Socioeconomic Associations with ADHD: Findings from a Mediation Analysis

Support for primary care prescribing for adult ADHD in England: national survey

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, for which there are effective pharmacological treatments that improve symptoms and reduce complications. Guidelines published by the National Institute for Health and Care Excellence recommend that primary care practitioners prescribe medication for adult ADHD under shared-care agreements with Adult Mental Health Services (AMHS). However, provision remains uneven, with some practitioners reporting a lack of support.

AIM

This study aimed to describe elements of support, and their availability/use, in primary care prescribing for adult ADHD medication in England to improve access for this underserved population and inform service improvement.

DESIGN AND SETTING

Cross-sectional surveys were used to elicit data from commissioners, health professionals (HPs), and people with lived experience of ADHD (LE) across England about elements supporting pharmacological treatment of ADHD in primary care.

METHOD

Three interlinked cross-sectional surveys were used to ask every integrated care board in England (commissioners), along with convenience samples of HPs and LEs, about prescribing rates, AMHS availability, wait times, and shared-care agreement protocols/policies for the pharmacological treatment of ADHD in primary care. Descriptive analyses, percentages, and confidence intervals were used to summarise responses by stakeholder group. Variations in reported provision and practice were explored and displayed visually using mapping software.

RESULTS

Data from 782 responders (42 commissioners, 331 HPs, 409 LEs) revealed differences in reported provision by stakeholder group, including for prescribing (95% of HPs versus 64% of LEs). In all, >40% of responders reported extended AMHS wait times of ≥2 years. There was some variability by NHS region - for example, London had the lowest reported extended wait time (25%), while East of England had the highest (55%).

CONCLUSION

Elements supporting appropriate shared-care prescribing of ADHD medication via primary care are not universally available in England. Coordinated approaches are needed to address these gaps.

Mapping associations of polygenic scores with autistic and ADHD traits in a single city region

BACKGROUND

The genetic and environmental aetiology of autistic and Attention Deficit Hyperactivity Disorder (ADHD) traits is known to vary spatially, but does this translate into variation in the association of specific common genetic variants?

METHODS

We mapped associations between polygenic scores for autism and ADHD and their respective traits in the Avon Longitudinal Study of Parents and Children (N = 4,255-6,165) across the area surrounding Bristol, UK, and compared them to maps of environments associated with the prevalence of autism and ADHD.

RESULTS

Our results suggest genetic associations vary spatially, with consistent patterns for autistic traits across polygenic scores constructed at different p-value thresholds. Patterns for ADHD traits were more variable across thresholds. We found that the spatial distributions often correlated with known environmental influences.

CONCLUSIONS

These findings shed light on the factors that contribute to the complex interplay between the environment and genetic influences in autistic and ADHD traits.

The pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Attention-deficit/hyperactivity disorder is one of the most common childhood neurobehavioral disorders, which has a serious negative effect on educational achievement, peer relationships, social functioning, behavior, and self-esteem of children. However, the pooled prevalence of attention-deficit/hyperactivity disorder is not well known in Ethiopia. Therefore, the main objective of this systematic review and meta-analysis is to estimate the pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia.

METHODS

PubMed, HINARI, Science Direct, Psych INFO, Google Scholar, African Journals Online, and cross-referenced were searched to identify relevant articles. Quality appraisal was done using the Joanna Briggs Institute checklist. Heterogeneity was tested using the I-square statistics. Publication bias was tested using a funnel plot visual inspection. Further, trim and fill analysis was done to correct publication bias.Forest plots and tables were used to present results. The random effect model was used to compute the pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents.

RESULTS

The overall pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia was 14.2% (95% CI: 8.48, 22.83). Being male (OR: 2.19, 95% CI: 1.54; 3.12), being aged 6-11 years (OR: 3.67, 95% CI: 1.98; 6.83), low family socioeconomic status (OR: 3.45 95% CI: 2.17; 5.47), maternal complication during pregnancy (OR: 3.29, 95% CI: 1.97; 5.51) and family history of mental illness (OR: 3.83, 95% CI:2.17; 6.77) were factors associated with a higher odds of attention-deficit/hyperactivity disorder among children and adolescents.

CONCLUSIONS

The overall pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents is high in Ethiopia as compared to previous literature. To reduce the prevalence of attention-deficit/hyperactivity disorder among children and adolescents, emphasis has to be given to prevention, early detection, and management of pregnancy-related complications. Moreover, parents with mental illness should be supported and properly treated to reduce the impact of hostile parenting on their child's health.

TRIAL REGISTRATION

Registered in PROSPERO with ID: CRD42024536334.

The Relationship Between Social Anxiety Disorder and ADHD in Adolescents and Adults: A Systematic Review

OBJECTIVE

This review aimed to systematically gather empirical data on the link between social anxiety disorder and ADHD in both clinical and non-clinical populations among adolescents and adults.

METHOD

Literature searches were conducted in PsycInfo, PubMed, Scopus, and Web of Science, resulting in 1,739 articles. After screening, 41 articles were included. Results were summarized using a narrative approach.

RESULTS

The prevalence of ADHD in adolescents and adults with SAD ranged from 1.1% to 72.3%, while the prevalence of SAD in those with ADHD ranged from 0.04% to 49.5%. Studies indicate that individuals with both SAD and ADHD exhibit greater impairments. All studies were judged to be of weak quality, except for two studies which were rated moderate quality.

DISCUSSION

Individuals with SAD should be screened for ADHD and vice versa, to identify this common comorbidity earlier. Further research is needed to better understand the prevalence of comorbid ADHD and SAD in adolescents.

Prevalence of adult attention deficit hyperactivity disorder in India: a systematic review and a cross-sectional study among young adults in Delhi-NCR

PURPOSE

The epidemiology of adult attention deficit hyperactivity disorder (ADHD) is not well explored in India. The present study aims to systematically review the literature on the prevalence of adult ADHD in India and also estimate the prevalence and sociodemographic correlates of adult ADHD among the young adults in Delhi-NCR.

METHODS

For the systematic review, 494 articles were identified of which 10 were included in the review. Simultaneously, a cross-sectional study was conducted involving 1665 adults (18-25 years; mean age 19.92) of both sexes (69.1% females) from different colleges in Delhi-NCR, India. Data was collected using structured interviews and standardized diagnostic tool ASRS V1.1 was used for screening of ADHD.

RESULT

The systematic review revealed a high prevalence of adult ADHD ranging from 5.48 to 25.7% among general and specific populations of India. Further, in the cross-sectional study, 14% of participants were screened positive for ADHD. While factors like South Indian origin and higher maternal education were associated with an increased risk of adult ADHD, low socioeconomic status was found to be protective.

CONCLUSION

Considering the high prevalence of adult ADHD in India, there is an urgent need to increase awareness regarding adult ADHD and identify vulnerable populations to facilitate informed interventions.

Rates of family history of autism and ADHD varies with recruitment approach and socio-economic status

Family history (FH) of autism and ADHD is not often considered during the recruitment process of developmental studies, despite high recurrence rates. We looked at the rate of autism or ADHD amongst family members of young children (9 to 46 months) in three UK-based samples (N = 1055) recruited using different methods. The rate of FH-autism or FH-ADHD was 3%-9% for diagnosed cases. The rate was highest in the sample recruited through an online participant pool, which also consisted of the most socio-economically diverse families. Lower parental education and family income were associated with higher rates of FH-ADHD and lower parental education with increased FH-autism. Thus, recruitment strategies have a meaningful impact on neurodiversity and the conclusions and generalizations that can be drawn. Specifically, recruitment using crowdsourcing websites could create a sample that is more representative of the wider population, compared to those recruited through university-related volunteer databases and social media.

Inferring skin-brain-skin connections from infodemiology data using dynamic Bayesian networks

The relationship between skin diseases and mental illnesses has been extensively studied using cross-sectional epidemiological data. Typically, such data can only measure association (rather than causation) and include only a subset of the diseases we may be interested in. In this paper, we complement the evidence from such analyses by learning an overarching causal network model over twelve health conditions from the Google Search Trends Symptoms public data set. We learned the causal network model using a dynamic Bayesian network, which can represent both cyclic and acyclic causal relationships, is easy to interpret and accounts for the spatio-temporal trends in the data in a probabilistically rigorous way. The causal network confirms a large number of cyclic relationships between the selected health conditions and the interplay between skin and mental diseases. For acne, we observe a cyclic relationship with anxiety and attention deficit hyperactivity disorder (ADHD) and an indirect relationship with depression through sleep disorders. For dermatitis, we observe directed links to anxiety, depression and sleep disorders and a cyclic relationship with ADHD. We also observe a link between dermatitis and ADHD and a cyclic relationship between acne and ADHD. Furthermore, the network includes several direct connections between sleep disorders and other health conditions, highlighting the impact of the former on the overall health and well-being of the patient. The average R 2 for a condition given the values of all conditions in the previous week is 0.67: in particular, 0.42 for acne, 0.85 for asthma, 0.58 for ADHD, 0.87 for burn, 0.76 for erectile dysfunction, 0.88 for scars, 0.57 for alcohol disorders, 0.57 for anxiety, 0.53 for depression, 0.74 for dermatitis, 0.60 for sleep disorders and 0.66 for obesity. Mapping disease interplay, indirect relationships, and the key role of mediators, such as sleep disorders, will allow healthcare professionals to address disease management holistically and more effectively. Even if we consider all skin and mental diseases jointly, each disease subnetwork is unique, allowing for more targeted interventions.

