Teachers' recognition of children with ADHD: role of subtype and gender

Retrospective assessment of ICD-10/DSM-5 criteria of childhood ADHD from descriptions of academic and social behaviors in German primary school reports

BACKGROUND

The diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adolescence and adulthood is particularly challenging because retrospective confirmation of previous childhood ADHD is mandatory. Therefore, collecting valid diagnostic information about behavior at school is important. Primary school reports often contain descriptions of academic performance and social behaviors associated with ADHD criteria. Yet, there is no systematic approach available how to assess such reports quantitatively, and therefore, there is also no study on how valid such an approach could predict an ADHD diagnosis.

METHODS

We examined primary school reports from Germany (ADHD: n = 1197, typically developing controls: n = 656) for semantic references to ICD-10/DSM-5 main and sub-criteria of ADHD. Descriptions were assessed on a quantitative scale (blinded clinical expert rating) for disorder-associated behaviors (symptoms scale) as well as for desired, adaptive behaviors (competencies scale) according to these criteria. The scores of these developed scales have been summarized to summary scores. Scores were analyzed using linear mixed models, and sensitivity and specificity were estimated using receiver operating characteristics (ROC).

RESULTS

Ratings showed highly significant differences between school reports of children with and without ADHD. For the summary scores, both symptoms and competencies scales showed high diagnostic accuracy (ROC area under the curve at least 0.96) with best discrimination when combining both into an integrated index (sensitivity and specificity > 0.97).

CONCLUSIONS

Our findings suggest that systematic quantitative analysis of primary school reports should be further explored to construct a valid instrument for retrospective assessment of childhood ADHD criteria to aid the diagnostic process in adolescents and adults.

Why are females less likely to be diagnosed with ADHD in childhood than males?

ADHD is less likely to be diagnosed in females than males, especially in childhood. Females also typically receive the diagnosis later than males and are less likely to be prescribed ADHD medication. Understanding why these sex differences in clinical care and treatment for ADHD occur is key to improving timely diagnosis in people affected by ADHD. This Personal View is a conceptual review synthesising literature on this topic. This publication considers potential biological explanations (eg, genetic factors), influence of diagnostic practices (eg, criteria suitability, diagnostic overshadowing, and sex-specific diagnostic thresholds), and sociocultural explanations (eg, sex differences in presentation and compensatory behaviours), for the observed sex differences in ADHD clinical practice. This Personal View also outlines future research directions for improving understanding of sex differences in recognition and diagnosis of ADHD.

Transcranial random noise stimulation combined with cognitive training for treating ADHD: a randomized, sham-controlled clinical trial

Non-invasive brain stimulation has been suggested as a potential treatment for improving symptomology and cognitive deficits in Attention-Deficit/Hyperactivity Disorder (ADHD), the most common childhood neurodevelopmental disorder. Here, we examined whether a novel form of stimulation, high-frequency transcranial random noise stimulation (tRNS), applied with cognitive training (CT), may impact symptoms and neural oscillations in children with ADHD. We conducted a randomized, double-blind, sham-controlled trial in 23 unmedicated children with ADHD, who received either tRNS over the right inferior frontal gyrus (rIFG) and left dorsolateral prefrontal cortex (lDLPFC) or sham stimulation for 2 weeks, combined with CT. tRNS + CT yielded significant clinical improvements (reduced parent-reported ADHD rating-scale scores) following treatment, compared to the control intervention. These improvements did not change significantly at a 3-week follow-up. Moreover, resting state (RS)-EEG periodic beta bandwidth of the extracted peaks was reduced in the experimental compared to control group immediately following treatment, with further reduction at follow-up. A lower aperiodic exponent, which reflects a higher cortical excitation/inhibition (E/I) balance and has been related to cognitive improvement, was seen in the experimental compared to control group. This replicates previous tRNS findings in adults without ADHD but was significant only when using a directional hypothesis. The experimental group further exhibited longer sleep onset latencies and more wake-up times following treatment compared to the control group. No significant group differences were seen in executive functions, nor in reported adverse events. We conclude that tRNS + CT has a lasting clinical effect on ADHD symptoms and on beta activity. These results provide a preliminary direction towards a novel intervention in pediatric ADHD.

