Adolescent clinical outcomes for young people with attention-deficit hyperactivity disorder

The clinical pathway in ADMiRE, Ireland's first public specialist service for children and adolescents with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder occurring in approximately one in twenty young people in Ireland, and in one-third of those attending Irish Child and Adolescent Mental Health Services (CAMHS). It is important to treat ADHD, as un/poorly treated ADHD is associated with a raft of negative health and socio-economic outcomes. Effective interventions for ADHD are available, and the use of standardised, evidence-based pathways for assessment and management of ADHD optimises outcomes. Despite this, there is no national standardised clinical pathway for assessment and treatment of ADHD in Ireland. ADMiRE, the first public healthcare specialist service for children and adolescents in Ireland, has developed a strongly evidence-based, efficient, effective and safe clinical pathway for assessment and management of ADHD. This paper describes the ADMiRE Clinical Pathway and references ADMiRE resources that are available to other services.

Can a nation-wide e-cohort of ADHD and ASD in childhood be established using Welsh routinely available datasets?

OBJECTIVES

We investigated the feasibility and validity of establishing a nationwide e-cohort of individuals with a diagnosis of attention deficit hyperactivity disorder (ADHD) and/or autism spectrum disorder (ASD) for future longitudinal research.

DESIGN

Individuals with a childhood diagnosis of ADHD/ASD as recorded on routinely available healthcare datasets were compared with matched controls and a sample of directly assessed individuals with ADHD.

SETTING

This study used data from the Welsh Secure Anonymised Information Linkage Databank in Wales, UK. Routinely collected data from primary care, emergency department and hospital admissions were linked at person level.

PARTICIPANTS

All individuals in Wales, UK born between 1 January 1991 and 31 December 2000. Individuals with a recorded diagnosis of ADHD and/or ASD by age 18 years were identified using International Classification of Diseases, 10th Revision and National Health Service (NHS) READ codes and matched to 3 controls each and 154 individuals with ADHD recruited from an established research study.

OUTCOME MEASURES

Recorded service use for anxiety and depression, alcohol and drug use and self-harm including emergency department use in young adulthood (age 16-25 years).

RESULTS

7726 individuals had a recorded diagnosis of ADHD (80% male) and 5001 of ASD (79% male); 1.4% and 0.9% of the population, respectively. Cox's regression analyses showed ADHD was associated with increased risks of anxiety/depression (HR: 2.36, 95% CI: 2.20 to 2.53), self-harm (HR: 5.70, 95% CI: 5.07 to 6.40), alcohol (HR: 3.95, 95% CI: 3.42 to 4.56), drug use (HR: 5.88, 95% CI: 5.08 to 6.80) and emergency department service use (HR: 1.36, 95% CI: 1.31 to 1.41). Those with ASD were at increased risk of anxiety/depression (HR: 2.11, 95% CI: 1.91 to 2.34), self-harm (HR: 2.93, 95% CI: 2.45 to 3.50) and drug use (HR: 2.21, 95% CI: 1.66 to 2.95) but not alcohol use. The ADHD e-cohort were similar to the directly assessed cohort.

CONCLUSIONS

Our identification strategy demonstrated the feasibility of establishing a large e-cohort of those with ADHD/ASD with expected patterns of poorer early adult outcomes, demonstrating a valid method of identifying large samples for future longitudinal studies without selective attrition.

Interconnections between Emotion Recognition, Self-Processes and Psychological Well-Being in Adolescents

Background: Adolescence is a critical developmental period for mentalization and emotion regulation skills. Studies show that during this time, adolescents may experience greater vulnerability to challenges of mental and emotional well-being. Studies also show that self-skills, such as mentalization, self-compassion, and self-control are independently associated with feelings of global self-worth or psychological well-being. To date, no known studies have explored interconnected relations among these self-skills, despite significant overlaps in the social-biological development of these skills. Aims: To investigate interconnected relations among psychological well-being, mentalization, self-compassion and self-control. Gender differences in these relations are explored. Method: As part of a larger, longitudinal study of adolescent well-being, this cross-sectional study drew on a variety of self-report measures, investigating relations among adolescents’ self-reports of psychological well-being, emotion recognition, self-control, and self-compassion. Participants consisted of 88 girls and 57 boys, mean age 13.38. Results: Main results showed associations among emotion recognition, self-control and self-compassion and feelings of global self-worth. Specifically, results showed that understanding negative emotions in others relates to lower levels of self-compassion and feelings of self-worth. Further, adolescents who report low levels of self-control reported uncompassionate self-responding and lower levels of self-worth. Gender differences and implications for further research and adolescent social-emotional interventions are discussed.

Associations of impulsivity, hyperactivity, and inattention with nonsuicidal self-injury and suicidal behavior: longitudinal cohort study following children at risk for neurodevelopmental disorders into mid-adolescence

BACKGROUND

The knowledge of how the separate Attention-Deficit/Hyperactivity Disorder (ADHD) subdimensions (impulsivity, hyperactivity, and inattention) are associated with nonsuicidal self-injury (NSSI) and suicidal behavior (SB) is limited. The objective of this study was to investigate the associations of childhood ADHD subdimensions with NSSI and SB in children at risk of neurodevelopmental disorders (NDDs; including ADHD).

METHODS

The sample (N = 391) included twin pairs where at least one twin screened positive for at least one NDD or common comorbidity at age 9 or 12. Data on ADHD subdimensions was collected through a telephone interview with a caregiver/legal guardian at age 9 or 12, and data on NSSI and SB was collected through an in-person clinical assessment at age 15. The associations between the ADHD subdimensions and NSSI or SB were tested in three different models: (1) univariable, (2) together with the other ADHD subdimensions, and (3) in a confounder-adjusted model including other NDD symptoms in addition to ADHD subdimensions, for NSSI and SB separately.

RESULTS

A total of 32 (8.2%) adolescents reported life-time engagement of NSSI, and 18 (4.6%) SB. Childhood impulsivity was associated with SB and childhood inattention with NSSI, in all models. Hyperactivity was not meaningfully associated with any of the outcomes.

CONCLUSION

Impulsivity and inattention, but not hyperactivity, may be of particular importance in understanding SB and NSSI. Brief screening for impulsivity and inattention in childhood could facilitate detection of children vulnerable to NSSI and SB and indicate valuable information for preventive and intervention strategies.

Internalizing-Externalizing Comorbidity and Impaired Functioning in Children

BACKGROUND

The comorbidity of mental illnesses is common in child and adolescent psychiatry. Children with internalizing-externalizing comorbidity often experience worse health outcomes compared to children with a single diagnosis. Greater knowledge of functioning among children with internalizing-externalizing comorbidity can help improve mental health care.

OBJECTIVE

The objective of this exploratory study was to examine whether internalizing-externalizing comorbidity was associated with impaired functioning in children currently receiving mental health services.

METHODS

The data came from a cross-sectional clinical sample of 100 children aged 4-17 with mental illness and their parents recruited from an academic pediatric hospital. The current mental illnesses in children were measured using the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID), and the level of functioning was measured using the World Health Organization Disability Assessment Schedule (WHODAS) 2.0. Linear regression was used to estimate the association between internalizing-externalizing comorbidity and level of functioning, adjusting for demographic, psychosocial, and geographic covariates.

RESULTS

Internalizing-externalizing comorbidity in children was associated with worse functioning compared to children with strictly internalizing comorbidities, β = 0.32 (p = 0.041). Among covariates, parent's psychological distress, β = 0.01 (p = 0.004), and distance to the pediatric hospital, β = 0.38 (p = 0.049) were associated with worse functioning in children.

CONCLUSIONS

Health professionals should be mindful that children with internalizing-externalizing comorbidity may experience worsening functioning that is disruptive to daily activities and should use this information when making decisions about care. Given the exploratory nature of this study, additional research with larger and more diverse samples of children is warranted.