Associations between symptoms of attention-deficit hyperactivity disorder, socioeconomic status and asthma in children

Socioeconomic status (SES) influences the risk of both physical diseases, such as asthma, and neurodevelopmental conditions, including attention-deficit/hyperactivity disorder (ADHD). Using Causal Mediation Analysis on French birth-cohort data, we found a causal pathway from SES to ADHD symptoms, in part mediated by asthma. An increase in family income at age 3 by one unit resulted in lower ADHD symptoms at age 5, by -0.37 [95% CI: -0.50, -0.24] SDQ-score-points, with additional -0.04 [95% CI: -0.08, -0.01] points reduction indirectly via asthma at age 3, both with statistical significance. Importantly, family income at age 3 exerted both direct and indirect (via asthma) negative effects on later ADHD symptoms with much higher magnitudes for the direct effect. Our findings underscore the importance of apprehending ADHD symptoms in the broader context of socioeconomic disparities, along with their comorbidities with asthma, potentially influencing public health interventions and clinical practice in managing ADHD.

Educational attainment, income, and attention deficit hyperactivity disorder: A mediation analysis based on two-step Mendelian randomization

Previous studies have reported the relationship between educational attainment and attention deficit hyperactivity disorder (ADHD). However, the mechanism of this relationship remains unknown. It is well known that educational attainment correlates with income. Therefore, based on summary data from a genome-wide association study we used two-step Mendelian randomization (MR) to explore the role of income between education and ADHD. The inverse variance weighted (IVW) method was used in our analysis. The IVW results suggested that educational attainment and income were protective factors against ADHD. Educational attainment affects ADHD through income [ADHD: Beta = -0.68, 95% confidence interval (CI) = -0.87, -0.49; female: Beta = -0.87, 95% CI = -1.28, -0.47; male: Beta = -1.01, 95% CI = -1.34, -0.68; childhood: Beta = -0.52, 95% CI = -0.74, -0.30; late-diagnosed: Beta = -0.78, 95% CI = -1.11, -0.47; persistent: Beta = -0.82, 95% CI = -1.33, -0.31]. Income also affected ADHD through educational attainment [female: Beta = -1.08, 95% CI = -1.35, -0.83; male: Beta = -1.16, 95% CI = -1.57, -0.77; persistent: Beta = -1.48, 95% CI = -2.09, -0.94]. In the final analysis, data with heterogeneity were analyzed using IVW random effects results. The mechanism is that income will mediate the relationship between educational attainment and ADHD.

Combined and sequential exposure to prenatal second hand smoke and postnatal maternal distress is associated with cingulo-opercular global efficiency and attention problems in school-age children

BACKGROUND

Prenatal exposure to secondhand (environmental) tobacco smoke (SHS) is associated with adverse neurodevelopmental outcomes, including altered functional activation of cognitive control brain circuitry and increased attention problems in children. Exposure to SHS is more common among Black youth who are also disproportionately exposed to socioeconomic disadvantage and concomitant maternal distress. We examine the combined effects of exposure to prenatal SHS and postnatal maternal distress on the global efficiency (GE) of the brain's cingulo-opercular (CO) and fronto-parietal control (FP) networks in childhood, as well as associated attention problems.

METHODS

Thirty-two children of non-smoking mothers followed in a prospective longitudinal birth cohort at the Columbia Center for Children's Environmental Health (CCCEH) completed magnetic resonance imaging (MRI) at ages 7-9 years old. GE scores were extracted from general connectivity data collected while children completed the Simon Spatial Incompatibility functional magnetic resonance imaging (fMRI) task. Prenatal SHS was measured using maternal urinary cotinine from the third trimester; postnatal maternal distress was assessed at child age 5 using the Psychiatric Epidemiology Research Interview (PERI-D). The Child Behavior Checklist (CBCL) measured Attention and Attention Deficit Hyperactivity Disorder (ADHD) problems at ages 7-9. Linear regressions examined the interaction between prenatal SHS and postnatal maternal distress on the GE of the CO or FP networks, as well as associations between exposure-related network alterations and attention problems. All models controlled for age, sex, maternal education at prenatal visit, race/ethnicity, global brain correlation, and mean head motion.

RESULTS

The prenatal SHS by postnatal maternal distress interaction term associated with the GE of the CO network (β = 0.673, Bu = 0.042, t(22) = 2.427, p = .024, D = 1.42, 95% CI [0.006, 0.079], but not the FP network (β = 0.138, Bu = 0.006, t(22) = 0.434, p = .668, 95% CI [-0.022, 0.033]). Higher GE of the CO network was associated with more attention problems (β = 0.472, Bu = 43.076, t(23) = 2.780, p = .011, D = 1.74, n = 31, 95% CI [11.024, 75.128], n = 31) and ADHD risk (β = 0.436, Bu = 21.961, t(29) = 2.567, p = .018, D = 1.81, 95% CI [4.219, 39.703], n = 30).

CONCLUSIONS

These preliminary findings suggest that sequential prenatal SHS exposure and postnatal maternal distress could alter the efficiency of the CO network and increase risk for downstream attention problems and ADHD. These findings are consistent with prior studies showing that prenatal SHS exposure is associated with altered function of brain regions that support cognitive control and with ADHD problems. Our model also identifies postnatal maternal distress as a significant moderator of this association. These data highlight the combined neurotoxic effects of exposure to prenatal SHS and postnatal maternal distress. Critically, such exposures are disproportionately distributed among youth from minoritized groups, pointing to potential pathways to known mental health disparities.

Risk of new onset and persistent psychopathology in children with long-term physical health conditions: a population-based cohort study

Children and young people (CYP) with long-term physical health conditions (pLTCs) have increased risk of psychopathology compared to physically healthier peers. We explored risk factors for new onset and persistent psychiatric disorders in CYP with pLTCs compared to CYP without pLTCs. This 3-year follow-up study involved a UK representative sample of CYP from the British Child and Adolescent Mental Health Surveys (N = 7804). We examined potential baseline predictors of new onset and persistent psychiatric disorders at follow-up in four groups of children based on the presence of any physical and/or any psychiatric conditions at baseline. Psychiatric disorders were assessed using standardised multi-informant diagnostic assessment. Separate multivariable binary logistic regressions were conducted for each group. In CYP with pLTCs, rented housing (aOR = 1.42, 95% CI  1.01 to 1.99), non-traditional family structure (aOR = 2.08, 95% CI  1.42 to 3.05), increased parental distress (aOR = 1.09, 95% CI  1.04 to 1.14), and greater peer relationship difficulties (aOR = 1.29, 95% CI  1.19 to 1.39) predicted future psychiatric disorder. Only peer relationship difficulties predicted persistent disorder (aOR = 1.27, 95% CI  1.17 to 1.38) in this group. A greater number of factors predicted the onset of psychiatric disorder in CYP with pLTCs compared to physically healthier peers and similarly, a higher number of factors predicted persistent disorder in CYP without pLTCs. CYP with pLTCs might comprise a group with different vulnerabilities, some of which are potentially tractable and may be useful indicators of patients who require preventable or management interventions.

Inattention symptom severity and cognitive processes in children at risk of ADHD: the moderating role of separation anxiety

Impairments in cognitive processes and their associations with dimensional measures of inattention, hyperactivity-impulsivity and anxiety were examined in children at risk of Attention-Deficit Hyperactivity Disorder. Children referred by teachers for exhibiting ADHD-type problems (n = 116; 43 meeting full diagnostic criteria for ADHD; 4-8 years) completed computerized tasks measuring episodic memory, response inhibition, visuomotor control and sustained attention, while parents were interviewed (DAWBA) to assess ADHD and anxiety symptoms. Of the 116 children assessed, 72% exhibited impaired cognitive processes; 47% had impaired visuomotor control, 37% impaired response inhibition, and 35% had impaired episodic memory. Correlational and hierarchical regression analyses using our final analytic sample (i.e., children who completed all cognitive tasks and a vocabulary assessment, n = 114) showed that poorer task performance and greater within-subject variability were significantly associated with more severe inattention symptoms but not with hyperactivity-impulsivity severity. Symptoms of separation anxiety, which were reported in over half of the sample, moderated associations between inattention and episodic memory, and between inattention and inhibition. Only children without separation anxiety showed significant correlations between ADHD symptoms and poor performance. However, separation anxiety had no moderating effect on associations between inattention and visuomotor control or sustaining attention. Children exhibiting signs of ADHD show impairments across a range of cognitive tasks. Further research to improve our understanding of these processes may be useful in the development of early interventions. Our results suggest that separation anxiety should be taken into account when considering interventions to address emerging neuropsychological deficits associated with this disorder.

Longitudinal Associations Between Physical Health Conditions in Childhood and Attention-Deficit/Hyperactivity Disorder Symptoms at Age 17 Years

OBJECTIVE

Although evidence suggests significant cross-sectional relationships between attention-deficit/hyperactivity disorder (ADHD) and several physical health conditions, less is known about their longitudinal associations. We investigated the cumulative effect of childhood physical health conditions on ADHD symptoms at age 17 years, controlling for environmental factors, ADHD medication status, and ADHD symptoms at age 3 years.

METHOD

Using Millennium Cohort Study data (weighted n = 8,059), we assessed whether 4 physical health clusters (sensory, neurological, atopic, and cardio-metabolic) were associated with scores on the ADHD subscale from the Strengths and Difficulties Questionnaire at age 17 years. Environmental factors were grouped into 5 cumulative risk indices: prenatal, perinatal, postnatal environment, postnatal maternal well-being, and sociodemographic factors. Regression analyses determined whether each physical health cluster was associated with ADHD score while controlling for environmental factors, ADHD medication, and earlier symptoms.