Mental Health Literacy for Supporting Children: A Systematic Review of Teacher and Parent/Carer Knowledge and Recognition of Mental Health Problems in Childhood

The level of mental health literacy (MHL) in adults who work with or care for children is likely to influence the timeliness and adequacy of support that children receive for mental health problems. The aim of this study was to systematically review the literature on mental health literacy for supporting children (MHLSC, recognition/knowledge) among parents and teachers of school aged children (5 to 12 years old). A systematic search was conducted for quantitative studies published between 2000 and June 2021 using three databases (MEDLINE, PsycINFO and ERIC) and relevant citations reviewed in Scopus. To be included, studies needed to measure at least either 'mental health knowledge' or 'recognition'. Synthesis proceeded according to study design, adult population, child MHP, then MHL outcome. Study quality was assessed using AXIS. 3322 documents were screened, 39 studies met inclusion criteria. 49% of studies examined teachers' knowledge or recognition of ADHD; only five studies reported on parent samples. Synthesis found a nascent field that was disparate in definitions, methods and measures. Little research focussed on knowledge and recognition for internalizing problems, or on parents. Methods used for measuring knowledge/recognition (vignette vs screening) were associated with different outcomes and the quality of studies was most often low to moderate. Adults appear to have good recognition of childhood ADHD but their knowledge of internalizing disorders is less clear. Further research is required to develop standard definitions and validated measures so gaps in MHLSC can be better identified across populations who have a role in supporting children with their mental health.

Distinguishing different types of attention deficit hyperactivity disorder in children using artificial neural network with clinical intelligent test

Background

Attention deficit hyperactivity disorder (ADHD) is a well-studied topic in child and adolescent psychiatry. ADHD diagnosis relies on information from an assessment scale used by teachers and parents and psychological assessment by physicians; however, the assessment results can be inconsistent.

Purpose

To construct models that automatically distinguish between children with predominantly inattentive-type ADHD (ADHD-I), with combined-type ADHD (ADHD-C), and without ADHD.

Methods

Clinical records with age 6-17 years-old, for January 2011-September 2020 were collected from local general hospitals in northern Taiwan; the data were based on the SNAP-IV scale, the second and third editions of Conners' Continuous Performance Test (CPT), and various intelligence tests. This study used an artificial neural network to construct the models. In addition, k-fold cross-validation was applied to ensure the consistency of the machine learning results.

Results

We collected 328 records using CPT-3 and 239 records using CPT-2. With regard to distinguishing between ADHD-I and ADHD-C, a combination of demographic information, SNAP-IV scale results, and CPT-2 results yielded overall accuracies of 88.75 and 85.56% in the training and testing sets, respectively. The replacement of CPT-2 with CPT-3 results in this model yielded an overall accuracy of 90.46% in the training set and 89.44% in the testing set. With regard to distinguishing between ADHD-I, ADHD-C, and the absence of ADHD, a combination of demographic information, SNAP-IV scale results, and CPT-2 results yielded overall accuracies of 86.74 and 77.43% in the training and testing sets, respectively.

Conclusion

This proposed model distinguished between the ADHD-I and ADHD-C groups with 85-90% accuracy, and it distinguished between the ADHD-I, ADHD-C, and control groups with 77-86% accuracy. The machine learning model helps clinicians identify patients with ADHD in a timely manner.

Teacher Educational Decision Making for Children With Specific Language Impairment

PURPOSE

Children with specific language impairment (SLI) are underidentified, despite a robust literature on their language abilities and a clinical grammar marker. Adlof and Hogan (2019) call for school systems to assess oral language and provide supports through response to intervention (RTI), with the aim of identifying and supporting children with SLI and other language impairments. However, it is unknown how teachers make educational decisions for children with SLI.

METHOD

A web-based survey was distributed to public school teachers nationwide (N = 304). In this observational study, teachers read six vignettes featuring profiles of children systematically varying in the linguistic characteristics relevant to SLI (e.g., difficulty with verb tense) and responded to items on the educational decisions that they would make in the absence of workplace constraints.

RESULTS

Teachers were likely to identify that the children in the vignettes needed language for classroom success and to indicate that they would provide in-class intervention. However, teachers were unlikely to recommend speech-language pathology services. These outcomes were mostly consistent across all child characteristics and teacher characteristics.

CONCLUSIONS

Findings show that teachers were sensitive to the language-based needs of children with SLI and elected to provide in-class intervention. Future work is needed to understand how workplace characteristics, including opportunities for interprofessional collaboration, and the heterogeneity of children with SLI, inform teacher educational decision making.