Individual differences in sensitivity to positive home environment among children "at risk" for attention-deficit/hyperactivity disorder: A review

Although the evidence for the genetic basis of attention-deficit/hyperactivity disorder (ADHD) is strong, environmental factors, such as the quality of parenting or the home environment, may moderate such genetic liability. The plausible negative effect of a low-quality home environment and negative parenting on child outcomes is well-established; however, the positive effect of a high-quality environment and positive parenting remained largely uninvestigated. Due to the presence of genetic, temperamental, or physiological factors, children who were traditionally considered at-risk for ADHD may be more sensitive to aspects of their environment compared to children who are not at such risk. Therefore, they would be more affected by their environmental experience, either for good or bad. Under supportive environmental conditions, such at-risk individuals might actually outperform their non-vulnerable peers, suggesting that these individual factors might be considered susceptibility factors rather than risk factors. Little is known regarding the positive effect of the environment in the ADHD literature, but it has been demonstrated in cognitive functions that are closely associated with ADHD, such as executive functions (EF). We review this literature and examine the extant empirical support for sensitivity to aspects of the home environment and parenting in the case of ADHD and EF. Moreover, we review factors that could help identify the specific aspects of the home environment and parenting that these children might be more susceptible to. Such knowledge could be valuable when designing preventive interventions and identifying those children that are especially sensitive and could benefit from such interventions. Recommendations for future studies are discussed as well.

The Benefits and Limitations of Stimulants in Treating ADHD

This chapter focusses on the benefits and limitations of stimulant medications in the treatment of ADHD. We highlight the key similarities and differences between the different stimulants used to treat ADHD and briefly discuss mechanisms of action, pharmacokinetics, and pharmacodynamics. We will discuss some of the political, ethical, and moral discussions about the use of stimulants including a consideration of the treatment of subsyndromal ADHD and the use of stimulants as cognitive enhancers. We review the comparative efficacy and effectiveness between stimulants and non-pharmacological treatments for ADHD, between stimulant classes and formulations and between stimulant and non-stimulant medications. We discuss the effects on core symptoms, common associated symptoms, cognition, and more distal outcomes including quality of life and functioning and issues related to tolerance, tolerability and adverse effects. Looking at the clinical implications of these findings, we discuss the importance of measurement-based care in the treatment of ADHD. Finally, we will look at the benefits and limitations of stimulants across several different populations and clinical subgroups.

Evidence-based pharmacological treatment options for ADHD in children and adolescents

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity, causing functional impairment. Its prevalence lies at approximately 5% in children and adolescents and at approximately 2.5% in adults. The disorder follows a multifactorial etiology and shows a high heritability. Patients show a high interindividual and intraindividual variability of symptoms, with executive deficits in several cognitive domains. Overall, ADHD is associated with high rates of psychiatric comorbidities, and insufficient treatment is linked to adverse long-term outcomes. Current clinical guidelines recommend an individualized multimodal treatment approach including psychoeducation, pharmacological interventions, and non-pharmacological interventions. Available medications include stimulants (methylphenidate, amphetamines) and non-stimulants (atomoxetine, guanfacine, clonidine). While available pharmacological treatment options for ADHD show relatively large effect sizes (in short-term trials) and overall good tolerability, there is still a need for improvement of current pharmacotherapeutic strategies and for the development of novel medications. This review summarizes available pharmacological treatment options for ADHD in children and adolescents, identifies current issues in research and evidence gaps, and provides an overview of ongoing efforts to develop new medications for the treatment of ADHD in children and adolescents by means of a systematic cross-sectional analysis of the clinical trials registry www.clinicaltrials.gov.

Mindful Parenting Behaviors and Emotional Self-Regulation in Children With ADHD and Controls

OBJECTIVE

Mindfulness is defined as paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally and these behaviors can be applied to parenting. Thus far, it is not understood whether mindful parenting (MP) differs in parents of children with and without attention-deficit/hyperactivity disorder (ADHD), and how MP relates to other parenting practices and children's self-regulation.

METHODS

This study examined the relationships between MP, parenting behaviors and children's self-regulation in 120 families with child ADHD (85% male; mean age = 11.93) and 105 control families (62% male; mean age = 11.98). Parents completed measures of MP (Interpersonal Mindfulness in Parenting Scale), parenting behaviors (parenting warmth, consistency, and anger assessed with the Longitudinal Study of Australian Children measures), psychological distress (Kessler 6), and children's self-regulation (Social Skills Improvement System-self-control subscale).

RESULTS

When compared with controls, parents of children with ADHD reported significantly lower MP. Higher MP was associated with lower levels of parent psychological distress, higher levels of parenting warmth and consistency, lower levels of parenting anger, and higher child emotion self-regulation in both groups. In mediation analyses, MP was indirectly associated with child emotion self-regulation through lower parenting anger, with the model accounting for 55% of the variance in child self-regulation.

CONCLUSIONS

MP is a useful construct for understanding parent behaviors, and children's emotion self-regulation.

Predicting the Adult Clinical and Academic Outcomes in Boys With ADHD: A 7- to 10-Year Follow-Up Study in China

Background: Attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood and causes adverse effects on social functioning. The present study aimed to widely investigate the predictors, particularly childhood intelligence quotient (IQ) and family environment factors, on adult clinical and academic outcomes in boys with ADHD. Methods: A total of 101 boys with ADHD in a Chinese Han ADHD cohort were followed up 7-10 years later. Baseline ADHD symptoms were evaluated using the parent version of the ADHD Rating Scale-IV (ADHD-RS-IV) and the Chinese version of the Conners' Parent Rating Scale-Revised (CPRS-48). The intelligence of the child was tested by the China-Wechsler Intelligence Scale for Children (C-WISC), and family function was assessed by the Family Environment Scale-Chinese Edition (FES-CV). Adult ADHD persistence was defined using DSM-IV criteria for ADHD, and academic outcome fell into two categories: higher academic level group (studying in senior middle school or above) and lower academic level group (studying in vocational secondary schools or below). Results: Stepwise multiple logistic regression analysis revealed that the father's character, impulsive-hyperactive index as measured by the CPRS-48, and intellectual-cultural index as measured by the FES-CV independently predicted clinical outcomes in adults, with an AUC of 0.770 (p < 0.001, 95% CI = 0.678-0.863). The corresponding sensitivity and specificity were 0.743 and 0.727, respectively. The father's education level, family economic level, and verbal IQ (VIQ) on the C-WISC independently predicted adult academic outcomes, with an AUC of 0.870 (p < 0.001, 95% CI = 0.796-0.944). The corresponding sensitivity and specificity were 0.813 and 0.783, respectively. Conclusion: Initial ADHD symptom severity and IQ, father's character and education level, and family atmosphere and function affect adult clinical and academic outcomes. Addressing these areas early may help to improve the prognosis of ADHD into adulthood.

Predicting ADHD symptoms and diagnosis at age 14 from objective activity levels at age 7 in a large UK cohort

Hyperactivity is one of the three core symptoms in children with attention deficit hyperactivity disorder (ADHD). Diagnosing ADHD typically involves self-report, third party report and observations. Objective activity data can make a valuable contribution to the diagnostic process. Small actigraphy studies in clinical samples have shown that children with ADHD move more than children without ADHD. However, differences in physical activity between children with and without ADHD have not been assessed in large community samples or longitudinally. This study used data from the Millennium Cohort Study to test whether symptoms of ADHD (parent-rating Strengths and Difficulties Questionnaire) and ADHD diagnosis at age 14 (reported by parents) could be predicted from objective activity data (measured with actigraphs) at age 7 in N = 6675 children (final N = 5251). Regressions showed that less sedentary behavior at age 7 predicted more ADHD symptoms at age 14 (β =  - 0.002, CI  - 0.004 to  - 0.001). The result remained significant when controlled for ADHD symptoms at age 7, sex, BMI, month of birth, SES and ethnicity (β  =  - 0.001, CI  - 0.003 to  - 0.0003). ADHD diagnosis at age 14 was also significantly predicted by less sedentary behavior at age 7 (β  =  - 0.008). Our findings show that symptoms of ADHD can be predicted by objective activity data 5 years in advance and suggest that actigraphy could be a useful instrument aiding an ADHD diagnosis. Interestingly, the results indicate that the key difference between children with and without ADHD lies in reduced sedentary activity, i.e., times of rest.