RESULTS

Sensory, neurological, and cardio-metabolic clusters were all significantly associated with ADHD symptoms (β range = 0.04-0.09, p < .001). The overall model explained 2% of the variance. This rose to 21% (ΔR2 = 0.06) after adjusting for confounders. The sensory (β = 0.06) and neurological (β = 0.06) clusters remained significant (R2 = 0.21, ΔR2 = 0.06), but the cardio-metabolic cluster was no longer a significant predictor.

CONCLUSION

Sensory or neurological conditions in childhood were associated with higher ADHD symptoms aged 17 after adjustment of confounders. This was not the case for atopic or cardio-metabolic conditions. These findings have implications for the care of children with sensory/neurological conditions and future research examining ADHD etiopathophysiology.

Attention-Deficit Hyperactivity Disorder among children of immigrants: immigrant generation and family poverty

OBJECTIVES

Attention-Deficit Hyperactivity Disorder (ADHD) is one of the most common disorders diagnosed among children in the US. However, little knowledge is available about ADHD prevalence among children of immigrants, the fastest-growing population in the US. This study seeks to examine ADHD rates among children of immigrants in different generations compared to children of US-born parents and their association with family poverty.

DESIGN

The sample includes 83,362 children aged 0-17 from the National Health Interview Survey (NHIS) 2010-2018 data. Multivariate logistic regression model is used to estimate prevalence of ADHD among children of immigrants compared to children of US-born parents. We then compare ADHD rates among the children sample in different immigrant generations. For all analyses, we examine ADHD occurrence separately for children in families living below the poverty threshold and those at or above the poverty threshold.

RESULTS

The odds of having ADHD were significantly lower among children of immigrants compared to children of US-born parents. Both first-generation children and second-generation children of immigrants had significantly lower odds of having ADHD than children of US-born parents. Post hoc tests find that first-generation children had lower odds of having ADHD compared to second-generation children. Likewise, additional analyses showed that children of immigrants, first-generation children in particular, were less likely to have ADHD compared to children of US-born parents, in both lower- and higher-income families.

CONCLUSION

Using a nationally representative sample of children, we find that the likelihood of having ADHD increases with higher generations, detecting differences in ADHD prevalence by immigration generation. Importantly, first-generation children had a significantly lower risk of having ADHD conditions compared to second-generation children and children of US-born parents, regardless of family socio-economic status. Public health policy and program development would gain from a clear comprehension of the shielding attributes of ADHD among immigrant families.

Prevalence and Factors Associated with Behavioral Problems in 5-Year-Old Children Born with Cleft Lip and/or Palate from the Cleft Collective

OBJECTIVES

To determine the UK prevalence of behavioral problems in 5-year-old children born with isolated or syndromic cleft lip and/or palate (CL/P) compared to the general population and identify potentially associated factors.

DESIGN

Observational study using questionnaire data from the Cleft Collective 5-Year-Old Cohort study and three general population samples.

MAIN OUTCOME MEASURE

The Strengths and Difficulties Questionnaire (SDQ).

PARTICIPANTS

Mothers of children (age: 4.9-6.8 years) born with CL/P (n  =  325). UK general population cohorts for SDQ scores were: Millennium Cohort Study (MCS) (n  =  12  511), Office of National Statistics (ONS) normative school-age SDQ data (n  =  5855), and Avon Longitudinal Study of Parents and Children (ALSPAC) (n  =  9386).

RESULTS

By maternal report, 14.2% of children born with CL/P were above clinical cut-off for behavioral problems, which was more likely than in general population samples: 7.5% of MCS (OR  =  2.05 [1.49-2.82], P < 0.001), 9.8% of ONS (OR  =  1.52 [1.10-2.09], P  =  0.008), and 6.6% of ALSPAC (OR  =  2.34 [1.70-3.24], P < 0.001). Children in the Cleft Collective had higher odds for hyperactivity, emotional and peer problems, and less prosocial behaviors. Maternal stress, lower maternal health-related quality of life and family functioning, receiving government income support, and maternal smoking showed evidence of association (OR range: 4.41-10.13) with behavioral problems, along with maternal relationship status, younger age, and lower education (OR range: 2.34-3.73).

CONCLUSIONS

Findings suggest elevated levels of behavioral problems in children born with CL/P compared to the general population with several associated maternal factors similar to the general population.

Socioeconomic disparities in attention deficit hyperactivity disorder (ADHD) in Sweden: An intersectional ecological niches analysis of individual heterogeneity and discriminatory accuracy (IEN-AIHDA)

We aimed (i) to gain a better understanding of the demographic and socioeconomical distribution of ADHD risk in Sweden; and (ii) to contribute to the critical discussion on medicalization, i.e., the tendency to define and treat behavioural and social problems as medical entities. For this purpose, we analysed the risk of suffering from ADHD in the whole Swedish population aged between 5 and 60 years, across 96 different strata defined by combining categories of gender, age, income, and country of birth. The stratified analysis evidenced considerable risk heterogeneity, with prevalence values ranging from 0.03% in high income immigrant women aged 50-59, to 6.18% in middle income immigrant boys aged 10-14. Our study questions the established idea that behavioural difficulties conceptualized as ADHD should be primarily perceived as a neurological abnormality. Rather, our findings suggest that there is a strong sociological component behind how some individuals become impaired and subject to medicalization.

The Prevalence of Risk Factors Among Children Diagnosed With Attention-Deficit/Hyperactivity Disorder, Aged 4-17 Years: A Cross-Sectional Study

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder commonly observed in children. Although the etiology of ADHD is still unclear, many risk factors have been shown to increase the prevalence of ADHD, such as genetics, environmental factors, socioeconomic status, maternal smoking, and low birth weight.

AIM

The current cross-sectional study aimed to assess the prevalence of several risk factors associated with ADHD-diagnosed children aged 4-17 years using parent-reported data.

METHODS

An observational cross-section study was conducted between December 2022 and February 2023 using a self-constructed questionnaire that we sent to parents whose children were diagnosed with ADHD. The questionnaire included socioeconomic information (income, gender, parent education, number of children), child information (age, ADHD type, academic achievement), pregnancy and neonatal period (smoking status, gestation age, mode of delivery, child weight), and if there is a history of ADHD in the family.

RESULTS

A total of 306 parents responded to the questionnaire. The majority of our study population was males (77.8%). The combined type, which includes symptoms of both hyperactivity and inattention, represented 70% of the population in our study, which is higher than the inattention type (23%) and the hyperactivity type (6%). The prevalence of several risk factors known to be associated with ADHD, such as family income, parental education, complications during pregnancy, and the low birth weight of the child, were also reported.

CONCLUSION

To the best of our knowledge, this is the first study that examines the frequency of risk factors among children diagnosed with ADHD in Saudi Arabia. The study revealed that males are more likely to be diagnosed with ADHD than females. We also found that the combined type is the most diagnosed ADHD among children. Furthermore, there are no significant differences in the prevalence of the risk factors during the gestational or neonatal period among ADHD-diagnosed children. Therefore, a large-scale prospective study is needed to aid in evaluating the frequency and significance of various risk factors among diagnosed children.

Athletes With Attention-Deficit/Hyperactivity Disorder: Position Statement of the American Medical Society for Sports Medicine

ABSTRACT

Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.

Predictors of Attention Deficit Hyperactivity Disorder in Sri Lankan Children: A School Based Community Study

OBJECTIVE

To evaluate potential risk-factors of ADHD among primary school-children (PSC) in state schools in Colombo district of Sri Lanka.

METHOD

A case-control study was conducted with 73 cases and 264 controls selected randomly among 6 to 10-year-old PSC from Sinhala medium state schools in Colombo district. Primary care givers completed the SNAP-IV P/T-S scale to screen for ADHD and an interviewer-administered questionnaire on risk-factors. Children's diagnostic status was confirmed by a Consultant Child and Adolescent Psychiatrist based on DSM-5 criteria.

RESULTS

A binomial regression model identified male sex (aOR = 3.45; 95% CI [1.65, 7.18]), lower educational level of the mother (aOR = 2.99; 95% CI [1.31, 6.48]), birth weight <2,500 g (aOR = 2.83; 95% CI [1.17, 6.81]),a neonatal complications (aOR = 3.82; 95% CI [191, 7.65]) and child having witnessed verbal/emotional aggression between parents (aOR = 2.08; 95% CI [1.01, 4.27])as significant predictors of ADHD.

CONCLUSION

Primary prevention should focus on strengthening neonatal, maternal and child health services within the country.

Prenatal Exposure to Air Pollutants and Attentional Deficit Hyperactivity Disorder Development in Children: A Systematic Review

Up to 9.5% of the world's population is diagnosed with attention deficit/hyperactivity disorder (ADHD), making it one of the most common childhood disorders. Air pollutants could be considered an environmental risk condition for ADHD, but few studies have specifically investigated the effect of prenatal exposure. The current paper reviews the studies conducted on the association between prenatal air pollutants (PM, NO_x, SO₂, O₃, CO and PAH) and ADHD development in children. From the 890 studies searched through PubMed, Google Scholar, Scopus, and Web of Science, 15 cohort studies met the inclusion criteria. NOS and WHO guidelines were used for quality and risk of bias assessment. The accumulative sample was 589,400 of children aged 3-15 years. Most studies reported an association between ADHD symptoms and prenatal PAH and PM exposure. Data available on NO₂ and SO₂ were inconsistent, whereas the effect of CO/O₃ is barely investigated. We observed heterogeneity through an odd ratio forest plot, and discrepancies in methodologies across the studies. Eight of the fifteen studies were judged to be of moderate risk of bias in the outcome measurement. In a nutshell, future studies should aim to minimize heterogeneity and reduce bias by ensuring a more representative sample, standardizing exposure and outcome assessments.