Social gradients in ADHD by household income and maternal education exposure during early childhood: Findings from birth cohort studies across six countries

OBJECTIVE

This study aimed to examine social gradients in ADHD during late childhood (age 9-11 years) using absolute and relative relationships with socioeconomic status exposure (household income, maternal education) during early childhood (<5 years) in seven cohorts from six industrialised countries (UK, Australia, Canada, The Netherlands, USA, Sweden).

METHODS

Secondary analyses were conducted for each birth cohort. Risk ratios, pooled risk estimates, and absolute inequality, measured by the Slope Index of Inequality (SII), were estimated to quantify social gradients in ADHD during late childhood by household income and maternal education measured during early childhood. Estimates were adjusted for child sex, mother age at birth, mother ethnicity, and multiple births.

FINDINGS

All cohorts demonstrated social gradients by household income and maternal education in early childhood, except for maternal education in Quebec. Pooled risk estimates, relating to 44,925 children, yielded expected gradients (income: low 1.83(CI 1.38,2.41), middle 1.42(1.13,1.79), high (reference); maternal education: low 2.13(1.39,3.25), middle 1.42(1.13,1.79)). Estimates of absolute inequality using SII showed that the largest differences in ADHD prevalence between the highest and lowest levels of maternal education were observed in Australia (4% lower) and Sweden (3% lower); for household income, the largest differences were observed in Quebec (6% lower) and Canada (all provinces: 5% lower).

CONCLUSION

Findings indicate that children in families with high household income or maternal education are less likely to have ADHD at age 9-11. Absolute inequality, in combination with relative inequality, provides a more complete account of the socioeconomic status and ADHD relationship in different high-income countries. While the study design precludes causal inference, the linear relation between early childhood social circumstances and later ADHD suggests a potential role for policies that promote high levels of education, especially among women, and adequate levels of household income over children's early years in reducing risk of later ADHD.

Following the Epidemic Waves: Child and Youth Mental Health Assessments in Ontario Through Multiple Pandemic Waves

Emerging studies across the globe are reporting the impact of COVID-19 and its related virus containment measures, such as school closures and social distancing, on the mental health presentations and service utilization of children and youth during the early stages of lockdowns in their respective countries. However, there remains a need for studies which examine the impact of COVID-19 on children and youth's mental health needs and service utilization across multiple waves of the pandemic. The present study used data from 35,162 interRAI Child and Youth Mental Health (ChYMH) assessments across 53 participating mental health agencies in Ontario, Canada, to assess the mental health presentations and referral trends of children and youth across the first two waves of the COVID-19 pandemic in the province. Wave 1 consisted of data from March to June 2020, with Wave 2 consisting of data from September 2020 to January 2021. Data from each wave were compared to each other and to the equivalent period one year prior. While assessment volumes declined during both pandemic waves, during the second wave, child and youth assessments in low-income neighborhoods declined more than those within high-income neighborhoods. There were changes in family stressors noted in both waves. Notably, the proportion of children exposed to domestic violence and recent parental stressors increased in both waves of the pandemic, whereas there were decreases noted in the proportion of parents expressing feelings of distress, anger, or depression and reporting recent family involvement with child protection services. When comparing the two waves, while depressive symptoms and recent self-injurious attempts were more prevalent in the second wave of the pandemic when compared to the first, a decrease was noted in the prevalence of disruptive/aggressive behaviors and risk of injury to others from Wave 1 to Wave 2. These findings highlight the multifaceted impact of multiple pandemic waves on children and youth's mental health needs and underscore the need for future research into factors impacting children and youth's access to mental health agencies during this time.

Failure of Healthcare Provision for Attention-Deficit/Hyperactivity Disorder in the United Kingdom: A Consensus Statement

Background: Despite evidence-based national guidelines for ADHD in the United Kingdom (UK), ADHD is under-identified, under-diagnosed, and under-treated. Many seeking help for ADHD face prejudice, long waiting lists, and patchy or unavailable services, and are turning to service-user support groups and/or private healthcare for help. Methods: A group of UK experts representing clinical and healthcare providers from public and private healthcare, academia, ADHD patient groups, educational, and occupational specialists, met to discuss shortfalls in ADHD service provision in the UK. Discussions explored causes of under-diagnosis, examined biases operating across referral, diagnosis and treatment, together with recommendations for resolving these matters. Results: Cultural and structural barriers operate at all levels of the healthcare system, resulting in a de-prioritization of ADHD. Services for ADHD are insufficient in many regions, and problems with service provision have intensified as a result of the response to the COVID-19 pandemic. Research has established a range of adverse outcomes of untreated ADHD, and associated long-term personal, social, health and economic costs are high. The consensus group called for training of professionals who come into contact with people with ADHD, increased funding, commissioning and monitoring to improve service provision, and streamlined communication between health services to support better outcomes for people with ADHD. Conclusions: Evidence-based national clinical guidelines for ADHD are not being met. People with ADHD should have access to healthcare free from discrimination, and in line with their legal rights. UK Governments and clinical and regulatory bodies must act urgently on this important public health issue.