The Mechanism, Clinical Efficacy, Safety, and Dosage Regimen of Atomoxetine for ADHD Therapy in Children: A Narrative Review

Atomoxetine, a selective norepinephrine (NE) reuptake inhibitor, was approved for attention deficit/hyperactivity disorder (ADHD) treatment in children, adolescents and adults. We searched the database PubMed/MEDLINE (2000 to October 1, 2021). Only publications in English were considered. Atomoxetine inhibits the presynaptic norepinephrine transporter (NET), preventing the reuptake of NE throughout the brain along with inhibiting the reuptake of dopamine in specific brain regions such as the prefrontal cortex (PFC). The novel mechanism of atomoxetine also includes several new brain imaging studies and animal model studies. It is mainly metabolized by the highly polymorphic drug metabolizing enzyme cytochrome P450 2D6 (CYP2D6). Atomoxetine is effective and generally well tolerated. ADHD is often accompanied by multiple comorbidities. A series of studies have been published suggesting that atomoxetine is effective in the treatment of ADHD symptoms for children with various types of comorbidity. In some cases, it is possible that atomoxetine may have a positive influence on the symptoms of comorbidities. Atomoxetine can be administered either as a single daily dose or split into two evenly divided doses, and has a negligible risk of abuse or misuse. The latest guideline updated that clinical dose selection of atomoxetine was recommended based on both CYP2D6 genotype and the peak concentration. To have a more comprehensive understanding of atomoxetine, this review sets the focus on the mechanism, clinical efficacy and dosage regimen in detail, and also touches on those studies regarding adverse reactions of atomoxetine.

Cognitive and Emotional Profiles of CU Traits and Disruptive Behavior in Adolescence: a Prospective Study

In this study we followed 82-90 adolescents, 50% boys, from 15 to 16 years, investigating CU traits and disruptive behaviors as predictors of cognitive skills and arousal to emotional pictures. At age 15, CU traits were rated by adolescents and disruptive (aggregated ADHD-ODD-delinquent) behaviors were rated by parents and adolescents. At age 16, executive function, reaction time variability (RTV), IQ and arousal to negative pictures were assessed. The results showed that, with control for disruptive behaviors, CU traits predicted lower RTV, higher IQ and lower arousal to negative pictures. With control for CU traits, disruptive behaviors predicted lower spatial working memory, lower interference control and higher RTV. Our findings are of theoretical and clinical relevance as they point to highly diverging cognitive and emotional profiles of CU traits and disruptive behaviors.

ADHD and Covid-19: current roadblocks and future opportunities

Attention deficit hyperactivity disorder (ADHD) is the commonest disorder presenting to Child and Adolescent Mental Health Services in Ireland. This article considers the impact of the Covid-19 pandemic on the provision of mental health services for young people with ADHD with specific reference to the difficulties that have been experienced in ADMiRE, a specialist ADHD service in Dublin, since the outbreak of Covid-19 in Ireland. Current guidelines and alternative ways of ensuring adequate service provision are discussed. Restrictions to mitigate the spread of Covid-19 are likely to continue for many months, and child and adolescent mental health services need to find new ways to provide a sustainable service to young people in Ireland. There is a growing evidence base for the use of telepsychiatry in the assessment and management of ADHD. Factors that should be considered when developing a telepsychiatry service for children and adolescents with ADHD are highlighted.

Pupillometry measurement and its relationship to retinal structural changes in children with attention deficit hyperactivity disorder

PURPOSE

This study aims to assess the pupillometry measurements of the attention deficit hyperactivity disorder (ADHD) patients and to investigate their correlations with macular and RNFL thickness parameters by comparing the values with a healthy control group.

METHODS

Newly diagnosed ADHD patients in a child and adolescent clinic of a tertiary hospital were consulted in an ophthalmology clinic. All participants had undergone a standard ophthalmological examination including refractometry, best corrected visual acuity, color vision, anterior segment biomicroscopy, fundoscopy, pupillometry, and OCT. All results were compared with a healthy control group at the same age.

RESULTS

The study group consisted of 32 patients and there were 43 children in the control group. Mean pupillary velocities of ADHD patients and control group were 0.60 ± 0.11 mm/s and 0.63 ± 0.11 mm/s, and 0.49 ± 0.12 mm/s and 0.50 ± 0.10 mm/s, for right and left eyes, respectively. The difference was statistically significant for both eyes (p < 0.05). Mean RNFL thickness measurements of the study group were 90.69 ± 8.58 μm and 89.63 ± 8.14 μm for right and left eyes, respectively and those were 87.35 ± 7.67 μm and 88.77 ± 7.44 μm, respectively in the healthy group. Correlation between right pupillary velocity and RNFL thickness was statistically significant (r = 0.339, p = 0.003).

CONCLUSION

Higher pupillary velocity values were observed in both eyes of children with ADHD and that was positively correlated with RNFL measurements of their right eyes.

ADHD-Related Mental Health Issues of Young Adult Male Prisoners in Pravieniškės Correction House-Open Colony (Lithuania)

The aim of this study was to evaluate mental health issues related to attention-deficit/hyperactivity disorder (ADHD) in young adult male prisoners.

The study was performed in the Pravieniškės Correction House-Open Prison Colony and represents the first study on adult ADHD in Lithuania. The sample consisted of 100 young males imprisoned for mild to moderate crimes. ADHD symptoms were assessed using the Adult Self-Report Scale v1.1 (ASRS v1.1) and Wender Utah Rating Scale (WURS) self-rating scales. Related mental health issues were evaluated using the DSM-5 Level 1 Cross-Cutting Symptom Measure, the Personality Inventory for DSM-5, and data from both medical files and offenses-incentives lists.

Clinically significant ADHD symptoms were found in 17% of the respondents. Prisoners with ADHD were younger and had shorter incentives lists. Personality traits of negative affect, antagonism, disinhibition, and psychoticism with increased personality dysfunction were more prevalent in the respondents with ADHD. Medical files of prisoners with ADHD more frequently included data on substance abuse, psychiatric diagnoses, and psychopharmacological treatment. None of the respondents had been diagnosed or treated for this disorder.

Clinically significant ADHD symptoms were highly prevalent among imprisoned males, but ADHD was not diagnosed or treated correctly. These findings show that the problem of ADHD in young male adults with increased risk for criminal behavior needs recognition by the politicians and professionals responsible for health care in Lithuania in order to better care for prisoners with this psychopathology.

Investigating the agreement between the clinician and research diagnosis of attention deficit hyperactivity disorder and how it changes over time; a clinical cohort study

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a common reason for referral to Child and Adolescent Mental Health Services (CAMHS), but families experience long delays between first professional contact and diagnosis, which risks development of secondary impairments. This study explores the agreement between clinician and research diagnoses of ADHD among children attending CAMHS, and their access to interventions. From the limited literature, we anticipated fluctuation and delays, but no other study has focused prospectively on ADHD diagnoses.

METHODS

This was a secondary analysis of a cohort of children attending two CAMHS between 2006 and 2009. The sample included 288 consecutive referrals of children aged between 5 and 11 years. Parents and teachers completed the Development and Well-Being Assessment (DAWBA) when the child was recruited to the study, which provided the research diagnosis of ADHD from the baseline. Clinicians reported no, possible, or definite diagnosis of ADHD and interventions provided at 6-monthly intervals for up to 2 years while the child attended CAMHS. We assessed agreement between the diagnoses using Kendall's Tau-B.

RESULTS

Of the 101 children with a research diagnosis of ADHD, 26 received a definite clinician diagnosis during 2-year follow-up, and 47 received a possible clinician diagnosis. The chance-corrected agreement was poor at all time points (Kendall's Tau-B 0.14-0.48). Clinician diagnoses were unstable, particularly if possible ADHD was recorded at the initial assessment. Of those with a research diagnosis, 15 were prescribed medication and 11 were offered parent training.

CONCLUSIONS

The use of standardised diagnostic assessments could reduce diagnostic uncertainty and increase access to evidence-based interventions.

Predicting ADHD Symptoms in Adolescence from Early Childhood Temperament Traits

Extreme levels of certain temperament traits can be early markers of different developmental pathways of attention-deficit/hyperactivity disorder (ADHD). However, the long-term utility of using these traits as predictors of ADHD is not fully known. This study includes 64 male adolescents (M age = 13.5), who have been followed since birth as part of a longitudinal study. The primary aim was to test effortful control (EC), activity level, and anger, measured in early childhood - both with mother's reports and laboratory assessments -as predictors of ADHD symptoms in adolescence. Further, we investigated the specificity of this prediction to the different ADHD symptom domains. The results demonstrated that early temperament dimensions of EC and activity level were predictive of ADHD symptoms about 10 years later, when the participants reached adolescence. Moreover, activity level showed specificity only to hyperactivity-impulsivity symptoms whereas EC was a predictor of the two symptom domains. Anger had a predictive correlation with ADHD symptoms; however, it did not have a unique predictive contribution. These results emphasize the relevance of EC and activity level in the developmental course of ADHD. Identification of early risk factors can lead to more efficient design and implementation of intervention programs.