The Association of Socioeconomic Vulnerability and Race and Ethnicity With Disease Burden Among Children in a Statewide Medicaid Population

OBJECTIVE

Individuals enrolled in Medicaid have disproportionately worse health outcomes due to challenges related to Social Determinants of Health. We aim to examine the prevalence of 3 childhood conditions (asthma, type 2 diabetes, and attention deficit hyperactivity disorder [ADHD]) in children within the Texas Medicaid system. In order to recognize the layers of vulnerability, we examine prevalence at the intersection of socioeconomic status with race and ethnicity within this economically challenged population.

METHODS

Children ages 0 to 17 were identified from claims and encounter data for all children enrolled in Texas Medicaid in 2017 for at least 6 months. All children were placed into one of 5 quintiles based on their census tract socioeconomic vulnerability. The Rate Ratio statistical test was employed to identify the statistical significance of the disparity in health outcomes related to higher neighborhood vulnerability within each racial or ethnic group.

RESULTS

Asthma for each race and ethnicity group was significantly more prevalent in the higher vulnerability census tracts. Increased vulnerability related to significant increase in type 2 diabetes for Hispanic children, but not for other groups. Diagnosed ADHD prevalence was significantly higher in less vulnerable non-Hispanic white children compared to more vulnerable.

CONCLUSIONS

This study found that even among children who receive Medicaid and are thus economically disadvantaged, socioeconomic vulnerability applies an additional burden within racial and ethnic groups to produce disparities in health-related burden. However, the trend of the relationship varied by race and ethnicity group and health condition.

County-level prevalence estimates of ADHD in children in the United States

PURPOSE

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood disorder often characterized by long-term impairments in family, academic, and social settings. Measuring the prevalence of ADHD is important as treatment options increase around the U.S. Prevalence data helps inform decisions by care providers, policymakers, and public health officials about allocating resources for ADHD. In addition, measuring geographic variation in prevalence estimates can facilitate hypothesis generation for future analytic work. Most U.S. studies of ADHD prevalence among children focus on national or demographic group rates.

METHODS

Using a small area estimation approach and data from the 2016 to 2018 National Survey of Children's Health, we estimated childhood ADHD prevalence estimates at the census regional division, state, and county levels. The sample included approximately 70,000 children aged 5-17 years.

RESULTS

The national ADHD rate was estimated to be 12.9% (95% Confidence Interval: 11.5%, 14.4%). Counties in the West South Central, East South Central, New England, and South Atlantic divisions had higher estimated rates of childhood ADHD (55.1%, 53.6%, 49.3%, and 46.2% of the counties had rates of 16% or greater, respectively) compared to counties in the Mountain, Mid Atlantic, West North Central, Pacific, and East North Central divisions (2.1%, 4%, 5.8%, 6.9%, and 11.7% of the counties had rates of 16% or greater, respectively).

CONCLUSIONS

These local-level rates are useful for decision-makers to target programs and direct sufficient ADHD resources based on communities' needs.

The effects of bilingualism on cognition and behaviour in individuals with attention deficits: A scoping review

Background

Weaknesses in executive function have persistently been found to be associated with Attention Deficit Hyperactivity Disorder (ADHD), while bilinguals have been argued to show advantages in executive functions. While there has been some research into how bilingualism affects cognitive skills and behaviour in individuals with attention deficits, the question is still very much open. The aim of this systematic review is to gather, synthesise and evaluate existing evidence on how bilingual language experience and attention deficits affect executive function performance and ADHD-related symptoms in children and adults.

Methods

Following PRISMA guidelines, a comprehensive literature search in relevant databases (PsycInfo, PubMed, Scopus, ERIC, Web of Science, EMBASE, MEDLINE, LLBA) was performed using search strings related to attention difficulties/ADHD and bilingualism. All quantitative studies were included that presented original empirical data on the combined effects of bilingualism and attention levels, regardless of age group and methodology. The screening procedure revealed nine relevant studies.

Results

Across the nine identified studies, a total of 2071 participants were tested. Of these, seven studies involved children and two adults. The studies varied considerably with respect to their design and methodology, the targeted executive function skills or behavioural symptoms, as well as their measure of bilingualism and attention levels. Most studies assessed aspects of executive function performance such as interference control, response inhibition, working memory or cognitive flexibility. Three studies looked at the effects of bilingualism on ADHD-related symptoms or ADHD diagnosis. Across the studies, no systematic advantage or disadvantage of bilingualism on cognitive performance or behaviour in people with attention deficits was observed.

Conclusion

The limited number of identified studies provide no consistent evidence that bilingualism alleviates or intensifies attention difficulties in adults or children with ADHD. Based on the current state of research, individuals with ADHD and their families should not be concerned that learning additional languages has a negative impact on functioning or cognitive performance.

Systematic review registration

https://doi.org/10.17605/OSF.IO/PK768.

Características das prescrições de metilfenidato em ambulatório de neuropediatria

RESUMO O metilfenidato não é disponibilizado pelo Sistema Único de Saúde (SUS), pois não faz parte da Relação Nacional de Medicamentos Essenciais. Todavia, o metilfenidato 10 mg é disponibilizado pela rede pública em Maringá-PR de acordo com a Política da Assistência Farmacêutica do município. Objetivou-se analisar as características das prescrições médicas de metilfenidato para crianças em ambulatório de neuropediatria vinculado ao SUS no município. Estudo transversal observacional retrospectivo de caráter quantitativo, realizado por meio da coleta de dados dos prontuários cadastrados no Sistema Gestor da rede pública de saúde do município, pelo ambulatório de neuropediatria na Unidade Básica de Saúde, Zona 7, entre janeiro de 2017 e novembro de 2019. Analisaram-se os dados por frequência relativa e absoluta. Emitiram-se 339 prescrições pelo neuropediatra responsável do ambulatório para 107 pacientes de 6 a 11 anos. Notou-se distribuição geográfica desigual das crianças atendidas conforme bairro da cidade, o que denota influência socioeconômica na prescrição de medicamentos. Ressaltam-se picos de prescrições coincidindo com o período do ano letivo escolar. Concluiu-se que o acompanhamento especializado adequado é premissa para o tratamento, não dispensando a rede longitudinal de assistência. Ademais, evidencia-se o impacto das condições socioeconômicas, tanto na prescrição como na aquisição do medicamento.

Postpartum depression and ADHD in the offspring: Systematic review and meta-analysis

BACKGROUND

Postpartum depression (PPD) is a disorder that has a severe impact on a woman's mental state and mood after birth. Research has shown that postnatal levels of family adversity and maternal psychopathology are associated with Attention Deficit Hyperactivity Disorder (ADHD). This paper is intended to examine the association among maternal PPD and the risk of ADHD in the offspring.

METHODS

Keyword search was conducted for PsycINFO, PubMed, Google Scholar, and Embase up to Feb 28, 2021; studies in English were deemed eligible. Random-effects meta-analysis and meta-regression analysis took place. Subgroup analyses by study design, geographical region, level of adjustment and study setting were performed.

RESULTS

Nine cohort studies and two case-control studies published from 2003 to 2019 were included in the qualitative synthesis; among them, eight studies were synthesized in the meta-analysis. Overall, maternal PPD was associated with an increased risk of ADHD in the offspring (pooled relative risk, RR = 1.69, 95%CI: 1.27-2.26). Significant associations were noted in the subsets of cohort studies, studies implementing multivariate analyses and registry-based surveys.

LIMITATIONS

Overall, a larger number of studies of the field are needed. Data collection relied on self-report and attrition bias limited the validity of eligible studies. Studies from developing countries were underrepresented. There was significant publication bias (p = 0.035, Egger's test).

CONCLUSIONS

The relationship between PPD and ADHD in children was found to be significant in this systematic review and meta-analysis and reveals the need for further investigation in various geographical regions.

PM2.5 exposure and incident attention-deficit/hyperactivity disorder during the prenatal and postnatal periods: A birth cohort study

Only a few studies have assessed the effects of fine particulate matter (PM_2.5) exposure during the prenatal and postnatal periods on the development of attention-deficit/hyperactivity disorder (ADHD). We investigated the association of exposure to PM_2.5 during pregnancy and early life with ADHD. This birth cohort consisted of 425,736 singleton live-term births between 2004 and 2015 in Taiwan. Daily PM_2.5 concentrations were derived from a 1-km satellite-based estimation model. A time-dependent Cox model was used to assess the effects of PM_2.5 on ADHD during the first, second, and third trimesters and from age 1-5 years after birth. The distributed lag nonlinear model was utilized to explore the dose-response relationship. Total 9,294 children were diagnosed with ADHD during the study period. The hazard ratio (HR) of ADHD was significantly associated with a 10 μg/m³ increase in PM_2.5 during the first trimester (HR = 1.26; 95% confidence interval [CI]: 1.13-1.40) and increased at PM_2.5 over 16 μg/m³. For postnatal periods, the HR of ADHD was significantly associated with increased PM_2.5 at the first to third year of life (HR ranged between 1.40 and 1.87). According to the dose-response relationship of exposure to PM_2.5 at the third year of life, the HR of ADHD was significantly associated with PM_2.5 above 16 μg/m³ and sharply increased as PM_2.5 >50 μg/m³. We did not observe a significant modification of sex on the relation between PM_2.5 and ADHD. Exposure of pregnant women to PM_2.5 above 16 μg/m³ from conception to the early life of their children may increase the risk of ADHD. The government should improve the criteria for air quality control and meet the WHO air quality guidelines to protect pregnant women and children from developing ADHD in the future.

