and emotional management may reduce sleep problems and improve sleep duration for children with ADHD symptoms.

The Prevalence of Attention Deficit/Hyperactivity Disorder among Chinese Children and Adolescents

Updating the worldwide prevalence estimates of attention-deficit hyperactivity disorder (ADHD) has significant applications for the further study of ADHD. However, previous reviews included few samples of Chinese children and adolescents. To conduct a systematic review of ADHD prevalence in Mainland China, Hong Kong, and Taiwan to determine the possible causes of the varied estimates in Chinese samples and to offer a reference for computing the worldwide pooled prevalence. We searched for PubMed, Embase, PsycINFO, Web of Science, China National Knowledge Infrastructure, VIP, WANFANG DATA, and China Science Periodical Database databases with time and language restrictions. A total of 67 studies covering 642,266 Chinese children and adolescents were included. The prevalence estimates of ADHD in Mainland China, Hong Kong, and Taiwan were 6.5%, 6.4%, and 4.2%, respectively, with a pooled estimate of 6.3%. Multivariate meta-regression analyses indicated that the year of data collection, age, and family socioeconomic status of the participants were significantly associated with the prevalence estimates. Our findings suggest that geographic location plays a limited role in the large variability of ADHD prevalence estimates. Instead, the variability may be explained primarily by the years of data collection, and children's socioeconomic backgrounds, and methodological characteristics of studies.

Multi-disciplinary assessment of attention-deficit hyperactivity disorder: a tertiary assessment package

Aims and method

A tertiary assessment package was set up for the more equivocal cases of attention-deficit hyperactivity disorder (ADHD) who present with problems of inattention, impulsivity and overactivity. The structure of the three-day package was discussed, with an analysis of our experience in assessing 12 children using the pilot project. The package and Its use in clinical practice are presented.

Results

The pilot project described can be modified into a two-day package.

Clinical implications

Assessment of ADHD conducted in multiple settings inherently has many advantages over single clinic assessment. We suggest that such an assessment protocol can be conducted cost effectively.

Attention-deficit hyperactivity disorder and the use of methylphenidate

Aims and Method

General practitioners (GPs) were surveyed on their experience of and attitudes towards attention-deficit hyperactivity disorder (ADHD) treatment using methylphenidate, and asked about prescribing practice.

Results

Most GPs have experience of children with ADHD and the use of methylphenidate. The majority felt that it was a drug that should be initiated by a specialist who should continue to provide clinical monitoring, but that primary care could provide ongoing prescribing and physical monitoring. There was a lack of training in this area, with most GPs requesting further training both on ADHD and its management.

Clinical Implications

ADHD is a topical issue both in the health service and with the public. This survey suggests that GPs may be willing to play a role in the management of ADHD once the child has seen a specialist, but that child and adolescent mental health services need to consider how training will be provided.

Attention-deficit hyperactivity disorder: should we believe the mass media or peer-reviewed literature?

Bailly's review describes the author's perspectives on the ‘intense controversies' surrounding attention-deficit hyperactivity disorder (ADHD) and its treatment with stimulant medications. Drawing on a range of literature sources, including the UK press, pharmaceutical industry websites and peer-reviewed scientific papers, he questions the validity of ADHD as a concept and disorder, the accuracy and reliability of diagnosis, the use of stimulant medications and the impact of advertising by the pharmaceutical industry. There are, however, additional sources and alternative interpretations.

Estimated prevalence and incidence of diagnosed ADHD and health care utilization in adults in Sweden - a longitudinal population-based register study

BACKGROUND

Although the worldwide prevalence of attention-deficit/hyperactivity disorder (ADHD) in adults is estimated to be between 2% and 5%, it is considered to be underdiagnosed. This register study explored the prevalence of diagnosed ADHD and incidence of newly diagnosed ADHD in Swedish adults over time, and assessed comorbidities and pharmacologic treatment.

METHODS

National Patient Register data were used to estimate the overall prevalence of adults (≥18 years) with a registered ADHD diagnosis from 2006 to 2011, and the incidence of newly registered diagnoses from 2007 to 2011. Data from the Prescribed Drug Register were used to estimate the mean dose of the most frequently prescribed ADHD medication.