The emergence of psychotic experiences in the early adolescence of 22q11.2 Deletion Syndrome

Individuals with 22q11.2 Deletion Syndrome (22q11.2DS) are at substantial increased risk of psychosis spectrum outcomes including schizophrenia. We conducted a prospective, longitudinal study of the psychopathological and neurocognitive correlates of early psychotic phenomena in young people with 22q11.2DS (n = 75, mean age time 1 (T1) 9.9 years, time 2 (T2) 12.5 years). We also assessed unaffected control siblings (n = 33, mean age T1 10.6 years, T2 13.4 years). The prevalence of psychotic experiences, defined as subthreshold psychotic phenomena, substantially increased in children with 22q11.2DS from 4% (n = 3) in childhood (T1) to 21% (n = 16) in early adolescence (T2) (p = 0.001), and at T2 prevalence was significantly elevated (p = 0.020) relative to control siblings (3%). The emergence of psychotic experiences was associated with levels of childhood anxiety symptoms at T1 and differential development of the attention-executive domain. IQ ability and IQ change, however, were not associated with the emergence of psychotic experiences, indicating that initial changes in attention-executive functioning may precede the decline in global cognition that has been reported to be associated with later stages of psychosis development. Our study highlights that psychotic phenomena emerge early in 22q11.2DS and we implicate attention-executive functioning and anxiety as key domains associated with the development of these psychotic experiences.

Psychiatric Disorders After Attention-Deficit/Hyperactivity Disorder: A Nationwide Population-Based Study in Taiwan

PURPOSE

To investigate the risk for psychiatric disorders in patients newly diagnosed with attention deficit hyperactive disorder (ADHD) from two longitudinal groups of children with and without ADHD.

STUDY DESIGN

In total, 1,745 children newly diagnosed with ADHD and 6,980 participants without ADHD were identified from Taiwan's National Health Insurance Research Database in 2005 and followed until 2010. Risks for psychiatric disorders in the ADHD and non-ADHD groups were compared.

RESULTS

The ADHD group was 3.82 times more likely to develop psychiatric disorders than their counterparts. The ADHD group showed the highest risk for oppositional defiant disorder, followed by adult ADHD and autism spectrum disorder. Moreover, the time effects of psychiatric disorders in the ADHD group were significant. Patients with ADHD subtypes had a significant risk for psychiatric disorders compared to their counterparts.

CONCLUSIONS

A high risk for psychiatric disorders was revealed in this study among children with ADHD. Childhood ADHD, the duration after the ADHD diagnosis, and the ADHD subtype were associated with psychiatric disorders.

CLINICAL RELEVANCE

Various psychiatric disorders were observed in children after they had been newly diagnosed with ADHD, indicating a need for integrated care that includes medical practitioners, family members, social workers, and early intervention workers for patients newly diagnosed with ADHD to decrease the risk for comprehensive psychiatric disorders.

ADHD symptoms in a young patient with central diabetes insipidus

Diabetes insipidus is known to be associated with neurodevelopmental disorders. In this case report, we present a child suffering from a central diabetes insipidus (DI) and an attention-deficit/hyperactivity disorder (ADHD). The DI was due to a mutation on the vasopressin gene, impairing its secretion. We discuss the effects of this impairment on the central nervous system and how it might be linked to ADHD symptoms.

Children's Reward and Punishment Sensitivity Moderates the Association of Negative and Positive Parenting Behaviors in Child ADHD Symptoms

Atypical reward processing, including abnormal reward responsivity and sensitivity to punishment, has long been implicated in the etiology of ADHD. However, little is known about how these facets of behavior interact with positive (e.g., warmth, praise) and negative (e.g., hostility, harsh discipline) parenting behavior in the early expression of ADHD symptoms in young children. Understanding the interplay between children's reward processing and parenting may be crucial for identifying specific treatment targets in psychosocial interventions for ADHD, especially given that not all children benefit from contingency-based treatments (e.g., parent management training). The study consisted of a sample of kindergarten children (N = 201, 55% male) and their parents, who completed questionnaires about their parenting practices, their child's behaviors and participated in an observed parent-child play task in the laboratory. Children's reward responsivity and sensitivity to punishment were positively associated with child ADHD symptoms. However, children with high reward responsivity had more symptoms of ADHD but only under conditions of low negative parenting (self-reported and observed) and high self-reported positive parenting, compared to children with low reward responsivity. Children with high sensitivity to punishment had more ADHD symptoms relative to children with low sensitivity to punishment, but only under conditions in which observed praise was infrequent. Results provide evidence that individual differences in sensitivity to reward/punishment may be an important of marker of risk for ADHD, but also highlights how children's responses to positive and negative parenting behavior may vary by children's sensitivities. Clinical and treatment implications are discussed.

A Meta-Analysis of the Association Between Birth Weight and Attention Deficit Hyperactivity Disorder

A large body of work has investigated the association between birth weight and ADHD and has resulted in mixed findings with regard to the direction and magnitude of this association. Despite the vast amount of research on this topic, a comprehensive and systematic quantification of the association between birth weight and ADHD has yet to be undertaken. A meta-analysis of 88 unique studies (N = 4,645,482) was conducted to quantify the overall effect size of birth weight on ADHD symptoms. Several variables were examined as moderators that may contribute to systematic variation in effect sizes. Overall, birth weight was found to have a small, but significant, association with ADHD symptoms such that individuals born at lower birth weights manifested greater symptoms of ADHD (r = -0.15). Sample type, mean birth weight of the sample, geographic region, the informant of ADHD symptoms, ADHD symptom measurement method, and race were all found to contribute significantly to heterogeneity in effect sizes. Notably, several early life risk factors previously found to be associated with both ADHD and birth weight, gestational age and prenatal smoking exposure, were not found to contribute to heterogeneity in effect sizes. The findings of the current analyses align with the growing recognition that early life adversity contributes to neurodevelopmental difficulties, and the findings highlight the importance of a better understanding of the mechanisms underlying the association between early life risk factors and adverse neurodevelopmental sequela, such as that observed in ADHD.

Growing out of attention deficit hyperactivity disorder: Insights from the 'remitted' brain

We consider developmental and cognitive models to explain why some children 'grow out' of attention deficit hyperactivity disorder (ADHD) by adulthood. The first model views remission as a convergence towards more typical brain function and structure. In support, some studies find that adult remitters are indistinguishable from those who were never affected in the neural substrates of 'top-down' mechanisms of cognitive control, some 'bottom-up' processes of vigilance/response preparation, prefrontal cortical morphology and intrinsic functional connectivity. A second model postulates that remission is driven by the recruitment of new brain systems that compensate for ADHD symptoms. It draws support from demonstrations of atypical, but possibly beneficial, patterns of connectivity within the cognitive control network in adult remitters. The final model holds that some childhood ADHD anomalies show lifelong persistence, regardless of adult outcome, supported by shared reports of anomalies in remitters and persisters in posterior cerebral and striato-thalamic regions. The models are compatible: different processes driving remission might occur in different brain regions. These models provide a framework for future studies which might inform novel treatments to 'accelerate' remission.

The presentation of depression symptoms in attention-deficit/hyperactivity disorder: comparing child and parent reports

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) frequently co-occurs with depression, and outcomes are poor when both are present. Little is known about whether depression symptoms present differently in ADHD compared to the general population, or how reliable young people with ADHD are at reporting these symptoms. This study aimed to describe depression symptoms in a clinical ADHD sample compared to a population sample, and compare self-reports of depression symptoms with parent-reports.

METHODS

Two hundred and forty-nine children with ADHD and their parents completed follow-up questionnaires around 5 years after taking part in a Cardiff University ADHD study. Child depression symptoms were measured using parent- and child-reported Mood and Feelings Questionnaires (MFQ) and compared to a population sample with MFQ data (n = 1460). Within both samples, child- and parent-reported depression symptoms were compared.

RESULTS

Although the profile of depression symptoms was similar between young people with ADHD and those in the general population, depression symptoms were much more common in the ADHD sample (parent-rated MFQ score = 24.52 vs. 9.39; child-rated = 21.02 vs. 11.86). The most common symptoms in both samples included irritability, restlessness and concentration difficulties, with core depression symptoms such as feeling miserable/unhappy also prominent. Within the ADHD sample, but not the population sample, children reported depression symptoms less frequently than their parents.

CONCLUSIONS

Young people with ADHD are at high risk of experiencing symptoms of depression but may under-report the severity of their symptoms. Obtaining parent reports of depression symptoms in this group may be important to avoid missing key indicators of risk.