Maternal pre-pregnancy obesity and offspring hyperactivity-inattention symptoms at 5 years in preterm and term children: a multi-cohort analysis

The objective of this study was to determine the relationship between maternal pre-pregnancy body mass index (BMI) and child hyperactivity-inattention symptoms (HIS) at 5 years, including preterm and term-born children, and to determine whether this association varied with gestational age. Maternal pre-pregnancy BMI and offspring HIS were assessed in 10,898 participants born ≥ 33 weeks of gestation from the ELFE cohort and 2646 children born between 23 and 34 weeks from the EPIPAGE 2 cohort. Reported pre-pregnancy weight (kg) and measured height (m) were collected from mothers at inclusion and used to classify BMI (kg/m²). Child HIS were evaluated using the Strengths and Difficulties Questionnaire around 5 years of age. Logistic regression estimated odds ratios (OR) of a high HIS score (≥ 90th percentile) in the ELFE cohort and generalized estimated equations were used in EPIPAGE 2 to account for non-independence of multiple births. As a negative control, paternal BMI was also considered as an exposure of interest in sensitivity analyses. Maternal pre-pregnancy obesity and overweight were associated with child HIS at 5 years in ELFE (adjusted OR [aOR] for obesity 1.27 [1.06, 1.53]; overweight aOR 1.16 [1.00, 1.36]) and pre-pregnancy obesity was associated with high HIS scores in preterm infants of EPIPAGE 2 (aOR 1.48 [1.06, 2.08]). In ELFE, the magnitude of the association increased with decreasing gestational age (interaction p = 0.02). High maternal pre-pregnancy BMI is associated with greater likelihood of high HIS scores in both at-term and preterm children at 5 years of age.

Prenatal smoking, alcohol and caffeine exposure and offspring externalizing disorders: a systematic review and meta-analysis

BACKGROUND AND AIMS

Several studies have indicated an association between maternal prenatal substance use and offspring externalizing disorders; however, it is uncertain whether this relationship is causal. We conducted a systematic review to determine: (1) if the literature supports a causal role of maternal prenatal substance use on offspring externalizing disorders diagnosis and (2) whether these associations differ across externalizing disorders.

METHODS

We searched Web of Science, Embase, PsycINFO and Medline databases. Risk of bias assessment was conducted using the Newcastle-Ottawa Scale (NOS), and where possible meta-analysis was conducted for studies classed as low risk of bias. We included studies of any design that examined prenatal smoking, alcohol or caffeine use. Studies in non-English language, fetal alcohol syndrome and comorbid autism spectrum disorders were excluded. Participants in the included studies were mothers and their offspring. Measurements included prenatal smoking, alcohol or caffeine use as an exposure, and diagnosis of attention-deficit hyperactivity disorder (ADHD), conduct disorder (CD) and oppositional defiant disorder (ODD) in offspring as an outcome.

RESULTS

We included 63 studies, 46 of which investigated smoking and ADHD. All studies were narratively synthesized, and seven studies on smoking and ADHD were meta-analysed. The largest meta-analysis based on genetically sensitive design included 1 011 546 participants and did not find evidence for an association [odds ratio (OR)_{1-9 cigarettes}  = 0.90, 95% confidence interval (CI) = 0.83-1.11; OR _{> 10 cigarettes}  = 1.04, 95% CI = 0.79-1.36). Studies on alcohol exposure in all the outcomes reported inconsistent findings and no strong conclusions on causality can be made. Studies on caffeine exposure were mainly limited to ADHD and these studies do not support a causal effect.

CONCLUSIONS

There appears to be no clear evidence to support a causal relationship between maternal prenatal smoking and offspring attention-deficit hyperactivity disorder. Findings with alcohol and caffeine exposures and conduct disorder and oppositional-defiant disorder need more research, using more genetically sensitive designs.

Socioeconomic deprivation in early life and symptoms of depression and anxiety in young adulthood: mediating role of hippocampal connectivity

BACKGROUND

Experience of early-life socioeconomic deprivation (ELSD) may increase the risk of mental disorders in young adulthood. This association may be mediated by structural and functional alterations of the hippocampus.

METHODS

We conducted a prospective cohort study on 122 participants of the European Longitudinal Study of Pregnancy and Childhood. Information about ELSD was collected via questionnaire from mothers during the first 18 months of participants' lives. At age 23-24, participants underwent examination by structural magnetic resonance imaging, resting-state functional connectivity and assessment of depressive symptoms (Mood and Feelings Questionnaire) and anxiety (Spielberger State-Trait Anxiety Inventory). The association of ELSD with brain outcomes in young adulthood was assessed with correlations, linear regression (adjusting for sex, socioeconomic position and mother's mental health) and moderated mediation analysis.

RESULTS

Higher ELSD was associated with greater depressive symptoms (B = 0.22; p = 0.001), trait anxiety (B = 0.07; p = 0.02) and lower global connectivity of the right hippocampus (B = -0.01; p = 0.02). These associations persisted when adjusted for covariates. In women, lower global connectivity of the right hippocampus was associated with stronger trait anxiety (B = -4.14; p = 0.01). Global connectivity of the right hippocampus as well as connectivity between the right hippocampus and the left middle temporal gyrus mediated the association between ELSD and trait anxiety in women. Higher ELSD correlated with a lower volume of the right hippocampus in men, but the volume of the right hippocampus was not related to mental health.

CONCLUSIONS

Early preventive strategies targeted at children from socioeconomically deprived families may yield long-lasting benefits for the mental health of the population.

Classifying Young Children with Attention-Deficit/Hyperactivity Disorder Based on Child, Parent, and Family Characteristics: A Cross-Validation Study

We aimed to identify subgroups of young children with differential risks for ADHD, and cross-validate these subgroups with an independent sample of children. All children in Study 1 (N = 120) underwent psychological assessments and were diagnosed with ADHD before age 7. Latent class analysis (LCA) classified children into risk subgroups. Study 2 (N = 168) included an independent sample of children under age 7. A predictive model from Study 1 was applied to Study 2. The latent class analyses in Study 1 indicated preference of a 3-class solution (BIC = 3807.70, p < 0.001). Maternal education, income-to-needs ratio, and family history of psychopathology, defined class membership more strongly than child factors. An almost identical LCA structure from Study 1 was replicated in Study 2 (BIC = 5108.01, p < 0.001). Indices of sensitivity (0.913, 95% C.I. 0.814−0.964) and specificity (0.788, 95% C.I. 0.692−0.861) were high across studies. It is concluded that the classifications represent valid combinations of child, parent, and family characteristics that are predictive of ADHD in young children.

Prenatal smoking, alcohol and caffeine exposure and maternal-reported attention deficit hyperactivity disorder symptoms in childhood: triangulation of evidence using negative control and polygenic risk score analyses

BACKGROUND AND AIMS

Studies have indicated that maternal prenatal substance use may be associated with offspring attention deficit hyperactivity disorder (ADHD) via intrauterine effects. We measured associations between prenatal smoking, alcohol and caffeine consumption with childhood ADHD symptoms accounting for shared familial factors.

DESIGN

First, we used a negative control design comparing maternal and paternal substance use. Three models were used for negative control analyses: unadjusted (without confounders), adjusted (including confounders) and mutually adjusted (including confounders and partner's substance use). The results were meta-analysed across the cohorts. Secondly, we used polygenic risk scores (PRS) as proxies for exposures. Maternal PRS for smoking, alcohol and coffee consumption were regressed against ADHD symptoms. We triangulated the results across the two approaches to infer causality.

SETTING

We used data from three longitudinal pregnancy cohorts: Avon Longitudinal Study of Parents and Children (ALSPAC) in the United Kingdom, Generation R study (GenR) in the Netherlands and Norwegian Mother, Father and Child Cohort study (MoBa) in Norway.

PARTICIPANTS

Phenotype data available for children were: NALSPAC  = 5455-7751; NGENR  = 1537-3119; NMOBA  = 28 053-42 206. Genotype data available for mothers was: NALSPAC  = 7074; NMOBA  = 14 583.

MEASUREMENTS

A measure of offspring ADHD symptoms at age 7-8 years was derived by dichotomizing scores from questionnaires and parental self-reported prenatal substance use was measured at the second pregnancy trimester.

FINDINGS

The pooled estimate for maternal prenatal substance use showed an association with total ADHD symptoms [odds ratio (OR)SMOKING  = 1.11, 95% confidence interval (CI) = 1.00-1.23; ORALCOHOL  = 1.27, 95% CI = 1.08-1.49; ORCAFFEINE  = 1.05, 95% CI = 1.00-1.11], while not for fathers (ORSMOKING  = 1.03, 95% CI = 0.95-1.13; ORALCOHOL  = 0.83, 95% CI = 0.47-1.48; ORCAFFEINE  = 1.02, 95% CI = 0.97-1.07). However, maternal associations did not persist in sensitivity analyses (substance use before pregnancy, adjustment for maternal ADHD symptoms in MoBa). The PRS analyses were inconclusive for an association in ALSPAC or MoBa.

CONCLUSIONS

There appears to be no causal intrauterine effect of maternal prenatal substance use on offspring attention deficit hyperactivity disorder symptoms.

Family, personal, parental correlates and behavior disturbances in school-aged boys with attention-deficit/hyperactivity disorder (ADHD): a cross-sectional study

BACKGROUND

To evaluate the relationship among family, personal, parental correlates, and behavioral disturbances in boys with attention-deficit/hyperactivity disorder (ADHD).