RESULTS

The estimated annual prevalence (N=44,364) of diagnosed ADHD increased from 0.58 per 1,000 persons in 2006 to 3.54 per 1,000 persons in 2011. The estimated annual incidence of newly diagnosed ADHD (N=24,921) increased from 0.39 per 1,000 persons to 0.90 per 1,000 persons between 2007 and 2011. At least one comorbidity was diagnosed in 52.6% of adults with ADHD (54.0% of newly diagnosed adults), with anxiety, substance use disorders, and depression being the most common. Among all adults with ADHD, 78.9% (65.7% of newly diagnosed adults) were prescribed ADHD medication and one-third were prescribed more than one add-on medication. Osmotic release oral system methylphenidate was the most commonly used medication. The mean daily dose was 51.5 mg, and was significantly higher in males, patients with substance use disorders, patients with drug holidays, and patients with at least one add-on medication. The most frequent concomitant medications were anxiolytics and hypnotics.

CONCLUSION

In Sweden, the number of adults diagnosed with ADHD increased between 2006 and 2011, and the majority of patients were prescribed ADHD-specific medication. Over one-half of patients had psychiatric comorbidities; one-third were prescribed more than one add-on medication. Consumption of pharmacologic ADHD medication was high in specific patient subpopulations.

The Relationship between the SNAP-25 Polymorphism and Omission Errors in Korean Children with Attention Deficit Hyperactivity Disorder

Objective

This study aimed to investigate the association between the synaptosomal-associated protein 25 kDa (SNAP-25) genotype and performance on the continuous performance test (CPT) in Korean children with attention-deficit/hyperactivity disorder (ADHD).

Methods

Eighty-seven children with ADHD (mean age, 9.23±1.99 years) participated in this study. Omission errors, commission errors, reaction time, and reaction time variability on the CPT were analyzed. The single-nucleotide polymorphism (SNP) rs3746544 (1065 T>G) of SNAP-25 was genotyped to examine the association with CPT performance.

Results

We found significantly more omission errors on the CPT among children with the TT genotype of SNAP-25 (t=2.56, p=0.012) after correcting for multiple testing.

Conclusion

Our results suggest the possible involvement of the SNAP-25 1065 T>G polymorphism in the inattention phenotype in children with ADHD. Further studies with more refined neuropsychological measures and much larger sample sizes are needed to confirm our findings.

Safety, Tolerability and Efficacy of Drugs for Treating Behavioural Insomnia in Children with Attention-Deficit/Hyperactivity Disorder: A Systematic Review with Methodological Quality Assessment

OBJECTIVE

A large proportion of paediatric patients with attention-deficit/hyperactivity disorder (ADHD) have associated sleep problems which not only affect the child's wellbeing but also impact family functioning. Management of sleep problems is consequently an important aspect of overall ADHD management in paediatric patients. Although some drugs are being used off-label for the management of paediatric insomnia, there is scant clinical evidence supporting their use. Our aim was to identify and assess the quality of published studies reporting the safety, tolerability and efficacy of drugs used for treating behavioural insomnia in children with ADHD.

METHODS

After an initial screen to determine which drugs were most commonly used, we conducted a systematic review of English-language publications from searches of PubMed, EMBASE, PsycINFO and two trial register databases to February 2017, using keywords 'clonidine', 'melatonin', 'zolpidem', 'eszopiclone', 'L-theanine', 'guanfacine', 'ADHD', 'sleep disorder' and 'children'. For quality assessment of included studies, we used the CONSORT checklist for randomised control trials (RCTs) and the Downs and Black checklist for non-RCTs.

RESULTS

Twelve studies were included. Two case series for clonidine, two RCTs and four observational studies for melatonin and one RCT each for zolpidem, eszopiclone, L-theanine and guanfacine. Of the 12 included studies, only one on eszopiclone scored excellent for quality. The quality of the rest of the studies varied from moderate to low. For clonidine, melatonin and L-theanine, improvements in sleep-onset latency and total sleep duration were reported; however, zolpidem, eszopiclone and guanfacine failed to show any improvement when compared with placebo. Clonidine, melatonin, L-theanine, eszopiclone and guanfacine were well tolerated with mild to moderate adverse events; zolpidem was associated with neuropsychiatric adverse effects.