Sex-specific trajectories of ADHD symptoms from adolescence to young adulthood

Reports of current ADHD symptoms in adults with a childhood diagnosis of ADHD are often discrepant: While one subgroup reports a particularly high level of current ADHD symptoms, another reports-in contrast-a very low level. The reasons for this difference remain unclear. Although sex might play a moderating role, it has not yet been examined in this regard. In an epidemiological cohort study from birth to young adulthood, childhood ADHD diagnoses were assessed at the ages of 4.5, 8, and 11 years based on parent ratings. Sex-specific development of ADHD symptoms was analyzed from the age of 15 to 25 years via self-reported ADHD symptoms in participants with (n = 47) and without childhood ADHD (n = 289) using a random coefficient regression model. The congruence between parent reports and adolescents' self-ratings was examined, and the role of childhood ADHD diagnosis, childhood OCC/CD, and childhood internalizing disorder as possible sex-specific predictors of self-reported ADHD symptoms at age 25 years was investigated. With regard to self-reported ADHD symptoms, females with a childhood ADHD diagnosis reported significantly more ADHD symptoms compared to females without childhood ADHD and males with and without ADHD throughout adolescence and young adulthood. In contrast, males with childhood ADHD did not differ from control males either at age 15 or at age 25 years. Only in females did a childhood diagnosis of an externalizing disorder (ADHD and CD/ODD) predict self-reported ADHD symptoms by age 25 years. Our findings suggest that self-reports of young adults with a childhood diagnosis of ADHD are influenced by sex. Specifically, females with childhood ADHD report increased levels of ADHD symptoms upon reaching adulthood. To correctly evaluate symptoms and impairment in this subgroup, other, more objective, sources of information may be advisable, such as neurophysiological measures.

Mindfulness for children with ADHD and Mindful Parenting (MindChamp): Protocol of a randomised controlled trial comparing a family Mindfulness-Based Intervention as an add-on to care-as-usual with care-as-usual only

BACKGROUND

Self-control in childhood has been linked to long-term and cascading effects on health, academic, criminality, wealth and parenting outcomes. Hence it is important to target self-control deficits early in life. Self-control deficits are a hallmark of Attention Deficit/Hyperactivity Disorder (ADHD). Even after receiving care-as-usual (CAU) for ADHD, impaired self-control often remains. Pharmacotherapy can be hampered by side-effects, low adherence and short-term effectiveness. Other limitations of CAU are decreased effectiveness when parents have ADHD and little effect on parental well-being. Mindfulness-Based Interventions (MBIs) are an emerging non-pharmacological approach with potential to improve self-control and well-being in both children and parents. However, there is a lack of sufficiently powered randomised controlled trials (RCTs) to establish their effects in families with ADHD. This study protocol describes an RCT to investigate the effectiveness of a family MBI as an add-on to CAU in treatment of youth with ADHD, and is described in accordance with Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT).

METHODS/DESIGN

An RCT will be conducted in N = 100 children (aged 8-16 years) with ADHD and their parents. The experimental condition will consist of a family MBI (MYmind): 8-week group-based MBI for youth combined with parallel group-based Mindful Parenting for their parents, as an add-on to CAU. The control condition will consist of CAU-only. Assessments will take place at baseline, end of treatment (3 months later), 2 and 6 months' follow-up. Primary outcome measure will be an ecologically valid assessment of child self-control with the parent-rated Behaviour Rating Inventory of Executive Function (BRIEF). Secondary child outcome measures will be teacher-rated BRIEF, computerised self-control tasks and questionnaires on psychological symptoms (e.g. ADHD, symptoms of autism), well-being and mindfulness. For parental outcomes, secondary measures will be self-rated BRIEF, computerised self-control tasks and questionnaires on psychological symptoms, well-being and mindful parenting.

DISCUSSION

The proposed RCT will take account of methodological limitations of previous studies on MBIs in child ADHD populations. The current study will provide valuable information on family MBI as a potential effective intervention in targeting self-control deficits for youth with ADHD and their parents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03220308 . Retrospectively registered 18 July 2017.

A smartphone-based ecological momentary assessment of parental behavioral consistency: Associations with parental stress and child ADHD symptoms

Inconsistent parental discipline is a robust correlate of child attention-deficit/hyperactivity disorder (ADHD) symptoms, but few studies have considered the role of inconsistent positive parenting on ADHD, as well as the effects of stress on negative and positive parental consistency. This study advanced a novel ecological momentary assessment (EMA) using participant smartphones to measure parental consistency, and examined its associations with family, social, and parenting-related dimensions of stress and child ADHD symptoms. Participants were 184 kindergartners with and without ADHD and their parents. Harsh and warm dimensions of parental behavior were assessed using questionnaires, observations, and an EMA administered through parents' smartphones, which measured parent-child behaviors every day for a period of 1 week. Family, social, and parenting-related stress were assessed from questionnaires, and child ADHD symptoms were assessed from a fully structured diagnostic interview with the parent. Child ADHD symptoms were associated with variability in warm parenting behaviors, and higher levels of parenting-related stress were related to greater variability in harsh parenting behaviors. No significant interactions were detected between parental stress and child ADHD on parental variability. These findings suggest that different factors influence the consistency in parenting behavior, depending on whether positive parenting or negative parenting is assessed. Parent-based treatment programs for children with ADHD should include a stronger focus on reducing stress from parenting (e.g., teaching coping skills for parents), as this may lead to greater consistency in parental behavior more generally, and presumably better child outcomes. (PsycINFO Database Record

Efficacy and safety of ginkgo preparations for attention deficit hyperactivity disorder: a systematic review protocol

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated childhood psychiatric disorders. The analogous diagnosis adopted in Europe is hyperkinetic disorder, which is defined in the WHO's International Classification of Diseases 10th edition (ICD-10). Hyperkinetic disorder includes more severe conditions. Ginkgo preparations are used in the treatment of ADHD. The present study will assess the efficacy and safety of ginkgo preparations in the treatment of ADHD in the currently published literature.

MATERIALS AND METHODS

All prospective randomised controlled trials (RCTs) will be included in this systematic review. Patients diagnosed with ADHD according to American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV), Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), ICD-10 or Chinese Classification and Diagnosis of Mental Diseases third edition (CMDD) will be included. A comprehensive search for RCTs to evaluate the effectiveness and tolerance of ginkgo preparations will be performed. The primary outcomes are the ADHD Rating Scale-IV and Revised Conners' Parent Rating Scale. The secondary outcomes are quality of life evaluated by the KINDL scale, adverse effects/events, Conners' Teacher Rating Scale, Strengths and Weaknesses of ADHD Symptoms and Normal Behaviour Scale and Fremdbeurteilungsbogen für Hyperkinetische Störungen. Exclusion criteria are the following: (1) case reports, not randomised trial, non-comparative studies and (2) patients who were not diagnosed based on DSM-IV, DSM-5, ICD-10 or CMDD. The following databases will be searched from their inception until January 2018: Medline, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, China Biology Medicine Disc, China National Knowledge Infrastructure Database, Wanfang Database and Chinese Scientific Journals Database. Two authors will independently perform the study selection, extract the data and assess the study quality and risk of bias.

ETHICS AND DISSEMINATION

This systematic review does not require ethics approval. It will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42017077190.

ADHD in children and young people: prevalence, care pathways, and service provision

Attention-deficit hyperactivity disorder (ADHD) is a common childhood behavioural disorder. Systematic reviews indicate that the community prevalence globally is between 2% and 7%, with an average of around 5%. At least a further 5% of children have substantial difficulties with overactivity, inattention, and impulsivity that are just under the threshold to meet full diagnostic criteria for ADHD. Estimates of the administrative prevalence (clinically diagnosed or recorded) vary worldwide, and have been increasing over time. However, ADHD is still relatively under-recognised and underdiagnosed in most countries, particularly in girls and older children. ADHD often persists into adulthood and is a risk factor for other mental health disorders and negative outcomes, including educational underachievement, difficulties with employment and relationships, and criminality. The timely recognition and treatment of children with ADHD-type difficulties provides an opportunity to improve long-term outcomes. This Review includes a systematic review of the community and administrative prevalence of ADHD in children and adolescents, an overview of barriers to accessing care, a description of associated costs, and a discussion of evidence-based pathways for the delivery of clinical care, including a focus on key issues for two specific age groups-younger children (aged ≤6 years) and adolescents requiring transition of care from child to adult services.