METHODS

We performed a hospital-based cross-sectional study. School-aged boys who first visited the hospital between 2000 and 2011 with ADHD were identified. Through medical records review, demographic information, family characteristics, personal characteristics, parental characteristics, and the Child Behavior Checklist (CBCL) collected during the first outpatient visit were retrieved. A T-score higher than 63 in the internalizing or externalizing subscale of the CBCL indicated severe behavioral disturbances in each domain. Multivariable logistic regression was used to evaluate the relationship between the correlates and behavioral disturbances. Eligible patients were further classified into groups without behavioral disturbance, with either only severe internalizing or only severe externalizing behaviors, or with both behaviors. Multivariable ordinal logistic regression was used to investigate the association between the correlates and the number of types of behavioral disturbances.

RESULTS

A total of 1855 boys with ADHD were included. In the multivariable logistic regression, family factors, including being first-born, living in a family not with both parents, and family history of mental disorder, were associated with severe internalizing and externalizing behaviors. Personal factors, including prenatal complications, perinatal complications, and medical and psychiatric comorbidities, were associated with severe internalizing behaviors, but only prenatal complications and medical comorbidities were associated with severe externalizing behaviors. Parental factors were only associated with severe externalizing behaviors. A higher paternal education level had a protective effect, but younger motherhood increased the risk. In ordinal logistic regression, these factors were also associated with more types of behavioral disturbances.

CONCLUSIONS

Multiple factors are related to behavioral disturbances in ADHD. Our study reported the association among family, personal, parental factors, severe internalizing behavior, severe externalizing behavior, and number of behavioral disturbances in boys with ADHD. However, the impacts differed as the behavior phenotypes varied. Further research is needed to better understand the heterogeneity of ADHD behavior.

The impact and causal directions for the associations between diagnosis of ADHD, socioeconomic status, and intelligence by use of a bi-directional two-sample Mendelian randomization design

BACKGROUND

Previous studies have reported associations between attention-deficit/hyperactivity disorder (ADHD) and lower socioeconomic status and intelligence. We aimed to evaluate the causal directions and strengths for these associations by use of a bi-directional two-sample Mendelian randomization (MR) design.

METHODS

We used summary-level data from the largest available genome-wide association studies (GWAS) to identify genetic instruments for ADHD, intelligence, and markers of socioeconomic status including the Townsend deprivation index, household income, and educational attainment. Effect estimates from individual genetic variants were combined using inverse-variance weighted regression.

RESULTS

A genetically predicted one standard deviation (SD) increment in the Townsend deprivation index conferred an odds ratio (OR) of 5.29 (95% confidence interval (CI) 1.89-14.76) for an ADHD diagnosis (p<0.001). A genetically predicted one SD higher education level conferred an OR of 0.30 (95% CI 0.25-0.37) (p<0.001), and a genetically predicted one SD higher family income provided an OR of 0.35 (95% CI 0.25-0.49; p<0.001). The associations remained after adjustment for intelligence whereas the lower odds of an ADHD diagnosis with higher intelligence did not persist after adjustment for liability to greater educational attainment (adjusted OR 1.03, 95% CI 0.68-1.56; p=0.87). The MR analysis of the effect of ADHD on socioeconomic markers found that genetic liability to ADHD was statistically associated with each of them (p<0.001) but not intelligence. However, the average change in the socioeconomic markers per doubling of the prevalence of ADHD corresponded only to 0.05-0.06 SD changes.

CONCLUSIONS

Our results indicate that an ADHD diagnosis may be a direct and strong intelligence-independent consequence of socioeconomic related factors, whereas ADHD appears to lead only to modestly lowered socioeconomic status. Low intelligence seems not to be a major independent cause or consequence of ADHD.

Prevalence of neurodevelopmental disorders and their impact on the health and social well-being among looked after children (LAC): a systematic review protocol

BACKGROUND

Looked after children (LAC) that are placed in either a foster, kinship, residential care setting or transition to adoption continue to develop debilitating disorders that significantly impact their overall health and social well-being. The prevalence of these disorders is often depicted under broad categories such as mental, behavioural or neurodevelopmental disorders (NDDs). Limited in research is the prevalence of what specific disorders fall under these broad categories. NDDs such as autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) which fall under an umbrella group in the expert field of genetics and neuropsychiatry will be explored. Unsupported, these disorders can lead to suboptimal health and social outcomes for both the child and family. In the general population, the prevalence of these NDDs and impacts on health and social well-being are relatively well documented, but for minority groups such as LAC, research is extremely limited. This review aims to estimate the prevalence of NDDs among LAC and explore how they might impact the health and social well-being of these vulnerable children. If feasible, the review will compare the prevalence rates to those children who are not looked after, to illuminate any differences or similarities between populations.

METHODS

PubMed, ASSIA, IBSS, Web of Science, PsychINFO, Scopus, Psych articles, Social Care Online, secondary, grey literature and government publications will be searched to identify any eligible studies. No restrictions will be placed on country, design or year of publication. Studies must provide primary data on the prevalence or incidence of NDDs for individuals < 25 years of age, supported by either a diagnostic code, standardised diagnostic assessment tool or survey response. The Joanna Briggs Institute (JBI) critical appraisal tools will be utilised to assess the quality and bias and the random-effects model used to estimate a pooled prevalence of NDDs.

DISCUSSION

Attaining an estimated prevalence of these NDDs and identifying any impacts on health and social well-being might inform key stakeholders in health, educational and social sectors with important information that might aid in the early identification and intervention to safeguard and meet the unique needs of these children.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD4201913103 .

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

OBJECTIVE

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Factors that mediate the relationships between household socio-economic status and childhood Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents: A systematic review

BACKGROUND

ADHD is one of the most prevalent mental health disorders among children and adolescents. Household socio-economic status (SES) in early childhood is inversely related to ADHD later in childhood or adolescence. We conducted a systematic review to examine psychological, social and behavioural factors that mediate these relationships (PROSPERO Registration number: CRD42020182832).

METHODS AND FINDINGS

We searched Medline, EMBASE, PsychINFo, and Web of Science from inception until May 2020. Both authors independently reviewed abstracts and identified papers for inclusion. We sought primary observational studies (cohort, cross-sectional and case control studies) of general population-based samples of children and adolescents aged 18 and under that investigated potential mediators of the relationships between SES and ADHD. Studies based upon non-general population-based samples, twins or biochemical/physiological changes were excluded. Direct and indirect effects derived from standard validated mediation analysis were extracted for potential mediators. We assessed risk of bias using a modified NIH tool and synthesised quantitative data without meta-analysis according to the (SWiM) protocol because of heterogeneity between included studies. Family adversity, paternal and maternal ADHD symptoms, Home Learning Environment, breastfeeding duration and a combined fine motor and language score at age 2 may lie on the SES-ADHD pathway. Evidence concerning the influence of maternal depression/anxiety and adverse parenting was inconsistent across studies. There was no evidence that mother's health-related behaviour, family characteristics, child's consumption of fizzy drinks or other developmental characteristics at birth/during infancy lie on the SES-ADHD pathway. Publication bias may have been introduced by our decision not to search grey literature, not to approach study authors and limit the search to the English language.

CONCLUSIONS

Evidence for mediation of the SES-ADHD pathway in childhood/adolescence is under-researched. Maternal mental health, family adversity, parenting and health-related behaviours warrant further research based on longitudinal data and employing the most advanced mediation analysis methods.

Associated Factors of Attention-Deficit/Hyperactivity Disorder Diagnosis and Psychostimulant Use: A Nationwide Representative Study

BACKGROUND

Connections between epidemiological findings and children's and adolescents' mental health policies have not been properly made in Brazil, and such nationwide studies are scarce. This epidemiological study (1) estimated the prevalence and predictors of parent-reported attention-deficit/hyperactivity disorder (ADHD) (ADHD-report), (2) estimated the probable diagnosis and risk of ADHD based on Diagnostic and Statistical Manual of Mental Disorders, 5th edition, criteria (ADHD-probable), and (3) estimated current psychostimulant use (ADHD-pst) in a representative nationwide sample of Brazilian school-aged children and adolescents.

METHODS

Data were obtained from 7114 school-aged children (49.9% boys) from 87 cities in 18 Brazilian states. Parents and teachers were interviewed using psychometrically sound questionnaires. Data and codes are available.

RESULTS

The prevalence of ADHD-report, ADHD-probable, and ADHD-pst were 7.1%, 3.9%, and 1.9%, respectively. The agreement was low between ADHD-probable and ADHD-report (22.6%) and between ADHD-report and ADHD-pst (15.6%). Logistic regression revealed that predictors of all three categories were male gender (odds ratio [OR] = 1.71, 2.32, and 1.96, respectively), divorced parents (OR = 1.47, 1.65, and 1.68, respectively), and below-expectation school performance (OR = 3.1, 13.74, and 3.95, respectively). Socioeconomic status was a significant predictor of ADHD-report, and participants from lower classes were less frequently diagnosed with ADHD than their peers from upper classes (OR = 0.57, 95% confidence interval = 0.37-0.88, P = 0.012).

CONCLUSIONS

The present findings provide an accurate description of ADHD in Brazil. We suggest disparities in agreement between report, risk, and psychostimulant use among children and adolescents and discrepancies between socioeconomic classes concerning the prevalence of an ADHD diagnosis.

The effect of special educational assistance in early childhood education and care on psycho-social difficulties in elementary school children

BACKGROUND

Three to seven percent of pre-schoolers have developmental problems or child psychiatric disorders. Randomized controlled trials (RCTs) indicate that interventions in early childhood education and care (ECEC) improve long-term outcomes of children from disadvantaged backgrounds. It is unknown if such effects generalize beyond the well-structured context of RCTs and to children who may not have a disadvantaged background but have developmental problems or psychiatric disorders.