CONCLUSION

There is generally poor evidence for prescribing drugs for behavioural insomnia in children with ADHD. Further controlled studies are warranted.

A Double Dissociation Between Inattentive and Impulsive Traits, on Tasks of Visual Processing and Emotion Regulation

OBJECTIVE

To dissociate between inattentive and impulsive traits common in attention deficit hyperactivity disorder (ADHD) using a non-dichotomous measurment of these traits.

METHOD

120 university students who completed the Conner's adult ADHD rating scales (CAARS) were also tested on the Microgenesis task which requires visual attention and on the Cyber Cruiser task which requires emotion regulation.

RESULTS

Results show that a measure of inattention was specifically related to a measure of effortful visual processing condition. In addition, a measure of impulsivity was specifically related to the tendency to fail in refueling one's car on time, although this relation was opposite to the predicted direction. Furthermore, by using exploratory and confirmatory factor analyses, the CAARS' factor structure was confirmed to be relevant to an Israeli population.

CONCLUSION

The current experiment supports the idea that visual attention may play a part in inattentive symptoms, and that emotion regulation may play a part in impulsivity symptoms.

Attention-deficit hyperactivity disorder in elementary school students in Shantou, China: prevalence, subtypes, and influencing factors

Attention-deficit hyperactivity disorder (ADHD) is a frequent childhood-onset psychiatric condition and categorized into three subtypes of predominantly inattentive (ADHD-I), hyperactive impulsive (ADHD-H), and combined (ADHD-C). The prevalence and subtypes of ADHD vary considerably. The primary aim of this study was to provide a prevalence estimate of ADHD in elementary school students living in Shantou, a district of China, and in addition to examine the influence of informants, age, and gender on the prevalence. A total of 3,497 students aged 7-12 years were enrolled by random and stratified sampling. In stage I, teachers and parents of all participating students in randomly selected schools were asked to complete Chinese versions of the Conners' 10-item scale. In stage II, students with high scores (>15) were interviewed by a psychiatrist for a diagnosis with or without ADHD. Parents rated many more students with high scores than teachers did in stage I. The prevalence of ADHD determined by Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) was 5.91% (5.27%-6.55%), which is comparable to the rates reported in previous studies with Chinese children. This hits the low border of the ADHD prevalence range from 5.9 to 7.1% worldwide, and is lower than that of Chinese children living in Hong Kong, suggesting an important influence of Chinese culture on the diagnosis of ADHD. The constituent ratios of ADHD-I, ADHD-C, and ADHD-H subtypes were 67.43, 24.57, and 8.00%, respectively. The rate of ADHD-H decreased with age, whereas that of ADHD-I remained at the highest levels in all age groups, suggesting that symptoms in the inattention domain are the most persistent and refractory.

Prevalence of ADHD in Qatari School-Age Children

OBJECTIVE

The purpose of this quantitative survey study is to provide current accurate estimates of the number of students with ADHD in Qatar Independent and English Medium Private Schools, so that adequate support will be available to assist in the educational growth and development of these students.

METHOD

This cross-sectional descriptive study of teacher observational ratings used a standardized rating scale. Teachers completed the SNAP-IV. Rating Scales for more than 5,000 students from Qatar Independent Schools and private English Medium Schools between November 2011 and November 2012 in Qatar Grades 1 through 12.

RESULTS

Results align with and extend the previous study of ADHD in Qatar and the current worldwide prevalence.

CONCLUSION

Enhanced analyses were conducted to identify differences between age groups, genders, and between Private and Independent Schools. Implications for teachers, administrators, and medical personnel are discussed.

Evidence-Based Considerations and Recommendations for Athletic Trainers Caring for Patients With Attention-Deficit/Hyperactivity Disorder

CONTEXT

Patients with attention-deficit/hyperactivity disorder (ADHD) can be noncompliant, impulsive, and disruptive in an athletic training or physical rehabilitation facility. Athletic trainers (ATs) are valuable and essential health care providers for active patients with ADHD. However, for a patient with ADHD to have a successful outcome in a busy athletic training environment, the AT or health care provider must tailor the treatment setting to the patient's needs.

