Childhood ADHD: a stepped diagnosis approach

Diagnostic error in mental health: a review

Diagnostic errors are associated with patient harm and suboptimal outcomes. Despite national scientific efforts to advance definition, measurement and interventions for diagnostic error, diagnosis in mental health is not well represented in this ongoing work. We aimed to summarise the current state of research on diagnostic errors in mental health and identify opportunities to align future research with the emerging science of diagnostic safety. We review conceptual considerations for defining and measuring diagnostic error, the application of these concepts to mental health settings, and the methods and subject matter focus of recent studies of diagnostic error in mental health. We found that diagnostic error is well understood to be a problem in mental healthcare. Although few studies used clear definitions or frameworks for understanding diagnostic error in mental health, several studies of missed, wrong, delayed and disparate diagnosis of common mental disorders have identified various avenues for future research and development. Nevertheless, a lack of clear consensus on how to conceptualise, define and measure errors in diagnosis will pose a barrier to advancement. Further research should focus on identifying preventable missed opportunities in the diagnosis of mental disorders, which may uncover generalisable opportunities for improvement.

Wild and Willful Kids: Can We Help Parents? The Effectiveness of a Group Parent Training Program Without a Psychiatric Label

Many children with a classification of attention-deficit/hyperactivity disorder exhibit mild-to-moderate problem behavior. For these children, a stepped diagnosis and stepped care approach has been proposed. Although a psychiatric classification may bring support to families, it may also have negative consequences. Therefore, in this preliminary study, the effect of a group parent training program without child-bound classifications (named Wild & Willful, Druk & Dwars in Dutch) was investigated. In 7 sessions, groups of parents (experimental, n=63; waiting list control, n=38) learned strategies to deal with wild and willful behavior in their children. Outcome variables were assessed by questionnaires. Multilevel analyses showed that, compared with the control group, the intervention group had significantly lower scores on parental stress and communication problems (Cohen d=0.47 and 0.52, respectively), but not on attention and hyperactivity problems, oppositional defiant problems, and responsivity. Zooming in on the course of outcome variables over time in the intervention group, improvements on all variables were seen, with small to moderate effect sizes (Cohen d=0.30 to 0.52). Overall, the group parent training program without the need for a classification for children seemed beneficial. The training is low cost, brings together parents who are facing similar problems in rearing their children, and may help to reduce overdiagnosis of mild and moderate problems, without risking undertreatment of severe difficulties.

Association of Liver Transplant and Attention-Deficit Hyperactivity Disorder: A Single-Center Experience

OBJECTIVES

This prospective cohort study aimed to determine the prevalence of attention-deficit hyperactivity disorder and to reveal how the diagnosis of attention-deficit/hyperactivity disorder can be made most accurately in children with liver transplant.

MATERIALS AND METHODS

We studied a group of 62 children from 6 and 18 years old who underwent liver transplant at least 1 year previous to our study and who were followed up in the Department of Pediatric Gastroenterology. A child and adolescent psychiatrist evaluated all liver transplant patients for attention- deficit hyperactivity disorder based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The Kiddie Schedule for Affective Disorders and Schizophrenia (in Turkish) was applied to the children. The Kiddie Schedule and the Conners Parent Rating Scale were applied to the children's parents. The Conners Teacher Rating Scale was applied to the children's teachers.

RESULTS

The frequency of attention-deficit hyperactivity disorder in the sample was found to be 24.5% according to Kiddie Schedule, 45.9% according to the Conners Parent Rating Scale, and 24% according to the Conners Teacher Rating Scale. However, clinical examination showed that 9.67% of the children had attention-deficit hyperactivity disorder.

CONCLUSIONS

We concluded that detailed clinical examination is more important than neuropsychological tests and scales when diagnosing attention-deficit hyperactivity disorder in pediatric liver transplant recipients.