METHODS

We used data from the population-based Norwegian Mother, Father and Child Cohort Study, recruiting pregnant women from 1999 to 2009, with child follow-up from ages 6, 18, and 36 months to ages 5, 7, and 8 years. This sub-study included 2499 children with developmental problems or psychiatric disorders at age five. We investigated the effects of special educational assistance at age five on mother-reported internalizing, externalizing, and communication problems at age eight. We analysed bias due to treatment by indication with directed acyclic graphs, adjusted for treatment predictors to reduce bias, and estimated effects in different patient groups and outcome domains with a hierarchical Bayesian model.

RESULTS

In the adjusted analysis, pre-schoolers who received special educational assistance had on average by 0.1 (0.04-0.16) standardised mean deviation fewer psycho-social difficulties in elementary school.

CONCLUSION

In a sample of children from mostly higher socioeconomic backgrounds we estimate a positive effects of special educational assistance during the transition from preschool to the school years. It may therefore be considered as an intervention for pre-schoolers with developmental or behaviour problems. More research with improved measurements of treatment and outcomes is needed to solidify the findings and identify success factors for the implementation of special educational assistance in ECEC.

What's race got to do with it? Informant rating discrepancies in neuropsychological evaluations for children with ADHD

OBJECTIVE

To evaluate race-based discrepancies in informant ratings and in rates of Attention-Deficit/Hyperactivity Disorder (ADHD) diagnosis among a clinically referred sample of Black and White children.

METHOD

Demographic information and ratings of inattention, hyperactivity/impulsivity, and conduct were collected from caregivers and teachers as part of neuropsychological evaluations at an outpatient clinic. The final sample included 3,943 children (6-18 years), of which 70% were White and 30% were Black.

RESULTS

Teachers, but not caregivers, endorsed more inattentive symptoms and conduct problems for Black than for White children, irrespective of ADHD diagnostic status and socioeconomic status (SES), and after controlling for child sex, child age, and learning difficulties. Teachers endorsed more hyperactive/impulsive symptoms for Black children with ADHD of lower SES than for White children with these characteristics. Caregivers of Black children of higher SES reported fewer hyperactive/impulsive symptoms than caregivers of White children of higher SES. Despite differences in teachers' ratings by race, diagnostic rates of ADHD in the context of neuropsychological evaluations were comparable for Black and White children.

CONCLUSIONS

Consistent with previous literature, teachers endorsed more ADHD and conduct problems in Black children. Within our clinically referred sample, this may reflect teacher bias rather than actual prevalence differences by rafce, given that Black caregivers endorsed fewer or similar numbers of symptoms relative to White caregivers. This lack of racial disparities in rates of ADHD diagnosis is inconsistent with findings in community- and population-based samples, and reflectspossible benefit of the use of neuropsychological evaluations in diagnostic decision-making for ADHD.

Social Determinants of Health and ADHD Symptoms in Preschool-Age Children

OBJECTIVE

Attention-Deficit/Hyperactivity Disorder (ADHD) disproportionately affects socioeconomically disadvantaged children, but for unclear reasons. We examined the association between social determinants of health (SDH) and ADHD symptoms in a national sample of preschool-age children.

METHODS

We conducted exploratory factor analysis (EFA) and exploratory structural equation modeling (ESEM) with a sample of 7,565 preschool-age children from the 2016 National Survey of Children's Health, to examine the association between ADHD symptoms and SDH.

RESULTS

EFA indicated a one-factor structure for ADHD symptoms, and three factors for SDH (socioeconomic status, access to basic needs, and caregiver well-being). Independently, all three SDH were significantly associated with higher ADHD symptoms. However, in the ESEM model, only worse caregiver well-being (β = .39, p < .01) was significantly associated with ADHD symptoms, and fully mediated the relationship between SDH and ADHD symptoms.

CONCLUSION

Addressing caregiver well-being in preschoolers with ADHD symptoms could be an early intervention strategy.

Educational level, attention problems, and externalizing behaviour in adolescence and early adulthood: the role of social causation and health-related selection-the TRAILS study

Social causation and health-related selection may contribute to educational differences in adolescents' attention problems and externalizing behaviour. The social causation hypothesis posits that the social environment influences adolescents' mental health. Conversely, the health-related selection hypothesis proposes that poor mental health predicts lower educational attainment. From past studies it is unclear which of these mechanisms predominates, as attention problems and externalizing behaviour have the potential to interfere with educational attainment, but may also be affected by differences in the educational context. Furthermore, educational gradients in mental health may reflect the impact of 'third variables' already present in childhood, such as parental socioeconomic status (SES), and IQ. We investigated both hypotheses in relation to educational differences in externalizing behaviour and attention problems throughout adolescence and young adulthood. We used data from a Dutch cohort (TRAILS Study; n = 2229), including five measurements of educational level, externalizing behaviour, and attention problems from around age 14-26 years. First, we evaluated the directionality in longitudinal associations between education, externalizing behaviour, and attention problems with and without adjusting for individual differences using fixed effects. Second, we assessed the role of IQ and parental SES in relation to attention problems, externalizing behaviour, and educational level. Attention problems predicted decreases in education throughout all of adolescence and young adulthood. Differences in parental SES contributed to increases in externalizing behaviour amongst the lower educational tracks in mid-adolescence. Childhood IQ and parental SES strongly predicted education around age 14. Parental SES, but not IQ, also predicted early adolescent attention problems and externalizing behaviour. Our results provide support for the health-related selection hypothesis in relation to attention problems and educational attainment. Further, our results highlight the role of social causation from parental SES in determining adolescent educational level, attention problems, and externalizing behaviour.

Attention Deficit Hyperactivity Disorder (ADHD) among elementary students in rural China: Prevalence, correlates, and consequences

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a widely recognized mental health problem in developed countries but remains under-investigated in developing settings. This study examines the prevalence, correlates, and consequences of ADHD symptoms among elementary school students in rural China.

METHODS

Cross-sectional data were collected from 6,719 students across 120 rural primary schools in China on ADHD symptoms, demographic characteristics, and academic performance in reading and math. ADHD symptoms were evaluated using the caregiver-reported ADHD Rating Scale-IV.

RESULTS

The prevalence of ADHD symptoms was 7.5% in our sample. Male students, students in lower grade levels, and students with lower cognitive ability showed a significantly higher prevalence of ADHD symptoms (ORs = 2.56, 2.06, and 1.84, respectively; p<0.05). Left-behind children showed a significantly lower prevalence of ADHD symptoms than did children who were living with their parents (OR = 0.74, p < 0.05). Adjusted regressions show that students with ADHD symptoms scored 0.12 standardized deviations lower in reading (p < 0.05) and 0.19 standardized deviations lower in math (p < 0.01).

LIMITATIONS

The ADHD Rating Scale-IV is a screening scale rather than a diagnostic test. Caregiver self-report measures also may underestimate ADHD symptoms for our sample.

CONCLUSIONS

ADHD is a common disorder among rural students in China and appears to be contributing to poor academic outcomes. The higher prevalence of ADHD among students with low cognitive ability also suggests that many rural children in China face multifactorial learning challenges. Taken together, the findings indicate a need for educators and policymakers in rural China to develop programs to reduce risk and support students with ADHD symptoms.

Attention-Deficit/Hyperactivity Disorder Symptoms and Community Violence Exposure in Russian Adolescents

A large body of research has shown that exposure to community violence is common for many children across the world. However, less is known about exposure in particular subgroups such as those children with developmental disorders. To address this research gap, the aim of this study was to examine community violence exposure (CVE) in adolescents with attention-deficit/hyperactivity disorder (ADHD) symptoms and the role of gender in this association. Data were analyzed from 2,782 adolescents aged 13 to 17 years from Arkhangelsk, Russia that were collected during the Social and Health Assessment (SAHA). ADHD status was assessed with the hyperactivity/inattention scale of the Strengths and Difficulties Questionnaire (SDQ). Information was obtained on past-year witnessing and violence victimization in the community. Results showed that CVE was more prevalent in children with ADHD symptoms. Specifically, 75.1% of children with ADHD symptoms had been exposed to any violence versus 62.3% in the non-ADHD group (χ² = 18.65, p < .001). Multivariate analyses of covariance (MANCOVAs) revealed that CVE was significantly higher for adolescents with ADHD symptoms for both witnessing and victimization, while exposure was significantly higher for ADHD boys compared with girls. The findings of this study suggest that CVE may be elevated in adolescents with higher ADHD symptoms. Given that CVE has been associated with a variety of negative social and psychological outcomes in typically developing children, an important task for future research is to determine what factors are associated with CVE in adolescents with ADHD symptoms including those relating to such phenomena as comorbid psychopathology, the family, and peer relations, so that interventions can be designed and implemented to reduce CVE and its detrimental effects in this population.