Attention-Deficit/Hyperactivity Disorder and Very Preterm/Very Low Birth Weight: A Meta-analysis

CONTEXT

Although very preterm (VP), extremely preterm (EP), very low birth weight (VLBW), and extremely low birth weight (ELBW) newborns seem to have a higher risk of later attention-deficit/hyperactivity disorder (ADHD), the magnitude of the risk is not well-defined.

OBJECTIVE

To systematically review and meta-analyze the risk of VP/VLBW and EP/ELBW individuals to develop a ADHD categorical diagnosis or dimensional symptomatology compared with controls with normal weight and/or birth age.

DATA SOURCES

We used PsycINFO, Medline, Embase, and Cochrane databases.

STUDY SELECTION

We selected cross-sectional, prospective, or retrospective studies with no time or language restriction.

DATA EXTRACTION

Independent reviewers screened and extracted data using predefined standard procedures.

RESULTS

In 12 studies (N = 1787), researchers relying on a categorical diagnosis showed that both VP/VLBW and EP/ELBW subjects have a higher ADHD risk (odds ratio [OR] = 3.04 higher than controls; 95% confidence interval [CI] 2.19 to 4.21). In subgroup analyses, we demonstrated that the more extreme the cases, the higher the ORs (VP/VLBW: OR = 2.25 [95% CI 1.56 to 3.26]; EP/ELBW: OR = 4.05 [95% CI 2.38 to 6.87]). We drew data from 29 studies (N = 3504) on ADHD symptomatology and found significant associations with inattention (standardized mean difference [SMD] = 1.31, 95% CI 0.66 to 1.96), hyperactivity and impulsivity (SMD = 0.74, 95% CI 0.35 to 1.13), and combined symptoms (SMD = 0.55, 95% CI 0.42 to 0.68) when compared with controls.

LIMITATIONS

Heterogeneity was significantly high for all analyses involving the 3 ADHD dimensions.

CONCLUSIONS

With our results, we provide evidence that VP/VLBW subjects have an increased risk of ADHD diagnosis and symptomatology compared with controls, and these findings are even stronger in the EP/ELBW group. Future researchers should address which risk factors related to prematurity or low birth weight lead to ADHD.

Attention Deficit Hyperactivity Disorder: Is There an App for That? Suitability Assessment of Apps for Children and Young People With ADHD

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a complex highly comorbid disorder, which can have a huge impact on those with ADHD, their family, and the community around them. ADHD is currently managed using pharmacological and nonpharmacological interventions. However, with advances in technology and an increase in the use of mobile apps, managing ADHD can be augmented using apps specifically designed for this population. However, little is known regarding the suitability and usability of currently available apps.

OBJECTIVE

The aim of this study was to explore the suitability of the top 10 listed apps for children and young people with ADHD and clinicians who work with them. It is hypothesized that mobile apps designed for this population could be more suitably designed for this population.

METHODS

The top 10 listed apps that are specifically targeted toward children and young people with ADHD in the United Kingdom were identified via the Google Play (n=5) and iTunes store (n=5). Interviews were then undertaken with 5 clinicians who specialize in treating this population and 5 children and young people with ADHD themselves, to explore their opinions of the 10 apps identified and what they believe the key components are for apps to be suitable for this population.

RESULTS

Five themes emerged from clinician and young people interviews: the accessibility of the technology, the importance of relating to apps, addressing ADHD symptoms and related difficulties, age appropriateness, and app interaction. Three additional themes emerged from the clinician interviews alone: monitoring symptoms, side effects and app effect on relationships, and the impact of common comorbid conditions. The characteristics of the apps did not appear to match well with the views of our sample.

CONCLUSIONS

These findings suggest that the apps may not be suitable in meeting the complex needs associated with this condition. Further research is required to explore the value of apps for children and young people with ADHD and their families and, in particular, any positive role for apps in the management of ADHD in this age group. A systematic review on how technology can be used to engage this population and how it can be used to help them would be a useful way forward. This could be the platform to begin exploring the use of apps further.

Organisation of services for managing ADHD

There is considerable variation in practice, both between and with different countries in the management of attention deficit hyperactivity disorder (ADHD). Whilst there is no one optimal model of service organisation there are general principles of care that can be introduced to reduce this variability. There are frequent debates and discussions about which professional group is best placed to manage ADHD at different points in the life cycle. Who delivers care is however less important than ensuring that training schemes provide adequate exposure, training and experience to both the core and non-core skills required to provide a comprehensive package of care. Most evidence-based guidelines recommend a multi-modal, multi-professional and multi-agency approach. Many also promote the use of both stepped care and shared care approaches for the management of ADHD. As most of those with ADHD continue to have ADHD-related problems into adulthood, it is important to consider how best to transition care into adulthood and think about who should deliver care to adults with ADHD. Young people with ADHD should generally be transferred to adult mental health services if they continue to have significant symptoms of ADHD or other coexisting conditions that require treatment. Unfortunately services for adults with ADHD remain relatively scarce across much of the world and some adult psychiatrists remain unsure of the diagnosis and uncertain about the appropriate use of ADHD medications in adults, but there is a strong case for increased services for adults. ADHD is on the one hand easy to treat; it is much more difficult to treat well. Although optimised care for ADHD requires routine measurement of outcomes, this often does not happen in routine clinical practice. Focusing on optimising symptoms and minimising adverse effects can significantly improve both short- and long-term outcomes.

Attention-Deficit/Hyperactivity Disorder: A Historical Review (1775 to Present)

As a new school year approaches, nurses will find themselves faced with students with symptoms of attention-deficit/hyperactivity disorder (ADHD). Navigating the diagnostic label changes and numerous psychopharmacological treatment options can prove time-consuming and confusing. The current article explores the early years of symptom identification, various diagnostic labels, and subsequent psychopharmacological treatments from psychostimulants to non-stimulant alternatives (including a prescription medical food). The current article also serves as a discussion guide for nurses and clinicians when providing education to patients and their loved ones, teachers, coaches, and others who may question the diagnosis and treatment of ADHD. This disorder can have a significant impact on one's ability to function within family, school, work, and social settings. A historical context is provided for the evolution of today's diagnostic criteria and the pharmacotherapy used in the treatment of ADHD. [Journal of Psychosocial Nursing and Mental Health Services, 55(9), 10-16.].

Discontinuation of pharmacological treatment of children and adolescents with attention deficit hyperactivity disorder: meta-analysis of 63 studies enrolling 11,788 patients

BACKGROUND

The risk-benefit balance of pharmacological treatment for children and adolescents with ADHD and the factors that moderate this relationship are unclear.

METHODS

A systematic review and meta-analysis of randomised, placebo-controlled clinical trials (RPCCTs) investigating the efficacy of pharmacological treatment in children or adolescents with ADHD was carried out. Meta-analysis of treatment discontinuation, clinician-, parent- and teacher-rated efficacy and adverse events was performed. The effect of covariates was studied.

RESULTS

Sixty-three studies were included. Ten drugs were investigated, with atomoxetine and methylphenidate the most frequently studied. RPCCTs had mostly a short duration (7.9 weeks). All-cause treatment discontinuation was lower with pharmacological treatment than placebo (OR = 0.68). Pharmacological treatment was more efficacious than placebo independently of the rater (clinician, standardised mean difference (SMD) 0.74; parent, SMD = 0.63; or teacher, SMD = 0.75). Evidence of publication bias was found for clinician-rated efficacy, especially in industry-sponsored RPCCT. Psychostimulants showed a higher efficacy and were associated with a better outcome on treatment discontinuation than non-stimulant drugs. Efficacy was smaller in RPCCTs for which a psychiatric comorbid disorder was an inclusion criterion, was larger in studies with a commercial sponsorship and showed a negative association with treatment length.

CONCLUSIONS

In the short term, pharmacological treatment provides moderate-high symptom relief, is safe and shows lower treatment discontinuation than placebo, suggesting a suitable risk-benefit balance, particularly with psychostimulants. The efficacy is lower in patients with a comorbid psychiatric disorder and should be assessed periodically, as it appears to reduce over time. Publication bias of clinician-rated efficacy in studies with a commercial sponsor is suggested.