OBJECTIVE

To educate and raise awareness among ATs about patients with ADHD and to provide ATs with strategies and tools that will allow them to treat patients with ADHD more effectively.

DATA SOURCES

We retrieved and reviewed articles from PubMed, PsychINFO, and Ovid without date restrictions. Search words were attention deficit hyperactivity disorder plus 1 of the following topics or search words: athletic training, athletics, coaching, sport, or sport psychology.

STUDY SELECTION

Any ADHD articles that were not applicable or translatable in good faith to athletic training, physical rehabilitation, or sport and exercise were excluded.

DATA EXTRACTION

Nonpharmacologic interventions were reviewed and amassed into categories from which the recommendations were created. No statistical analyses were conducted for this review.

DATA SYNTHESIS

We identified 1241 articles, and 86 met the inclusion criteria. Five groups of evidence were observed: (1) goal setting and coaching, (2) reinforcements and outcomes, (3) routines and treatment timing, (4) simplified feedback and instructions, and (5) environmental control. Reliable evidence suggests that these techniques can be translated and applied within an athletic training and physical rehabilitation setting.

CONCLUSIONS

Athletic trainers are a vital component in providing health care for patients with ADHD. Using goal contagion creates a structured environment and positive reinforcements that accommodate patients with ADHD. Furthermore, ATs may use the evidence-based recommendations in this review to create a treatment and physical rehabilitation program and space that are tailored to the needs of the ADHD patient to increase the chance of a successful outcome.

Occupational Therapy for Children with Attention Deficit Hyperactivity Disorder: A Survey on the Level of Involvement and Training Needs of Therapists

There has been a substantial increase in clinical activity related to the identification and treatment of children with attention deficit hyperactivity disorder (ADHD) in the United Kingdom. The accurate diagnosis and successful management of children with ADHD requires a multifaceted evaluation and treatment package provided by a team of medical, psychological, educational and therapy professionals. Occupational therapists can make distinctive contributions in the processes of evaluation, diagnosis and multifaceted intervention.

A national survey was carried out to investigate the level and nature of involvement of paediatric occupational therapists in services for children with ADHD in the United Kingdom. The learning needs of the therapists were also explored in this survey. A questionnaire was sent to all 941 members of the National Association of Paediatric Occupational Therapists.

The response rate of this survey was 30%, that is, 282 completed questionnaires were returned. The results showed that only 8.5% of the therapists who responded had involvement in a designated service for children with ADHD. Twenty-seven per cent of the therapists indicated that they did not see children with ADHD. The 63.8% of therapists who did see children with ADHD as part of their overall caseload in a community service did so mainly because of the children's associated problems in different sensory, perceptual, motor and functional performance areas. The reasons for non-involvement are explored and discussed and the learning needs of the therapists and their preferred modes of training are identified.

Occupational Therapy for Children with Attention Deficit Hyperactivity Disorder (ADHD), Part 1: A Delineation Model of Practice

An occupational therapy delineation model of practice is presented, which guides a multidimensional understanding of the psychopathology of attention deficit hyperactivity disorder (ADHD) and its management. Previous research has established that occupational therapists lack detailed training or theory in this field. The delineation model of practice is based on a literature review, clinical experience and a consensus study carried out with occupational therapists to determine their priorities for the evaluation of, and intervention with, children with ADHD.

Part 1 of this article presents the model and examines its implications for evaluation and intervention at the levels of child, task and environment. A family-centred assessment and treatment package, based on the delineation model, is described. Part 2 of this article will report the results of a multicentre study, which was designed to evaluate the effectiveness of this package.

Prescription trends in children with pervasive developmental disorders: a claims data-based study in Japan

BACKGROUND

The only drug approved for pervasive developmental disorders (PDD) in Japan is pimozide. Several psychotropic drugs are also prescribed for offlabel use in Japan, but details regarding their prescription and use are largely unknown. The purpose of this study was to clarify the use of drug treatment in Japanese children with PDD.

METHODS

Data were extracted from claims data from the Japan Medical Data Center for children younger than 18 years of age who were newly diagnosed with PDD (International Classification of Diseases version 10 codes: F84) from 2005 to 2010 (total of 3276 patients as of 2010). The prescription rates were presented as the percentage of PDD patients who were prescribed each drug.

