Psychiatric comorbidities in adolescents with attention-deficit hyperactivity disorder and their siblings

Looking beyond psychosocial adversity and sex: Clinical factors associated with ADHD and other psychiatric disorders in a non-Caucasian sample of high-risk siblings

This study examined the association of clinical factors, independent of sex and high psychosocial adversity (HPAd), with the presence of ADHD or other mental disorders, specifically within a middle-income country with a non-Caucasian population. A multi-centric cross-sectional study was conducted in three sites in Colombia. Our study recruited trios of an ADHD proband, one sibling, and one parent. We used valid instruments for assessing parents and siblings. The sample included 223 siblings, an average age of 12.3 (SD 3.9), and 51.1% Females. The ADHD recurrence risk ratio (λ) was 12. The clinical factors mainly associated with the presence of ADHD, independent of sex and HPAd, were 1) Pregnancy and childbirth complications, 2) Delayed psychomotor development, 3) Temperament, and 4) Sleep disturbances. Our research showed that, independently of HPAd and the male sex, there were other clinical factors associated with ADHD and other psychiatric disorders in this population. These findings need to be replicated in similar populations globally.

Psychopathological Risk in Siblings of Subjects with Attention-Deficit/Hyperactivity Disorder: A cross-Sectional Study

OBJECTIVE

We aim to determine the prevalence of mental disorders in siblings of children with attention deficit hyperactivity disorder (ADHD), and to determine how psychosocial adversity factors relate to this psychopathology, in a low-middle income country (Colombia).

METHODS

We evaluated subjects with ADHD diagnosed according to the DSM-5 criteria, one of their parents and one of their siblings (ages 8-19). We used the ADHD rating scale and a set of instruments to assess the presence of mental disorders as well as psychosocial adversity.

RESULTS

We evaluated 74 trios formed by the index case with ADHD, one sibling and one of the parents. We found that 24.3% of the participating siblings also met the criteria for ADHD and another 24.3% for other psychiatric disorders. The risk of these siblings having ADHD increased further when one of the parents reported a history of ADHD. We also found that 28.3% of the families faced high levels of psychosocial adversity as per their scores in the Rutter Adversity Index.

CONCLUSIONS

Siblings of subjects with ADHD showed a significant risk for ADHD and other mental disorders. That risk increased if a parent reported a history of ADHD and also when two or more psychosocial adversity factors were present. This study supports the importance of early detection in efforts to decrease the risk for other siblings.

Psychopathological Risk in Siblings of Subjects with Attention-Deficit/Hyperactivity Disorder: A cross-Sectional Study

OBJECTIVE

We aim to determine the prevalence of mental disorders in siblings of children with attention deficit hyperactivity disorder (ADHD), and to determine how psychosocial adversity factors relate to this psychopathology, in a low-middle income country (Colombia).

METHODS

We evaluated subjects with ADHD diagnosed according to the DSM-5 criteria, one of their parents and one of their siblings (ages 8-19). We used the ADHD rating scale and a set of instruments to assess the presence of mental disorders as well as psychosocial adversity.

RESULTS

We evaluated 74 trios formed by the index case with ADHD, one sibling and one of the parents. We found that 24.3% of the participating siblings also met the criteria for ADHD and another 24.3% for other psychiatric disorders. The risk of these siblings having ADHD increased further when one of the parents reported a history of ADHD. We also found that 28.3% of the families faced high levels of psychosocial adversity as per their scores in the Rutter Adversity Index.

CONCLUSIONS

Siblings of subjects with ADHD showed a significant risk for ADHD and other mental disorders. That risk increased if a parent reported a history of ADHD and also when two or more psychosocial adversity factors were present. This study supports the importance of early detection in efforts to decrease the risk for other siblings.