Sex Differences in the Meaning of Parent and Teacher Ratings of ADHD Behaviors: An Observational Study

Objective: To test explanations for the underrecognition of female ADHD by examining differences in adult ratings of boys and girls matched for levels of directly observed ADHD behaviors. Method: In a secondary analysis of a population-based sample, 3- to 4-year-olds (n = 153, 79 male) and 8- to 9-year-olds (n = 144, 75 male) were grouped according to levels of directly observed ADHD behaviors (low/moderate/high). Groups were then compared with parent/teacher ADHD ratings. Results: There were no sex differences in levels of directly observed ADHD behaviors within groups. For preschoolers, parents' ratings of males, but not females, significantly increased across groups-mirroring levels of observed behaviors. For older children, both parent and teacher mean ratings were significantly higher for males than females across groups. Conclusion: Identified differences in adult ratings of males and females matched for directly observed behaviors may contribute to understanding the substantial ADHD underrecognition in females.

Preliminary evidence of linguistic bias in academic reviewing

Recent years have seen a spirited debate over whether there is linguistic injustice in academic publishing. One way that linguistic injustice might occur is if gatekeepers (e.g., peer reviewers and editors) judge the scholarly quality of academic writing more harshly if the writing does not meet expectations for international academic English, even if the content is good. We tested this with a randomized control study in which scholars judged the scientific quality of several scientific abstracts. Each abstract had two versions with identical scientific content, such that the language in one version conformed to standards for international academic English, and the language in the other version did not (but was still comprehensible). While the data are preliminary and the effects statistically inconclusive, both pre-registered and exploratory analyses of the data suggest that scholars may give abstracts lower ratings of scientific quality when the writing does not conform to standards of international academic English. These results suggest that linguistic bias may occur in academic peer reviewing and motivate further study to better understand and address this phenomenon.

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.

Academic Outcomes Following a School-Based RCT for ADHD: 6-Year Follow-Up

Objective: For children with high levels of ADHD symptoms, to investigate the impact of early school-based interventions on academic outcomes in mid-childhood. Method: A 6-year follow-up of 4- to 5-year-olds (N = 52,075) whose schools participated in a cluster randomized controlled trial for children at risk of ADHD. School-level interventions involved the provision of a booklet with evidence-based information (book) and/or feedback of names (identification) of children with high levels of ADHD symptoms. At ages 10 to 11 years, outcome measures were scores in English and mathematics tests. Results: For children with high levels of ADHD symptoms, the interventions had no impact on academic outcomes. When all children were analyzed, the book intervention had a positive impact on mathematics. Baseline inattention was associated with poorer academic outcomes, whereas impulsiveness was associated with better academic outcomes. Conclusion: The provision of evidence-based information about helping children with ADHD at school may have wider academic benefits.

Conhecimentos e Lacunas dos Professores do 1. º Ciclo acerca da PHDA

Pretendeu-se analisar o conhecimento dos profesores (n = 419) acerca da Perturbação de Hiperatividade/Défice de Atenção (PHDA), através do “Questionário de Avaliação do Conhecimento da PHDA”, no qual se pronunciaram acerca de diferentes questões (e.g., etiología, intervenção). Os docentes mostraram-se moderadamente informados (e.g., 78.8% sabe que a utilização exclusiva da punição na gestão comportamental não é uma intervenção eficaz), embora haja espaço para melhoria, (e.g., apenas 26.7% considerou determinante o papel da hereditariedade). Estes dados devem ser considerados no planeamento da formação da classe docente. 

Clinical Reasoning in the Assessment and Intervention Planning for Attention-Deficit/Hyperactivity Disorder

The purpose of this article is to provide the reader with insight into the clinical reasoning involved in the assessment and intervention planning for a child with Attention-Deficit/Hyperactivity Disorder. The reader will be guided through the authors’ conceptualization of this case, and suggestions for intervention in the classroom will be discussed.