RESULTS

Prior to 2010, the prescription rates for atypical antipsychotics, other antipsychotics, psychostimulants, all other central nervous system drugs, anticovnvulsants, non-barbiturates, and Parkinson's disease/syndrome drugs significantly increased among the Anatomical Therapeutic Chemical classifications defined as the "nervous system" (trend P≤0.02). The prescription rate for risperidone consistently increased, reaching 6.9% in 2010 (trend P<0.0001), the highest rate of the surveyed drugs among the antipsychotics. The prescription rate for aripiprazole also increased (trend P<0.0001), reaching 1.9% in 2010. The prescription rate for pimozide showed no annual changes, with a low rate of 0.4% in 2010.

CONCLUSION

Compared with pimozide, the prescription rates for risperidone, aripiprazole and other psychotropic drugs have increased. Because safety data for these drugs in Japanese children are sparse, there is a need for future safety evaluations of these drugs in Japanese children.

Attention-Deficit/Hyperactivity Disorder and Lifestyle-Related Behaviors in Children

Attention-deficit/hyperactivity disorder (ADHD) has been associated with obesity in children. Lifestyle-related behaviors (external eating, screen time and physical inactivity) are well known to be associated with increased risk of obesity, but their associations with ADHD are unclear. The objectives of this study were to clarify the associations between ADHD symptoms in children and their associated lifestyle. A cross sectional study was carried out with a total of 785 primary students aged 9 to 13 years old and their parents were recruited by stratified random sampling from primary schools of China. The Cochran-Mantel-Haenszel (CMH) test was used to examine the relationships between ADHD symptoms and health related behaviors. We found that children with ADHD symptoms were likely to spend more time using a computer during school days; they were also more likely to eat while using a computer. These children were also more likely to eat while seated in a car, using a smart phone, using a computer at bedtime, and snacking before going to sleep than children without ADHD symptoms. An increased risk of obesity in children with ADHD symptoms was associated with the overuse of electronic devices, eating while using electronic devices, and delaying bedtimes to snack and use electronic devices.

Using Best-Worst Scaling to Measure Caregiver Preferences for Managing their Child's ADHD: A Pilot Study

BACKGROUND

Management of attention-deficit/hyperactivity disorder (ADHD) is a trade-off between caregivers' concerns about the benefits versus the risks of evidence-based treatment. Few studies have used choice-based methods to assess what treatment attributes matter most to caregivers.

OBJECTIVE

The aim was to develop and to pilot an instrument to elicit caregivers' preferences for evidence-based management of their child's ADHD.

METHODS

Mixed methods were used to develop a Best-Worst Scaling (BWS) instrument, and quantitative methods were used to pilot the instrument. Primary caregivers of children with ADHD from two community organizations were recruited for the development (n = 21) and pilot (n = 37) phase. The instrument was a BWS case 2, where 18 management profiles are presented one at a time, with respondents indicating the one best and one worst feature of each profile. Profiles were developed using a main effects orthogonal array. The mean of best-minus-worse scores was estimated, and attribute importance was based on the sum of maximum minus minimum scores for each attribute. Feasibility of eliciting stated preferences was evaluated with t tests and 95 % confidence intervals.

RESULTS

Seven attributes (medication, therapy, school, caregiver training, provider specialty, provider communication, and out-of-pocket costs) with three levels each were identified. All mean scores were significant except for pediatrician management of the child's ADHD (p = 0.089). Caregiver training had the highest relative importance, followed by medication and provider communication.

CONCLUSIONS

The BWS instrument was a relatively simple measure, caregivers completed it independently, and it distinguished the relative importance of different attributes in managing a child's ADHD.