Behavioural Measures of Infant Activity but Not Attention Associate with Later Preschool ADHD Traits

Mapping infant neurocognitive differences that precede later ADHD-related behaviours is critical for designing early interventions. In this study, we investigated (1) group differences in a battery of measures assessing aspects of attention and activity level in infants with and without a family history of ADHD or related conditions (ASD), and (2) longitudinal associations between the infant measures and preschool ADHD traits at 3 years. Participants (N = 151) were infants with or without an elevated likelihood for ADHD (due to a family history of ADHD and/or ASD). A multi-method assessment protocol was used to assess infant attention and activity level at 10 months of age that included behavioural, cognitive, physiological and neural measures. Preschool ADHD traits were measured at 3 years of age using the Child Behaviour Checklist (CBCL) and the Child Behaviour Questionnaire (CBQ). Across a broad range of measures, we found no significant group differences in attention or activity level at 10 months between infants with and without a family history of ADHD or ASD. However, parent and observer ratings of infant activity level at 10 months were positively associated with later preschool ADHD traits at 3 years. Observable behavioural differences in activity level (but not attention) may be apparent from infancy in children who later develop elevated preschool ADHD traits.

Resilience levels among adolescents with ADHD using quantitative measures in a family-design study

OBJECTIVES

To investigate resilience levels in adolescents with attention-deficit hyperactivity disorder (ADHD) using quantitative measures when compared to their non-affected siblings and controls. We also aimed to investigate the correlation between resilience and depression, anxiety, intelligence quotient (IQ) and socioeconomic status, which may affect resilience levels and be potential confounders.

METHODS

Adolescents (n=45) diagnosed with ADHD referred to an outpatient ADHD clinic, and their siblings without ADHD (n=27), with ages ranging from 12 to 17 years, were interviewed along with their parents using a semi-structured interview (Children's Interview for Psychiatric Syndromes - Parent Version). Intelligence was measured with the Block Design and Vocabulary subtests from the Wechsler Battery. Anxiety and depression were investigated using the Children State-Trait Anxiety Inventory (CSTAI) and the Child Depression Inventory (CDI), respectively. Resilience was investigated using the Resilience Scale. A control group (typically developing adolescents [TDA] and their siblings; n=39) was recruited in another outpatient facility and at two schools using the same methodology.

RESULTS

Socioeconomic status and intelligence levels, which may affect resilience, were similar in all groups. Adolescents with ADHD showed lower resilience levels compared to siblings and TDA even when controlled for anxiety and depression levels, which were higher in ADHD. Resilience levels were higher in siblings than in adolescents with ADHD, and lower than in TDA - this last result without statistical significance.

CONCLUSION

In our sample, ADHD in adolescents was associated with lower resilience, even when controlled for confounders often seen in association with the disorder.

Risk of Atopic Diseases among Siblings of Patients with Attention-Deficit Hyperactivity Disorder: A Nationwide Population-Based Cohort Study

BACKGROUND

Increasing evidence suggests a positive association between attention-deficit hyperactivity disorder (ADHD) and atopic diseases. However, the risk of atopic diseases in unaffected siblings of patients with ADHD has not been investigated.

OBJECTIVE

To investigate the risk of developing atopic diseases among unaffected siblings of ADHD probands.

METHODS

Using data from the Taiwan National Health Insurance Research Database, 20,170 unaffected siblings of patients with ADHD born between 1980 and 2000 and 80,680 age-, birth time-, and residence-matchedcontrols were included in this study. Diagnoses of atopic diseases, including asthma, atopic dermatitis, allergic rhinitis, and allergic conjunctivitis, were ascertained from 1996 or the birth time until the end of 2011.

RESULTS

Breslow-Cox proportional hazard regression analyses with adjustment for demographic data showed that compared with the controls, unaffected siblings of patients with ADHD had a higher risk of developing asthma (relative risk [RR], 1.19; 95% confidence interval [CI], 1.15-1.24), atopic dermatitis (RR, 1.10; 95% CI, 1.04-1.16), allergic rhinitis (RR, 1.17; 95% CI, 1.14-1.21), allergic conjunctivitis (RR, 1.13; 95% CI, 1.09-1.17), and any of these atopic diseases (RR, 1.13; 95% CI, 1.10-1.15).

CONCLUSION

The unaffected siblings of ADHD probands were more likely to develop atopic diseases compared with the controls, suggesting shared risk factors for both diseases.

Risks of bipolar disorder, depressive disorder, and traumatic brain injury among siblings of patients with attention-deficit hyperactivity disorder

BACKGROUND

Previous studies have suggested that the unaffected siblings of patients with attention-deficit hyperactivity disorder (ADHD) experience deficits in attention, impulsivity control, and behavior inhibition, which are associated with health-risk behaviors. However, risks to mental and physical health among the unaffected siblings of ADHD probands have rarely been investigated.