Association of Attention-Deficit/Hyperactivity Disorder Diagnosis With Adolescent Quality of Life

IMPORTANCE

Appropriate diagnosis of attention-deficit/hyperactivity disorder (ADHD) can improve some short-term outcomes in children and adolescents, but little is known about the association of a diagnosis with their quality of life (QOL).

OBJECTIVE

To compare QOL in adolescents with and without an ADHD diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study followed an emulated target trial design using prospective, observational data from the Longitudinal Study of Australian Children, a representative, population-based prospective cohort study with biennial data collection from 2006 to 2018 with 8 years of follow-up (ages 6-7 to 14-15 years). Propensity score matching was used to ensure children with and without ADHD diagnosis were well matched on a wide range of variables, including hyperactive/inattentive (H/I) behaviors. Eligible children were born in 1999 to 2000 or 2003 to 2004 and did not have a previous ADHD diagnosis. All incident ADHD cases were matched with controls. Data were analyzed from July 2021 to January 2022.

EXPOSURES

Incident parent-reported ADHD diagnosis at age 6 to 7, 8 to 9, 10 to 11, 12 to 13, or 14 to 15.

MAIN OUTCOMES AND MEASURES

Quality of life at age 14 to 15 was measured with Child Health Utility 9D (CHU9D) and 8 other prespecified, self-reported measures mapped to the World Health Organization's QOL domains. Pooled regression models were fitted for each outcome, with 95% CIs and P values calculated using bootstrapping to account for matching and repeat observations.

RESULTS

Of 8643 eligible children, a total of 393 adolescents had an ADHD diagnosis (284 [72.2%] boys; mean [SD] age, 10.03 [0.30] years; mean [SD] H/I Strengths and Difficulties Questionnaire score, 5.05 [2.29]) and were age-, sex-, and H/I score-matched with 393 adolescents without ADHD diagnosis at time zero. Compared with adolescents without diagnosis, those with an ADHD diagnosis reported similar QOL on CHU9D (mean difference, -0.03; 95% CI, -0.07 to 0.01; P = .10), general health (mean difference, 0.11; 95% CI, -0.04 to 0.27; P = .15), happiness (mean difference, -0.18; 95% CI, -0.37 to 0.00; P = .05), and peer trust (mean difference, 0.65; 95% CI, 0.00 to 1.30; P = .05). Diagnosed adolescents had worse psychological sense of school membership (mean difference, -2.58; 95% CI, -1.13 to -4.06; P < .001), academic self-concept (mean difference, -0.14; 95% CI, -0.02 to -0.26; P = .02), and self-efficacy (mean difference, -0.20; 95% CI, -0.05 to -0.33; P = .007); displayed more negative social behaviors (mean difference, 1.56; 95% CI, 0.55 to 2.66; P = .002); and were more likely to harm themselves (odds ratio, 2.53; 95% CI, 1.49 to 4.37; P < .001) than adolescents without diagnosis.

CONCLUSIONS AND RELEVANCE

In this cohort study, ADHD diagnosis was not associated with any self-reported improvements in adolescents' QOL compared with adolescents with similar levels of H/I behaviors but no ADHD diagnosis. ADHD diagnosis was associated with worse scores in some outcomes, including significantly increased risk of self-harm. A large, randomized clinical trial with long-term follow-up is needed.

Objective Measurement of Hyperactivity Using Mobile Sensing and Machine Learning: Pilot Study

BACKGROUND

Although hyperactivity is a core symptom of attention-deficit/hyperactivity disorder (ADHD), there are no objective measures that are widely used in clinical settings.

OBJECTIVE

We describe the development of a smartwatch app to measure hyperactivity in school-age children. The LemurDx prototype is a software system for smartwatches that uses wearable sensor technology and machine learning to measure hyperactivity. The goal is to differentiate children with ADHD combined presentation (a combination of inattentive and hyperactive/impulsive presentations) or predominantly hyperactive/impulsive presentation from children with typical levels of activity.