Adaptive Interventions in Child and Adolescent Mental Health

The treatment or prevention of child and adolescent mental health (CAMH) disorders often requires an individualized, sequential approach to intervention, whereby treatments (or prevention efforts) are adapted over time based on the youth's evolving status (e.g., early response, adherence). Adaptive interventions are intended to provide a replicable guide for the provision of individualized sequences of interventions in actual clinical practice. Recently, there has been great interest in the development of adaptive intervenions by investigators working in CAMH. The development of such replicable, real-world, individualized sequences of decision rules to guide the treatment or prevention of CAMH disorders represents an important "next step" in interventions research. The primary purpose of this special issue is to showcase some recent work on the science of adaptive interventions in CAMH. In this overview article, we review why individualized sequences of interventions are needed in CAMH, provide an introduction to adaptive interventions, briefly describe each of the articles included in this special issue, and describe some exciting areas of ongoing and future research. A hopeful outcome of this special issue is that it encourages other researchers in CAMH to pursue creative and significant research on adaptive interventions.

The cardiovascular safety of methylphenidate

What to make of studies that agree to disagree

Adult ADHD: A new disease?

OBJECTIVES

Until recently, it was believed that attention deficit and hyperactivity disorder (ADHD) are outgrown by the end of adolescence and the beginning of adulthood. The purpose of this review is to describe the characteristics of the disease in adults, depict comorbidities that accompany it, and expand the scope over methods of diagnosis and treatment of these ages.

METHODS

A search was conducted in the PubMed/MEDLINE database for relevant key words 'ADHD', 'attention deficit', 'hyperactivity' and 'adult'. Secondary search parameters were 'comorbid', 'prevalence', 'epidemiology', 'therapy' and 'drug therapy'. Search was limited to 'English' and 'Humans'.

RESULTS

Over the years, the persistent nature of the disorder has been clarified, elucidating prevalence rate, gender differences and subtype shifts among adult ADHD population. Nevertheless, even today, there is only limited awareness of the existence of the disorder across one's lifespan, its consequences and the appropriate treatment.

CONCLUSIONS

Our results emphasise the growing awareness of adult psychosocial impairments due to ADHD symptoms and comorbidities, as well as the need for further collaboration among practitioners and mental health-care professionals to better identify the condition and allow for effective treatment.

Psychometric validation of the Weiss Functional Impairment Rating Scale-Parent Report Form in children and adolescents with attention-deficit/hyperactivity disorder

BACKGROUND

Measurement properties of the Weiss Functional Impairment Rating Scale-Parent Report Form (WFIRS-P), which assesses attention-deficit/hyperactivity disorder (ADHD)-related functional impairment in children/adolescents (6-17 years), were examined.

METHODS

Data from seven randomized, controlled trials were pooled. Analyses were conducted in two random half-samples. WFIRS-P conceptual framework was evaluated using confirmatory factor analyses (CFA). Reliability was estimated using internal consistency (Cronbach's alpha) and test-retest reliability methods. Convergent validity was assessed using correlations between WFIRS-P domain scores and the ADHD-RS-IV and Clinical Global Impression-Severity (CGI-S) scales. Responsiveness was tested by comparing mean changes in WFIRS-P domain scores between responders and non-responders based on clinical criteria.

RESULTS

CFA adequately confirmed the item-to-scale relationships defined in the WFIRS-P conceptual framework. Cronbach's alpha coefficient exceeded 0.7 for all domains and test-retest reliability exceeded 0.7 for all but Risky Activities. With few exceptions, WFIRS-P domains correlated significantly (p < 0.05) with ADHD-RS-IV Total, Inattention and Hyperactivity-Impulsivity scores and CGI-S at baseline and follow-up in both random half-samples. Mean changes in WFIRS-P domain scores differed significantly between responder and non-responder groups in the expected direction (p < 0.001).

CONCLUSIONS

Study results support the reliability, validity and responsiveness of the WFIRS-P. Findings were replicated between two random samples, further demonstrating the robustness of results.

Pharmacological Management of Pediatric Patients with Comorbid Attention-Deficit Hyperactivity Disorder Oppositional Defiant Disorder

Attention-deficit hyperactivity disorder (ADHD) is a common developmental neurobiological condition of childhood characterized by age-inappropriate degrees of hyperactivity/impulsivity and inattention to tasks requiring sustained vigilance. Oppositional defiant disorder (ODD) is an externalizing behavior disorder characterized by difficulties with emotional and behavioral regulation that frequently brings the child into conflict with authority figures. In the clinical setting, ODD is the most common ADHD comorbidity. The combination portends more severe symptom severity, daily impairment, and a more at-risk prognosis than either disorder alone. We briefly review the literature on the characteristics and treatment of the ADHD and ODD child. A clinical approach to evaluation and treatment of ADHD and ODD is then presented. This approach emphasizes the importance of child and parent psychoeducation about the two disorders alone and in combination, the importance of behavioral management therapy approaches, the possible need for school and academic supports, and the decision to use evidence-based stimulant or non-stimulant ADHD medications depending on symptom severity combined with child and parental wishes and choice.