METHODS

Using the Taiwan National Health Insurance Research Database, 5128 unaffected siblings of ADHD probands born between 1980 and 2000 were included in our study along with 20,512 age- and sex-matched controls, and they were followed from 1996 or birth until the end of 2011. Mental and physical health risks, including affective disorders, traumatic brain injury (TBI), and sexually transmitted infection were identified during the follow-up period.

RESULTS

Logistic regression analyses with adjustments for demographic data showed that the unaffected siblings were more likely to develop unipolar depression (odds ratio [OR]: 1.76, 95% confidence interval [CI]: 1.39-2.22), bipolar disorder (OR: 2.10, 95% CI: 1. 09-4.05), and TBI (OR: 1.24, 95% CI: 1.14-1.36) than were the control group.

DISCUSSION

The unaffected siblings of patients with ADHD were prone to developing unipolar depression, bipolar disorder, and TBI later in life.

Attention training for infants at familial risk of ADHD (INTERSTAARS): study protocol for a randomised controlled trial

Background

Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder that can negatively impact on an individual’s quality of life. It is pathophysiologically complex and heterogeneous with different neuropsychological processes being impaired in different individuals. Executive function deficits, including those affecting attention, working memory and inhibitory control, are common. Cognitive training has been promoted as a treatment option, based on the notion that by strengthening the neurocognitive networks underlying these executive processes, ADHD symptoms will also be reduced. However, if implemented in childhood or later, when the full disorder has become well-established, cognitive training has only limited value. INTERSTAARS is a trial designed to test a novel approach to intervention, in which cognitive training is implemented early in development, before the emergence of the disorder. The aim of INTERSTAARS is to train early executive skills, thereby increasing resilience and reducing later ADHD symptoms and associated impairment.

Methods/design

Fifty 10–14-month-old infants at familial risk of ADHD will participate in INTERSTAARS. Infants will be randomised to an intervention or a control group. The intervention aims to train early attention skills by using novel eye-tracking technology and gaze-contingent training paradigms. Infants view animated games on a screen and different events take place contingent on where on the screen the infant is looking. Infants allocated to the intervention will receive nine weekly home-based attention training sessions. Control group infants will also receive nine weekly home visits, but instead of viewing the training games during these visits they will view non-gaze-contingent age-appropriate videos. At baseline and post treatment, infant attention control will be assessed using a range of eye-tracking, observational, parent-report and neurophysiological measures. The primary outcome will be a composite of eye-tracking tasks used to assess infant attention skills. Follow-up data will be collected on emerging ADHD symptoms when the infants are 2 and 3 years old.

Discussion

This is the first randomised controlled trial to assess the potential efficacy of cognitive training as a prevention measure for infants at familial risk of ADHD. If successful, INTERSTAARS could offer a promising new approach for developing early interventions for ADHD.

Trial registration

International Standard Randomised Controlled Trial registry: ISRCTN37683928. Registered on 22 June 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1727-0) contains supplementary material, which is available to authorized users.

Sleep disturbances in adolescents with ADHD: A systematic review and framework for future research

BACKGROUND

Biological mechanisms underlying symptom and prognostic heterogeneity in Attention-Deficit/Hyperactivity Disorder (ADHD) are unclear. Sleep impacts neurocognition and daytime functioning and is disrupted in ADHD, yet little is known about sleep in ADHD during adolescence, a period characterized by alterations in sleep, brain structure, and environmental demands as well as diverging ADHD trajectories.

METHODS

A systematic review identified studies published prior to August 2016 assessing sleep in adolescents (aged 10-19years) with ADHD or participating in population-based studies measuring ADHD symptoms.

RESULTS

Twenty-five studies were identified (19 subjective report, 6 using actigraphy/polysomnography). Findings are mixed but overall suggest associations between sleep disturbances and 1) ADHD symptoms in the population and 2) poorer clinical, neurocognitive, and functional outcomes among adolescents with ADHD. Common limitations of studies included small or non-representative samples, non-standardized sleep measures, and cross-sectional methodology.

CONCLUSIONS

Current data on sleep in adolescent ADHD are sparse and limited by methodological concerns. Future studies are critical for clarifying a potential role of sleep in contributing to heterogeneity of ADHD presentation and prognosis. Potential mechanisms by which sleep disturbances during adolescence may contribute to worsened symptom severity and persistence of ADHD into adulthood and an agenda to guide future research are discussed.