Dopamine transporter (DAT1/SLC6A3) polymorphism and the association between being born small for gestational age and symptoms of ADHD

Being small for gestational age (SGA) has been established as a risk factor for Attention Deficit Hyperactivity Disorder (ADHD). Likewise, several molecular genetic studies have found a link between DAT1 and ADHD. This study investigated whether SGA moderates the effect of dopamine transporter gene variants on the risk of ADHD. A total of 546 children of European descent were genotyped at age 11 for seven DAT1 SNPs (rs6347, rs11564774, rs40184, rs1042098, rs2702, rs8179029 and rs3863145). The Strengths and Difficulties Questionnaire was used to measure symptoms of ADHD at ages 3.5, 7 and 11. We found significant gene-environment interactions between birth weight and DAT1 SNPs (rs6347, rs40184, rs1042098, rs3863145) on ADHD symptoms at 3.5 years only. Results suggest that genotypic variation of DAT1 may confer a relative protective effect against ADHD in SGA individuals. This study supports the idea that being born SGA moderates the effect of the DAT1 gene on ADHD symptoms in the preschool years and may help to explain some of the heterogeneity in ADHD outcomes.

Non-diagnostic based approaches to helping children who could be labelled ADHD and their families

Mental health services are not always good for you. There are some troubling facts to confront such as the increase in the use of diagnostic based approaches and psychotropic medications for children and young people being associated with poorer rather than better outcomes. In this article I will outline some of the evidence around outcome as a result of treatment for young people diagnosed with attention deficit hyperactivity disorder (ADHD) and for those who are prescribed long-term stimulants. I will then discuss clinical approaches that move beyond a focus on symptom management that diagnostic paradigms encourage. This includes clinical models that take account of the diversity of contextual and relational issues that young patients present with and the possibility afforded of engaging in more positive and hopeful therapeutic approaches such as the Relational Awareness Programme (RAP).

The predictors of persistent DSM-IV disorders in 3-year follow-ups of the British Child and Adolescent Mental Health Surveys 1999 and 2004

BACKGROUND

The identification of the factors that influence the persistence of psychiatric disorder may assist practitioners to focus on young people who are particularly prone to poor outcomes, but population-based samples of sufficient size are rare.

METHOD

This secondary analysis combined data from two large, population-based cross-sectional surveys in Great Britain (1999 and 2004) and their respective follow-ups (2002 and 2007), to study homotypic persistence among the 998 school-age children with psychiatric disorder at baseline. Psychiatric disorder was measured using the Development and Well-Being Assessment applying DSM-IV criteria. Factors relating to the child, family, and the severity and type of psychopathology at baseline were analysed using logistic regression.

RESULTS

Approximately 50% of children with at least one psychiatric disorder were assigned the same diagnostic grouping at 3-year follow-up. Persistent attention-deficit/hyperactivity disorder and anxiety were predicted by poor peer relationship scores. Persistent conduct disorder was predicted by intellectual disability, rented housing, large family size, poor family function and by severer baseline psychopathology scores.

CONCLUSIONS

Homotypic persistence was predicted by different factors for different groups of psychiatric disorders. Experimental research in clinical samples should explore whether these factors also influence response to interventions.

Clinical and Functional Outcomes in Young Adult Males With ADHD

OBJECTIVE

To investigate clinical and functional outcomes in military men with ADHD.

METHOD

Clinical outcomes were measured via the Zung Self-Rating Depression Scale (Zung SDS) and the Zung Self-Rating Anxiety Scale (Zung SAS). Functional outcomes were measured using the "Car, Relax, Alone, Forget, Friends, Trouble" (CRAFFT) questionnaire and questionnaires about relationships, conduct problems, substance use, and sleep.

RESULTS

Men with ADHD ( n = 52) reported more depressive (34 [67.3%] vs. 19 [38%], p = .008) and anxiety symptoms (31 [61.5%] vs. 14 [28%], p = .009) compared with those without ( n = 50). They had relationships lasting less than 1 year (24 [80%] vs. 9 [37.5%], p = .006), were more likely to smoke (17 [32.7%] vs. 5 [10%], p = .005), were most likely to use illicit substances (6 [11.5%] vs. 0 [0%], p < .001), had more conduct problems at school (27 [51.9%] vs. 5 [10%], p < .001), and had longer sleep latency (53.96 min ± 46.48 vs. 25.78 min ± 25.93, p = .006).

CONCLUSION

Military men with ADHD are significantly associated with worse clinical and functional outcomes. They should be screened and monitored for depression, anxiety, sleep disorders, and substance use.

ADHD, comorbid disorders and psychosocial functioning: How representative is a child cohort study? Findings from a national patient registry

BACKGROUND

Cohort studies often report findings on children with Attention Deficit Hyperactivity Disorder (ADHD) but may be biased by self-selection. The representativeness of cohort studies needs to be investigated to determine whether their findings can be generalised to the general child population. The aim of the present study was to examine the representativeness of child ADHD in the Norwegian Mother and Child Cohort Study (MoBa).

METHODS

The study population was children born between January 1, 2000 and December 31, 2008 registered with hyperkinetic disorders (hereafter ADHD) in the Norwegian Patient Registry during the years 2008-2013, and two groups of children with ADHD were identified in: 1. MoBa and 2. The general child population. We used the multiaxial International Classification of Diseases (ICD-10) and compared the proportions of comorbid disorders (axes I-III), abnormal psychosocial situations (axis V) and child global functioning (axis VI) between these two groups. We also compared the relative differences in the multiaxial classifications for boys and girls and for children with/without axis I comorbidity, respectively in these two groups of children with ADHD.

RESULTS

A total of 11 119 children were registered with ADHD, with significantly fewer in MoBa (1.45%) than the general child population (2.11%), p < 0.0001. The proportions of comorbid axis I, II, and III disorders were low, with no significant group differences. Compared with the general child population with ADHD, children with ADHD in MoBa were registered with fewer abnormal psychosocial situations (axis V: t = 7.63, p < .0001; d = -.18) and better child global functioning (axis VI: t = 7.93, p < 0.0001; d = .17). When analysing relative differences in the two groups, essentially the same patterns were found for boys and girls and for children with/without axis I comorbidity.

CONCLUSIONS

Self-selection was found to affect the proportions of ADHD, psychosocial adversity and child global functioning in the cohort. However, the differences from the general population were small. This indicates that studies on ADHD and multiaxial classifications in MoBa, as well as other cohort studies with similar self-selection biases, may have reasonable generalisability to the general child population.

Childhood hyperactivity and mood problems at mid-life: evidence from a prospective birth cohort

PURPOSE

Childhood hyperactivity leads to mental health problems, but it is not known whether there are long-term risks for adult mood problems in unselected population cohorts that extend to mid-life. Aims were to examine links between childhood hyperactivity and mood problems up to age 50 years and to consider confounding factors and gender differences in associations.

METHODS

The National Child Development Study (NCDS) is a UK cohort of children born in 1958. Children with (N = 453) and without (N = 9192) pervasive and persistent hyperactivity were followed to age 50. Adult mood was assessed using the Malaise Inventory at ages 23, 33, 42, and 50 years and the CIS-R interview at 45 years.

RESULTS

Childhood hyperactivity predicted low mood at all adult assessments (ES = 0.27-0.45), including after covariate adjustment (childhood adversity, emotional and behavioural problems, and attainment).

CONCLUSION

Hyperactivity has enduring risk effects on low mood throughout the life course that extend to middle age.

Association of Genetic Risk Variants With Attention-Deficit/Hyperactivity Disorder Trajectories in the General Population

IMPORTANCE

Attention-deficit/hyperactivity disorder (ADHD) is a heritable neurodevelopmental disorder that shows clinical and genetic overlap with other childhood neurodevelopmental disorders. Levels of ADHD symptoms typically decline across childhood and adolescence, although they remain elevated for some individuals. The determinants of symptom persistence and decline are not yet fully understood.

OBJECTIVES

To test the hypothesis that genetic risk variant load for ADHD (indexed by polygenic risk scores [PRS]), but not for other psychiatric disorders, is associated with population-based ADHD symptom trajectories across childhood and adolescence, and to examine whether higher genetic liability for ADHD is correlated with total number of additional neurodevelopmental disorders (multimorbidity) in childhood.

DESIGN, SETTING, AND PARTICIPANTS

The Avon Longitudinal Study of Parents and Children, an ongoing prospective population-based cohort study, has been collecting data on 14 701 children, including 9757 with data on symptoms of ADHD at multiple time points, since September 6, 1990. The primary exposure variables, PRS, were generated using results of a genome-wide association study from the Psychiatric Genomics Consortium. Childhood multimorbidity scores (ages 7-9 years) were measured by total impairments in 4 domains known to share genetic liability with ADHD: IQ, social communication, pragmatic language, and conduct. Data analysis was conducted from March 1 to September 8, 2016.