METHODS

In this pilot study, we recruited 30 children, aged 6 to 11 years, to wear a smartwatch with the LemurDx app for 2 days. Parents also provided activity labels for 30-minute intervals to help train the algorithm. Half of the participants had ADHD combined presentation or predominantly hyperactive/impulsive presentation (n=15), and half were in the healthy control group (n=15).

RESULTS

The results indicated high usability scores and an overall diagnostic accuracy of 0.89 (sensitivity=0.93; specificity=0.86) when the motion sensor output was paired with the activity labels.

CONCLUSIONS

State-of-the-art sensors and machine learning may provide a promising avenue for the objective measurement of hyperactivity.

Time of onset and/or diagnosis of ADHD in European children: a systematic review

BACKGROUND

Attention-Deficit/ Hyperactivity Disorder (ADHD) is one of the most common childhood neurobehavioral conditions. Symptoms related to this disorder cause a significant impairment in school tasks and in the activities of children's daily lives; an early diagnosis and appropriate treatment could almost certainly help improve their outcomes. The current study, part of the Models Of Child Health Appraised (MOCHA) project, aims to explore the age at which children experience the onset or diagnosis of ADHD in European countries.

METHODS

A systematic review was done examining the studies reporting the age of onset/diagnosis (AO/AD) of ADHD in European countries (28 European Member States plus 2 European Economic Area countries), published between January 1, 2010 and December 31, 2019. Of the 2276 identified studies, 44 met all the predefined criteria and were included in the review.

RESULTS

The lowest mean AO in the children diagnosed with ADHD alone was 2.25 years and the highest was 7.5 years. It was 15.3 years in the children with ADHD and disruptive behaviour disorder. The mean AD ranges between 6.2 and 18.1 years.

CONCLUSIONS

Our findings indicate that there is a wide variability in both the AO and AD of ADHD, and a too large distance between AO and AD. Since studies in the literature suggest that an early identification of ADHD symptoms may facilitate early referral and treatment, it would be important to understand the underlying reasons behind the wide variability found.

TRIAL REGISTRATION

PROSPERO registration: CRD42017070631 .

Virtual Classroom Assessment for Children and Adolescents With Attention Deficits: A Systematic Review and Meta-Analysis of Measurement Properties

Objective: The virtual classroom (VC) is a head-mounted display immersive system for the assessment of attention. A meta-analysis was performed to examine the use of the VC to assess attention in children and adolescents. Method: We conducted a systematic literature search to select articles up to December 2017. Results: Thirteen studies using the VC to assess attention were included. Studies reporting comparisons between patients with various clinical conditions and healthy controls were included in the meta-analysis. The meta-analysis results revealed significant differences between groups for the percentage of identified targets (nine studies; total combined N = 431), for commission errors, and reaction time (eight studies; total combined N = 399) in favor of the nonclinical group. Conclusion: Preliminary evidence establishes the validity of the VC and suggests that this task has the potential to serve as a useful and enjoyable ecological assessment tool for the diagnosis of attention deficits in children and adolescents. (J. of Att. Dis. XXXX; XX(X) XX-XX).

Exploring neuropsychological effects of a self-monitoring intervention for ADHD-symptoms in school

Children who have symptoms of Attention Deficit/Hyperactivity Disorder (ADHD) often experience disruptive and off-task behavior and lower school performance than would be expected based on their cognitive abilities. These behavior and achievement difficulties are a challenge to teachers, who often provide inclusive education for children with ADHD. This study explored whether a self-monitoring intervention can help children with ADHD-symptoms to reduce off-task behavior as well as improve their cognition. The participating children were seven boys in special needs education with an age between nine and twelve. The students used an interval timer to remind themselves to monitor whether they were still on task. During math classes, observations, teacher ratings and neuropsychological tests were assessed. The results showed that off-task behavior was significantly reduced during the period the interval timer was used compared to baseline (reduction from 46.8 to 27.3%), as measured by observations (effect size: η²_p = .83) and this was confirmed by teacher ratings (effect size: η²_p = .69). With respect to cognition, children only showed significant improvements in inhibition (effect sizes: Cohen's d = 2.62 and 1.24). The teachers as well as students evaluated the intervention mainly as positive. In line with previous studies, we found that that a self-monitoring intervention can be beneficial for children with ADHD-symptoms. Larger studies including a control group and blind observers are necessary to establish these results and to investigate the underlying mechanisms.