Management of Attention-Deficit/Hyperactivity Disorder by Developmental-Behavioral Pediatricians: A DBPNet Study

OBJECTIVE

To describe practice patterns for developmental-behavioral pediatricians (DBPs) practicing within Developmental-Behavioral Pediatrics Research Network (DBPNet) academic medical centers providing follow-up for children with attention-deficit/hyperactivity disorder (ADHD) and determine how well they adhere to American Academy of Pediatrics ADHD Clinical Practice Guidelines.

METHODS

Seventy-eight DBPs at 12 academic medical centers participating in the DBPNet were asked to complete follow-up encounter surveys for patients with ADHD or autism spectrum disorder seen from 12/2011 through 6/2012. Data regarding patient characteristics, comorbid conditions, and medication management were obtained at the time of each visit.

RESULTS

Fifty-seven DBPs completed 301 ADHD follow-up encounter surveys; 75.3% of patients were male with mean age 9.57 years (SD = 3.3). Race/ethnicity was primarily white/non-Hispanic with similar numbers on private insurance (41.5%) versus Medicaid (45.5%). DBPs identified comorbid learning disorders in 27.6% of children ≥6 years. Only 58.3% of children <6 years received counseling/behavioral therapy or had it recommended during the visit. DBPs primarily (90.6%) prescribed medications FDA-approved for ADHD treatment and growth was monitored for >98% of visits during which stimulants were prescribed. Parent- and teacher-completed rating scales were reviewed/completed during 43.9% and 37.8% of visits, respectively. There were no child or physician factors consistently associated with variation in practice patterns.

CONCLUSION

Developmental-behavioral pediatricians practicing within DBPNet medical centers adhere to the recommended medication prescribing practices for ADHD, including use of FDA-approved medications and monitoring growth. However, DBPs within DBPNet do not consistently review ADHD rating scales or recommend behavioral counseling for children <6 years of age as recommended.

Comorbid Depressive Disorders in ADHD: The Role of ADHD Severity, Subtypes and Familial Psychiatric Disorders

OBJECTIVE

To evaluate the presence of Major Depressive Disorder (MDD) and Dysthymic Disorder (DD) in a sample of Italian children with Attention Deficit Hyperactivity Disorder (ADHD) and to explore specific features of comorbid depressive disorders in ADHD.

METHODS

Three hundred and sixty-six consecutive, drug-naïve Caucasian Italian outpatients with ADHD were recruited and comorbid disorders were evaluated using DSM-IV-TR criteria. To evaluate ADHD severity, parents of all children filled out the ADHD Rating Scale. Thirty-seven children with comorbid MDD or DD were compared with 118 children with comorbid conduct disorder and 122 without comorbidity for age, sex, IQ level, family psychiatric history, and ADHD subtypes and severity.

RESULTS

42 of the ADHD children displayed comorbid depressive disorders: 16 exhibited MDD, 21 DD, and 5 both MDD and DD. The frequency of hyperactive-impulsive subtypes was significantly lower in ADHD children with depressive disorders, than in those without any comorbidity. ADHD children with depressive disorders showed a higher number of familial psychiatric disorders and higher score in the Inattentive scale of the ADHD Rating Scale, than children without any comorbidity. No differences were found for age, sex and IQ level between the three groups.

CONCLUSION

Consistent with previous studies in other countries, depressive disorders affect a significant proportion of ADHD children in Italy. Patient assessment and subsequent treatment should take into consideration the possible presence of this comorbidity, which could specifically increase the severity of ADHD attention problems.

The self-medication hypothesis and psychostimulant treatment of cocaine dependence: an update

BACKGROUND

Stimulant medications have shown promise as a treatment for cocaine dependence (CD) for several decades, yet these treatments have not been widely studied and substantial barriers to clinical implementation remain. The "Self-Medication Hypothesis," posits that an individual's choice to use a particular substance is to some degree based on the substance's effect on subjective painful affects or unpleasant emotional states which may or may not be associated with a psychiatric disorder.

OBJECTIVES

The Self-Medication Hypothesis remains relevant, particularly when considering the scenario of cocaine dependence, both with and without and co-occurring attention-deficit/hyperactivity disorder (ADHD).