Practitioner Review: Pathways to care for ADHD - a systematic review of barriers and facilitators

BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder starting in childhood that may persist into adulthood. It can be managed through carefully monitored medication and nonpharmacological interventions. Access to care for children at risk of ADHD varies both within and between countries. A systematic literature review was conducted to investigate the research evidence related to factors which influence children accessing services for ADHD.

METHOD

Studies investigating access to care for children at risk of ADHD were identified through electronic searches of the international peer-reviewed and grey literature. Databases were searched from inception till 30th April 2012. This identified 23,156 articles which were subjected to three levels of screening (title, abstract and full text) by a minimum of two independent reviewers. Due to the heterogeneity in the study designs, a narrative approach was used to present the findings.

RESULTS

Twenty-seven papers met the inclusion criteria; these were grouped into four main themes, with some papers being included in more than one. These were wider determinants (10 papers); identification of need (9 papers); entry and continuity of care (13 papers) and interventions to improve access (4 papers). Barriers and facilitators to access were found to operate at the individual, organisational and societal level. Limited evidence of effective interventions to improve access was identified.

CONCLUSION

This review explored the multilayered obstacles in the pathway to care for children at risk of ADHD and the lack of evidence-based interventions designed to address these issues, thereby indicating areas for service development and further evaluative research.

Predictors of and barriers to service use for children at risk of ADHD: longitudinal study

Many children with, or at risk of, ADHD do not receive healthcare services for their difficulties. This longitudinal study investigates barriers to and predictors of specialist health service use. This is a 5-year follow-up study of children who participated in a cluster randomised controlled trial, which investigated school-level interventions (provision of books with evidence-based information and/or feedback of names of children) for children at risk of ADHD. 162 children who had high levels of ADHD symptoms at age 5 (baseline) were followed up at age 10 years. Using baseline data and follow-up information collected from parents and teachers, children who had and had not used specialist health services over the follow-up period were compared and predictors (symptom severity, comorbid problems, parental perception of burden, parental mental health, and socio-demographic factors) of specialist service use investigated. The most common parent-reported barrier reflected lack of information about who could help. Amongst children using specialist health services who met criteria for ADHD at follow-up, 36% had been prescribed stimulant medication. Specialist health service use was associated with each one-point increase in teacher-rated symptoms at baseline [inattention symptoms (adjusted OR = 1.40; 95% CI 1.12-1.76) and hyperactivity/impulsivity symptoms (adjusted OR = 1.23; 95% CI 1.05-1.44)]. Parental mental health problems were also independently associated with service use (for each one-point increase in symptoms, adjusted OR = 1.41; 95% CI 1.04-1.91). Severity of teacher-rated ADHD symptoms in early school years is a determinant of subsequent service use. Clinicians and teachers should be aware that parental mental health problems are independently associated with service use for children at risk of ADHD.

Primary school teachers' attitudes about children with attention deficit/hyperactivity disorder and the role of pharmacological treatment

BACKGROUND

Clinical experience and research suggest that teachers' attitudes about attention deficit/hyperactivity disorder (ADHD) are an important factor influencing access to specialist assessment and treatment, including medication.

METHODS

We performed a thematic analysis of comments written by primary school teachers who participated in a case-vignette study investigating the ability of teachers to recognise ADHD. Teachers read one of four types of vignette describing the behaviour of a nine-year-old child who met diagnostic criteria for ADHD (either a boy or a girl with inattentive or combined subtype of ADHD). They answered questions (identical for all types of vignette) about their views regarding the problems and their management. Teachers were invited to add their own comments.

RESULTS

Altogether 496 teachers from 110 schools completed the questionnaire: 250 (50%) teachers from 94 schools wrote at least one comment, adding up to 341 comments. Regarding their views on the need to refer the child to specialist services, 32 teachers made comments that reflected caution. The most frequent comments were that it was too early to say whether a referral was necessary, the problems were not severe enough or the main support would come from school. Teachers also reported a lack of knowledge about specialist services or criticised them. When asked whether medication might be beneficial for the child, 125 teachers expressed hesitant or negative views: that it was premature to express an opinion about medication or too soon to give medication to the child; that medication was not necessary or should not be used at all; or that the problems were not severe enough or were emotional in nature. Only five teachers reported having a positive experience of the effect of medication.

CONCLUSION

Teachers' comments suggested a strong preference in using within-school strategies for the management of children with ADHD. Teachers were reluctant to endorse medication for DHD and expressed negative views about its use. Health services should support teachers' management of ADHD-related behaviours in school and provide information to increase teachers' ability to identify the need for a referral to specialist health services.