MAIN OUTCOMES AND MEASURES

Attention-deficit/hyperactivity disorder symptom trajectories from ages 4 to 17 years (7 time points).

RESULTS

Among 9757 children with data on symptoms of ADHD at multiple time points (age range, 4-17 years; 4968 boys and 4789 girls), 4 ADHD symptom trajectories were identified: low (82.6%), intermediate (7.7%), childhood-limited (5.8%), and persistent (3.9%). Mean (SE) PRS for ADHD were higher in children in the persistent trajectory (0.254 [0.069]) compared with each of the other 3 trajectories (low, -0.018 [0.014], χ21 = 14.67, P < .001, odds ratio, 1.31; intermediate, 0.054 [0.055], χ21 = 4.70, P = .03, odds ratio, 1.22; and childhood-limited, 0.017 [0.060], χ21 = 6.50, P = .01, odds ratio, 1.27). Findings were specific to PRS for ADHD; PRS for other psychiatric conditions did not differ across trajectories. The proportion of children with multimorbidity was also highest in those in the persistent trajectory (42.5%; 95% CI, 33.9%-51.1%; P < .001) and was associated with persistence of ADHD symptoms independent of PRS.

CONCLUSIONS AND RELEVANCE

Persistence of ADHD symptoms across childhood and adolescence in the general population is associated with higher PRS for ADHD. Childhood multimorbidity was also associated with persistence of ADHD symptoms and may help to identify children with ADHD whose symptoms are most likely to continue into adolescence.

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.

Changing ASD-ADHD symptom co-occurrence across the lifespan with adolescence as crucial time window: Illustrating the need to go beyond childhood

Literature on the co-occurrence between Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) is strongly biased by a focus on childhood age. A review of the adolescent and adult literature was made on core and related symptoms of ADHD and ASD. In addition, an empirical approach was used including 17,173 ASD-ADHD symptom ratings from participants aged 0 to 84 years. Results indicate that ASD/ADHD constellations peak during adolescence and are lower in early childhood and old age. We hypothesize that on the border of the expected transition to independent adulthood, ASD and ADHD co-occur most because social adaptation and EF skills matter most. Lower correlations in childhood and older age may be due to more diffuse symptoms reflecting respectively still differentiating and de-differentiating EF functions. We plea for a strong research focus in adolescence which may -after early childhood- be a second crucial time window for catching-up pattern explaining more optimal outcomes. We discuss obstacles and oppportunities of a full lifespan approach into old age.

The Safety of Atomoxetine for the Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: A Comprehensive Review of Over a Decade of Research

Atomoxetine is a noradrenergic reuptake inhibitor prescribed for attention-deficit/hyperactivity disorder (ADHD) that first gained approval in the USA in 2002 and has been authorized in 97 countries worldwide. The aim of this paper is to comprehensively review publications that addressed one or more of seven major safety topics relevant to atomoxetine treatment of children and adolescents (aged ≥6 years) diagnosed with ADHD. While the review focuses on children and adolescents, publications in which data from patients aged >18 years and from 6 to 18 years were analyzed in the same dataset were included. Using a predefined search strategy, including agreement of two reviewers when selecting papers, reduced the potential for bias. Using this process, we identified 70 eligible papers (clinical trials, epidemiological studies, and case reports) across the seven topics. We also referred to the European Summary of Product Characteristics (SPC) and US label. We found 15 papers about suicidality, three about aggression/hostility, seven about psychosis/mania, six about seizures, seven about hepatic effects, 29 about cardiovascular effects, and 28 about growth and development. The main findings (i.e., those from the largest and most well-conducted studies/analyses) are as follows. A large register-based study of pediatric and adult patients (6818 received atomoxetine) calculated a hazard ratio of 0.96 for suicide-related events during treatment with atomoxetine, and a meta-analysis of 23 placebo-controlled studies (N = 3883), published in 2014, found no completed suicides and no statistically significant association between atomoxetine and suicidality. The frequency of aggression/hostility was not statistically significantly higher with atomoxetine, e.g., experienced by 1.6 % (N = 21/1308) of atomoxetine-treated patients versus 1.1 % (N = 9/806) of placebo-treated patients in one meta-analysis. Symptoms of psychosis and mania were mainly observed in patients with comorbid bipolar disorder/depression. Based on spontaneous reports, during a 2-year period when 2.233 million adult and pediatric patients were exposed to atomoxetine, the reporting rate for seizures was 8 per 100,000 patients. In the manufacturer's database, atomoxetine was a "probable cause" of three hepatic adverse events (AEs) (all reversible hepatitis), and 133 hepatic AEs had possible confounding factors and were "possibly related" to atomoxetine, during 4 years when atomoxetine exposure had reached about 4.3 million patients. Rare cases of severe liver injury are described in the US label and European SPC; a case requiring liver transplantation is described in the US label. In a comprehensive review of a clinical trials database (N = 8417 received atomoxetine), most pediatric patients experienced modest increases in heart rate and blood pressure, and 8-12 % experienced more pronounced changes (≥20 bpm, ≥15 to 20 mmHg). However, in three long-term analyses (≥2 years), blood pressure was within age norms, and few patients discontinued due to cardiovascular AEs. As described in the European SPC, QT interval prolongation is uncommon, e.g., in an open-label study, 1.4 % of 711 children and adolescents had prolonged QTc intervals (≥450 ms in males, ≥470 ms in females) that were not clinically significant at ≥3 years of treatment with atomoxetine. The European SPC warns about potential QT interval prolongation in patients with a personal or family history, or if atomoxetine is administered with other drugs that potentially affect the QT interval. Decreases in growth (weight and height gain) occurred and were greatest in patients of above average weight and height, but appeared to recover over 2-5 years of atomoxetine treatment. In conclusion, suicidality, aggression/hostility, psychosis, seizures, liver injuries, and prolonged QT interval are uncommon or rare in children and adolescents treated with atomoxetine, based on data from the predefined search and from the European SPC. Overall, the data that we assessed from our search do not suggest that associations exist between atomoxetine and suicidality or seizures. The data also suggest that an association may not exist between atomoxetine and aggression/hostility. While atomoxetine may affect the cardiovascular system, the data suggest these effects are not clinically significant in most patients. Reductions in growth appear to be reversible in the long term.

Personality disorders and Axis I comorbidity in adolescent outpatients with ADHD

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a lifelong condition which carries great cost to society and has an extensive comorbidity. It has been assumed that ADHD is 2 to 5 times more frequent in boys than in girls. Several studies have suggested developmental trajectories that link ADHD and certain personality disorders. The present study investigated the prevalence of ADHD, common Axis I disorders, and their gender differences in a sample of adolescent outpatients. We also wanted to investigate the relationship between ADHD and personality disorders (PDs), as well as how this relationship was influenced by adjustment for Axis I disorders, age and gender.

METHODS

We used a sample consisting of 153 adolescents, aged 14 to 17 years, who were referred to a non-specialized mental health outpatient clinic with a defined catchment area. ADHD, conduct disorder (CD) and other Axis I conditions were assessed using the Mini International Neuropsychiatric Interview (MINI). PDs were assessed using the Structured Interview for DSM-IV Personality (SIDP-IV).

RESULTS

13.7 % of the adolescents met diagnostic criteria for ADHD, with no significant gender difference. 21.6 % had at least one PD, 17.6 % had CD, and 4.6 % had both ADHD and a PD. There was a significantly elevated number of PD symptoms in adolescents with an ADHD diagnosis (p = 0.001), and this relationship was not significantly weakened when adjusted for age, gender and other Axis I disorders (p = 0.026). Antisocial (χ (2) = 21.18, p = 0.002) and borderline (χ (2) = 6.15, p = 0.042) PDs were significantly more frequent in girls than in boys with ADHD.

CONCLUSIONS

We found no significant gender difference in the prevalence of ADHD in a sample of adolescents referred to a general mental health outpatient clinic. Adolescent girls with ADHD had more PDs than boys, with antisocial and borderline PDs significantly different. The present study suggests that ADHD in girls in a general outpatient population may be more prevalent than previously assumed. It especially highlights the importance of assessing antisocial and borderline personality pathology in adolescent girls presenting with ADHD symptoms.