An Appraisal of the Life of Charles Thomas Jackson as Attention Deficit Hyperactivity Disorder

Charles Thomas Jackson claimed to have original ideas that led to the creation of guncotton, the electromagnetic telegraph, and the use of ether as an anesthetic. There was, though, a gap between when the idea was enunciated and when it became reality, with other individuals accomplishing the latter. An examination of Charles Jackson's life reveals a pattern of behavior that is compatible with attention deficit hyperactivity disorder with an associated diagnosis of oppositional defiant disorder. These diagnoses are explored in the context of Jackson's life to explain why he did not carry his initial thoughts to fruition.

Efficacy of chess training for the treatment of ADHD: A prospective, open label study

OBJECTIVE

To examine the effectiveness of playing chess as a treatment option for children with ADHD.

METHODS

Parents of 44 children ages 6 to 17 with a primary diagnosis of ADHD consented to take part in the study. Parents completed the Spanish version of the Swanson, Nolan and Pelham Scale for parents (SNAP-IV) and the Abbreviated Conner's Rating Scales for parents (CPRS-HI) prior to an 11-week chess-training program. We used a paired t-test to compare pre- and post-intervention outcomes, and Cohen-d calculations to measure the magnitude of the effect. The statistical significance was set at P<.05.

RESULTS

Children with ADHD improved in both the SNAP-IV (t=6.23; degrees of freedom (df)=41; P<.001) and the CPRS-HI (t=5.39; df=33; P<.001). Our results suggest a large effect in decreasing the severity of ADHD as measured by the SNAP-IV (d=0.85) and the CPRS-HI (d=0.85). Furthermore, we found a correlation between intelligence quotient and SNAP-IV improvement (P<.05).

CONCLUSIONS

The results of our pilot study should be interpreted with caution. This pilot project highlights the importance of carrying out larger studies with a case-control design. If our results are replicated in better designed studies, playing chess could be included within the multimodal treatment of ADHD.

INCLEN diagnostic tool for attention deficit hyperactivity disorder (INDT-ADHD): development and validation

OBJECTIVE

To develop and validate INCLEN Diagnostic Tool for Attention Deficit Hyperactivity Disorder (INDT-ADHD).

DESIGN

Diagnostic test evaluation by cross sectional design.

SETTING

Tertiary care pediatric centers.

PARTICIPANTS

156 children aged 65-117 months.

METHODS

After randomization, INDT-ADHD and Connors 3 Parent Rating Scale (C3PS) were administered, followed by an expert evaluation by DSM-IV-TR diagnostic criteria.

MAIN OUTCOME MEASURES

Psychometric evaluation of diagnostic accuracy, validity (construct, criterion and convergent) and internal consistency.

RESULTS

INDT-ADHD had 18 items that quantified symptoms and impairment. Attention deficit hyperactivity disorder was identified in 57, 87 and 116 children by expert evaluation, INDT-ADHD and C3PS, respectively. Psychometric parameters of INDT-ADHD for differentiating attention deficit hyperactivity disorder and normal children were: sensitivity 87.7%, specificity 97.2%, positive predictive value 98.0% and negative predictive value 83.3%, whereas for differentiating from other neuro-developmental disorders were 87.7%, 42.9%, 58.1% and 79.4%, respectively. Internal consistency was 0.91. INDT-ADHD has a 4-factor structure explaining 60.4% of the variance. Convergent validity with Conner's Parents Rating Scale was moderate (r =0.73, P= 0.001).

CONCLUSIONS

INDT-ADHD is suitable for diagnosing attention deficit hyperactivity disorder in Indian children between the ages of 6 to 9 years.