Incidence of Attention Deficit Hyperactivity Disorder (ADHD) Diagnoses in Navarre (Spain) from 2003 to 2019

(1) Background: Attention deficit hyperactivity disorder (ADHD) constitutes one of the leading mental health and behavioral disorders in childhood and adolescence. The main objective of this study was to analyze the time trend in the incidence of ADHD diagnoses in Navarre (Spain) from 2003 to 2019 in children and adolescents from 5 to 19 years old. Additionally, the seasonal trends of ADHD incidence and ADHD prevalence were determined. (2) Methods: A population-based observational retrospective study, which included people born between 1991 and 2011 and who attended compulsory education between 2007 and 2017 in Navarre (Spain), was carried out with data from both the Education and Health Department databases. (3) Results: The incidence rate increased from 4.18 cases per 1000 person-years in 2003 to 7.43 cases per 1000 person-years in 2009, before decreasing progressively to 2.1 cases per 1000 person-years in 2019. A peak incidence rate at 7–8 years of age was observed, which is consistent across the study period and for both genders. Males were more than twice as likely to be diagnosed with ADHD than females, with similar time trends in both. A seasonal pattern in ADHD diagnosis was found, with peaks in February–March and the lowest rates in the summer months. Inattentive cases were much more frequent than hyperactive cases, whereas combined cases remained low across the study period. (4) Conclusions: In this age-period-cohort analysis, a clear period and age effect was observed. We found a decreasing trend in the ADHD incidence rate since 2015. Further research is needed to confirm whether a change of trend is occurring globally.

Attention Deficit/Hyperactivity Disorder and Associated Factors Among Children Attending Pediatric Outpatient Departments of West Shewa Zone Public Hospitals, Central Ethiopia

Background

Attention deficit/hyperactivity disorder is a common childhood-onset neurodevelopmental disorder that affects the child’s psychosocial, educational, neuropsychological functioning self-esteem and quality of life from childhood to adulthood. It is estimated to affect about 5% of children and a third leading cause of disabilities.

Objective

To assess the prevalence of attention deficit/hyperactivity disorder and its associated factors among children attending pediatric OPD in hospitals found in West Shoa zone, Central Ethiopia, 2020.

Methods

Institution-based cross-sectional study was conducted from January 2020 to February 2020 among 422 children attending pediatric OPD in selected hospitals in West Shewa Zone and disruptive behavioral rating scale was used to collect data. OPD (out patient department) is section of hospital where patients who receive treatment without staying overnight are seen. Data were entered into Epi info version 7.1.2 and exported to SPSS version 21 for analysis. Descriptive statistics were done. Bivariate logistic regression was done to examine the relationship between different independent variables with attention deficit/hyperactivity disorder. Variable with p-value <0.05 was taken as statistically significant.

Results

The prevalence rate of attention deficit/hyperactivity disorder (ADHD) among children attending pediatric OPD was 8.4%, 95% CI (5.9, 11.1). Being male (AOR= 3.35, 95% CI (1.52, 7.38), age 6–11 (AOR=3.38 CI (1.22, 9.39)), having a family size greater than five (AOR=3.95, CI (1.44, 10.11)), low family income (AOR=3.47, 95% CI (1.25, 10.10), presence of one or more psychosocial stressors (AOR=4.50, 95% CI (1.77, 9.42)), family history of mental illness (AOR= 3.6, 95% CI (1.78, 8.21)) and mothers having complication during pregnancy (AOR= 3.05, CI (1.10, 8.48)) were factors found to be associated with ADHD.

Conclusion

Prevalence of attention deficit/hyperactivity disorder in this study is higher than global prevalence. This study has shown us ADHD is a public health issue that requires great emphasis and it is found to be associated with being male, younger age, large family size, low family income, psychosocial stressors, family history of mental illness and complication of pregnancy are factors associated with ADHD.

ADHD symptomatology of children with congenital heart disease 10 years after cardiac surgery: the role of age at operation

BACKGROUND

The aim of the present study was to investigate the differences in ADHD symptomatology between healthy controls and children who underwent cardiac surgery at different ages.

METHODS

Altogether, 133 children (54 patients with congenital heart disease undergoing first cardiac surgery under 3 years of age, 26 operated at the age of 3 or later, and 53 healthy controls) were examined. Patients completed the Youth Self Report (YSR), while their parents completed the Child Behaviour Checklist (CBCL) and the ADHD Rating Scale-IV.

RESULTS

Children receiving surgery for the first time under the age of 3 years were more likely diagnosed with cyanotic type malformation and have undergone to a greater number of operations. However, ADHD symptoms of those treated surgically at or above 3 years of age were more severe than that of the control group or those who were treated surgically at a younger age. The control group and those treated surgically below the age of three did not differ across any of the ADHD symptom severity indicators.

CONCLUSIONS

The age at the time of cardiac surgery might be associated with later ADHD symptom severity - with lower age at operation associated with better outcomes. Further, adequately powered studies are needed to confirm these exploratory findings and investigate the moderators of this relationship.

The whole is greater than the sum of its parts: profiles of multiple mental health risk factors using Latent class analysis

BACKGROUND

The exposure to an accumulation of various risk factors during childhood and adolescence relative to a single risk is associated with poorer mental health. Identification of distinct constellations of risk factors is an essential step towards the development of effective prevention strategies of mental disorders. A Latent class analysis (LCA) extracts different combinations of risk factors or subgroups and examines the association between profiles of multiple risk and mental health outcomes.

METHODS

The current study used longitudinal survey data (KiGGS) of 10,853 German children, adolescents and young adults. The LCA included 27 robust risk and protective factors across multiple domains for mental health.

RESULTS

The LCA identified four subgroups of individuals with different risk profiles: a basic-risk (51.4%), high-risk (23.4%), parental-risk (11.8%) and social-risk class (13.4%). Multiple risk factors of the family domain, in particular family instability were associated with negative mental health outcomes (e.g. mental health problems, depression, ADHD) and predominately comprised late adolescent girls. The social environment represented a more common risk domain for young males.

CONCLUSION

The understanding of multiple risk and different risk "profiles" helps to understand and adjust targeted interventions with a focus on vulnerable groups.

Racial Disparities in Diagnosis of Attention-Deficit/Hyperactivity Disorder in a US National Birth Cohort

IMPORTANCE

There are limited data on the racial disparities in the incidence of attention-deficit/hyperactivity disorder (ADHD) diagnosis in children at the national level.

OBJECTIVE

To explore differences in rates of diagnosis of ADHD and use of treatment among children by race and ethnicity.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study assessed insurance claims data of children born in the US between January 1, 2006, and December 31, 2012, who had continuous insurance coverage for at least 4 years. The last date of follow-up included in the cohort was June 30, 2019. Race/ethnicity designations were based on self-report and included non-Hispanic White, Black, Hispanic, and Asian. Data were analyzed between October 2019 and December 2020.

EXPOSURES

Race and ethnicity.

MAIN OUTCOMES AND MEASURES

ADHD diagnosis as defined by International Classification of Diseases codes (ninth or tenth editions) and treatment within 1 year of diagnosis, including medication and behavior therapy as defined by billing codes. Data on ADHD diagnosis and treatment were adjusted for sex, region, and household income in a multivariate Cox regression model.

RESULTS

Among 238 011 children in the cohort (116 093 [48.8%] girls; 15 183 [6.7%] Asian, 14 792 [6.2%] Black, 23 358 [9.8%] Hispanic, and 173 082 [72.7%] White children), 11 401 (4.8%) were diagnosed with ADHD. The cumulative incidence at age 12 was 13.12% (95% CI, 12.79%-13.46%). In multivariate Cox regression adjusting for sex, region, and household income, the hazard ratio for Asian children was 0.48 (95% CI, 0.43-0.53); Black children, 0.83 (95% CI, 0.77-0.90); and Hispanic children, 0.77 (95% CI, 0.72, 0.82) compared with White children. In the first year after diagnosis, 516 preschool children (19.4%) received behavioral therapy only, 860 (32.4%) had medications only, 505 (19.0%) had both, and 774 (29.2%) had no claims associated with either option. A higher percentage of school-aged children (2904 [65.6%]) were prescribed medications, and fewer had therapy only (639 [14.4%]) or no treatment at all (884 [20.0%]). Compared with other groups, White children were more likely to receive some kind of treatment. Asian children had the highest odds of receiving no treatment (odds ratio compared with White children, 0.54; 95% CI, 0.42-0.70).

CONCLUSIONS AND RELEVANCE

Racial and ethnic disparities in the diagnosis and treatment of ADHD are evident. Future study is needed to elucidate the mechanism behind these disparities, with special attention to Asian children. Clinicians should provide racially sensitive care in the evaluation and treatment of ADHD.

Risk of Colorectal Cancer in Patients With Attention-Deficit Hyperactivity Disorder: A Nationwide, Population-Based Cohort Study

Background: The association between attention-deficit hypersensitivity disorder (ADHD) and the risk of developing colorectal cancer (CRC) is, as yet, to be investigated, and thus, we have conducted this nationwide, cohort study to examine the association in patients from Taiwan. Methods: In this study, 798 individuals with newly diagnosed ADHD and 2,394 (1:3) age-, gender-, and index year- matched controls without ADHD were enrolled, between 2000 and 2013, from the Longitudinal Health Insurance Database, a subset of the National Health Insurance Research Database in Taiwan. The cumulative incidence of CRC was assessed in each cohort by the Kaplan-Meier method. The multivariate Cox proportional hazards model was used to estimate the crude, and the adjusted hazards ratios (HRs) with 95% confidence intervals (CIs), was conducted to estimate the association between ADHD and CRC. Results: The Kaplan-Meier analysis revealed that the cumulative incidence of CRC was significantly higher in patients with ADHD than in those without it (log rank test, p < 0.001). After adjustments for age, gender, comorbidities, and other covariates, the ADHD group was associated with an increased risk of CRC in comparison to the non-ADHD group (adjusted HR = 3.458, 95% CI = 1.640-7.293, p < 0.001). In addition, the usage of methylphenidate was not associated with the risk of developing CRC in patients with ADHD. Conclusion: This retrospective cohort study depicts the evidence that ADHD was associated with the increased risk of CRC. Further studies are needed to confirm the association and the underlying mechanisms.