Parental age and attention-deficit/hyperactivity disorder (ADHD)

Background

Previous studies have suggested that young mothers more often have children with ADHD. We used sibling comparisons to examine the nature of this association and to investigate if this association is explained by early environment or genetic and socioeconomic factors.

Methods

A large population-based cohort including all singletons born in Denmark from 1 January 1991 through 31 December 2005 was followed from birth until 30 April 2011. Data were available for 94% ( N  = 943 785) of the population. Offspring ADHD was identified by an ICD-10 diagnosis of Hyperkinetic Disorder (HKD). We used sibling-matched Cox regression to control for genetic and socioeconomic factors.

Results

In the population cohort we found that children born by parents aged 20 years or younger had more than twice the risk of being diagnosed with ADHD compared with children with parents between 26 and 30 years of age. When comparing full siblings the associations were attenuated, but we found a trend of increased risk of ADHD with decreasing maternal age, which was not seen for paternal age.

Conclusions

Sibling comparisons suggested that the associations between both maternal and paternal age and ADHD are partly explained by common genetic and socioeconomic factors. The trend of increased risk of ADHD with decreasing maternal age, but not with paternal age, may be linked to pregnancy or early-life environmental factors. Even though only a smaller part of the association can be attributed to environmental factors, there is a public health interest to support young parents through their first years of parenthood.

Why the Diagnosis of Attention Deficit Hyperactivity Disorder Matters

BACKGROUND

Attention Deficit Hyperactivity disorder (ADHD) is one of the most common and challenging childhood neurobehavioral disorders. ADHD is known to negatively impact children, their families, and their community. About one-third to one-half of patients with ADHD will have persistent symptoms into adulthood. The prevalence in the United States is estimated at 5-11%, representing 6.4 million children nationwide. The variability in the prevalence of ADHD worldwide and within the US may be due to the wide range of factors that affect accurate assessment of children and youth. Because of these obstacles to assessment, ADHD is under-diagnosed, misdiagnosed, and undertreated.

OBJECTIVES

We examined factors associated with making and receiving the diagnosis of ADHD. We sought to review the consequences of a lack of diagnosis and treatment for ADHD on children's and adolescent's lives and how their families and the community may be involved in these consequences.

METHODS

We reviewed scientific articles looking for factors that impact the identification and diagnosis of ADHD and articles that demonstrate naturalistic outcomes of diagnosis and treatment. The data bases PubMed and Google scholar were searched from the year 1995 to 2015 using the search terms "ADHD, diagnosis, outcomes." We then reviewed abstracts and reference lists within those articles to rule out or rule in these or other articles.

RESULTS

Multiple factors have significant impact in the identification and diagnosis of ADHD including parents, healthcare providers, teachers, and aspects of the environment. Only a few studies detailed the impact of not diagnosing ADHD, with unclear consequences independent of treatment. A more significant number of studies have examined the impact of untreated ADHD. The experience around receiving a diagnosis described by individuals with ADHD provides some additional insights.

CONCLUSION

ADHD diagnosis is influenced by perceptions of many different members of a child's community. A lack of clear understanding of ADHD and the importance of its diagnosis and treatment still exists among many members of the community including parents, teachers, and healthcare providers. More basic and clinical research will improve methods of diagnosis and information dissemination. Even before further advancements in science, strong partnerships between clinicians and patients with ADHD may be the best way to reduce the negative impacts of this disorder.