METHODS

Two case studies (N=2) and a review of the relevant literature are provided in this clinical update on psychostimulant treatment of cocaine dependence.

RESULTS

Two case studies are presented in which psychostimulant treatment of cocaine dependence was associated with a good clinical outcome.

DISCUSSION

While the use of psychostimulant medication for the treatment of cocaine dependence is controversial, emerging evidence suggests potential utility for this approach.

CONCLUSIONS

Cocaine use in individuals with CD may represent self-medication, and prescribed psychostimulants may have benefit in restoring dopaminergic function.

SCIENTIFIC SIGNIFICANCE

Psychostimulant treatment of cocaine dependence is consistent with the Self-Meidcation Hypothesis and is deserving of further study.

A meta-analysis of the consistency of atomoxetine treatment effects in pediatric patients with attention-deficit/hyperactivity disorder from 15 clinical trials across four geographic regions

OBJECTIVE

Atomoxetine has been approved as a treatment for children and adolescents with attention-deficit/hyperactivity disorder (ADHD) in the United States, throughout Europe, and in other countries. This meta-analysis was to assess the consistency of the treatment effect of atomoxetine across four global geographic regions.

METHODS

Data from 15 acute, double-blind, placebo-controlled trials were pooled (2 in Asia, 4 in Europe, 8 in North America, and 1 in Russia), yielding 2569 pediatric patients with ADHD. Improvements during 6-10 weeks of atomoxetine treatment were evaluated using the ADHD Rating Scale-IV or the Swanson, Nolan, and Pelham Scale-Revised. Consistency across regions was assessed by an interaction test and Higgins I(2). Consistency of one region versus other regions was assessed by effect sizes of individual regions and pairwise differences.

RESULTS

Patient demographics were generally similar across regions. More patients from Asia met diagnostic criteria for ADHD inattentive subtype and fewer for combined subtype compared with patients from Europe, North America, or Russia. Asian patients had a lower mean baseline ADHD total score and mean hyperactivity/impulsivity subscore. Treatment effects showed marginal inconsistency and moderate heterogeneity among the regions (percentage of patients achieving a 40% decrease from baseline ADHD scores, atomoxetine versus placebo: Asia 39.6%, 24.0%; Europe 40.2%, 12.1%; North America 45.3%, 21.7%; Russia 54.2%, 33.3%). Inconsistency was observed primarily in Asia versus the other regions. Completion rates with atomoxetine were higher in Asia and Russia (94.4% and 94.3%, respectively) than in Europe (84.3%) or North America (80.4%).

CONCLUSIONS

Atomoxetine was demonstrated as an effective treatment for ADHD in 15 clinical trials from four global regions. The current meta-analysis has revealed a degree of heterogeneity in treatment efficacy across regions, most notably in the comparison of Asian patients relative to those from the other regions.

Correlates for academic performance and school functioning among youths with and without persistent attention-deficit/hyperactivity disorder

Childhood attention-deficit hyperactivity disorder (ADHD) is associated with academic underachievement and school dysfunction. Little is known whether such association varies with the persistence of ADHD symptoms. The authors investigated school functioning among youths with and without persistent ADHD and identified the clinical correlates for school functioning in a large sample of 333 youths with persistent ADHD, 166 with non-persistent ADHD, and 266 without ADHD. The participants and their mothers received structured interviews for diagnosis of ADHD and other psychiatric conditions according to the DSM-IV diagnostic criteria by using the Kiddie epidemiologic version of the Schedule for Affective Disorders and Schizophrenia, and for school functioning by using the Chinese Social Adjustment Inventory for Children and Adolescents. The results showed that both ADHD groups had more impairment in all domains of school functioning than youths without ADHD with a gradient relationship in the order of persistent ADHD, non-persistent ADHD, and non-ADHD. The most consistent correlates for all domains of impaired school functioning were youth- and mother-reported inattention symptoms and increased age. Childhood hyperactivity-impulsivity symptoms also predicted more severe problems in social interactions and school behaviors. Psychiatric comorbid conditions also predicted poorer attitudes toward school works and interactions at school. Our findings indicate that lifetime diagnosis of ADHD, regardless of persistence of ADHD, associate with the impairment of overall school functioning sustaining from childhood into adolescence, and imply that early intervention of childhood inattention may offset school dysfunction at late childhood and adolescence.