Identifying learning problems in children evaluated for ADHD: the Academic Performance Questionnaire

A Quality Improvement Initiative for Detection of Attention-Deficit/Hyperactivity Disorder in an Urban, Academic Safety Net Hospital

OBJECTIVE

Improve detection of Attention Deficit/Hyperactivity Disorder (ADHD) in a safety net, hospital-based, academic pediatric practice by optimizing screening with the Pediatric Symptom Checklist attention score (PSC-AS) and further evaluation with the Vanderbilt ADHD Diagnostic Rating Scale (VADRS).

METHODS

We implemented a multi-component intervention by (1) optimizing electronic medical record (EMR) features; (2) adjusting clinic operational workflow; and (3) creating a decision-making algorithm for pediatric primary care clinicians (PPCCs). We extracted 4 outcomes manually from the EMR (pediatrician acknowledgment of a positive PSC-AS, documentation of a plan for further evaluation, distribution of VADRS, and completion of at least 1 VADRS). Outcomes were measured monthly in run charts compared to the pre-intervention control period, and implementation was optimized with Plan-Do-Study-Act cycles.

RESULTS

PPCCs were significantly more likely to acknowledge a positive PSC-AS in the intervention versus control (65.3% vs 41.5%; p < 0.001), although this did not change documentation of a plan (70% vs 67.1%; p -value = 0.565). Significantly more children with a positive PSC-AS were distributed a parent or teacher VADRS in the intervention versus control (30.6% vs 17.7%; p -value = 0.0059), but the percentage of returned VADRS rating scales did not improve (12.9% vs 9.2%; p -value = 0.269).

CONCLUSION

Our ADHD detection quality improvement initiative improved use of the PSC-AS to identify attention problems and distribution of VADRS diagnostic rating scales, but additional interventions are needed to improve the completion of ADHD evaluations in primary care to ensure that children are appropriately identified and offered evidence-based care.

Linguistic Inequities in ADHD Diagnosis among School-age Children Screened for Attention Problems in Primary Care

INTRODUCTION

Attention deficit/hyperactivity disorder (ADHD) remains underidentified among racial/ethnic minoritized populations. We examined whether parent reported screening questionnaires for attention problems in primary care mitigated these ADHD diagnostic inequities and identified contributing sociodemographic and clinical factors.

METHODS

We conducted a cross-sectional electronic medical record (EMR) study in an urban, hospital-based primary care pediatric clinic of school age children (N=2212) with a completed Pediatric Symptom Checklist (PSC-17). We examined differences between children with vs. without ADHD diagnoses, adjusting for positive PSC-17 attention score.

RESULTS

Adjusting for positive PSC attention score, children had higher odds of an ADHD diagnosis if they were English-speaking and had a documented Vanderbilt ADHD Diagnostic Rating Scale in their medical record.

CONCLUSION

Multilingual, parent-report screening for attention problems in pediatric primary care does not mitigate linguistic inequities in ADHD diagnosis.

Collecting big data with small screens: Group tests of children's cognition with touchscreen tablets are reliable and valid

Collecting experimental cognitive data with young children usually requires undertaking one-on-one assessments, which can be both expensive and time-consuming. In addition, there is increasing acknowledgement of the importance of collecting larger samples for improving statistical power Button et al. (Nature Reviews Neuroscience 14(5), 365-376, 2013), and reproducing exploratory findings Open Science Collaboration (Science, 349(6251), aac4716-aac4716 2015). One way both of these goals can be achieved more easily, even with a small team of researchers, is to utilize group testing. In this paper, we evaluate the results from a novel tablet application developed for the Resilience in Education and Development (RED) Study. The RED-app includes 12 cognitive tasks designed for groups of children aged 7 to 13 to independently complete during a 1-h school lesson. The quality of the data collected was high despite the lack of one-on-one engagement with participants. Most outcomes from the tablet showed moderate or high reliability, estimated using internal consistency metrics. Tablet-measured cognitive abilities also explained more than 50% of variance in teacher-rated academic achievement. Overall, the results suggest that tablet-based, group cognitive assessments of children are an efficient, reliable, and valid method of collecting the large datasets that modern psychology requires. We have open-sourced the scripts and materials used to make the application, so that they can be adapted and used by others.

Children Learning About Secondhand Smoke (CLASS II): A Pilot Cluster Randomized Controlled Trial

Introduction

Children exposed to secondhand smoke (SHS) are at increased risk of respiratory illnesses. We piloted a Smoke Free Intervention (SFI) and trial methods before investigating its effectiveness and cost-effectiveness in primary school children.

Methods

In a pilot cluster randomized controlled trial in Bangladesh, primary schools were allocated to usual education (control) or SFI, using minimization. Year-5 children were recruited. Masking treatment allocation was not possible. Delivered by schoolteachers, SFI consisted of two 45-min and four 15-min educational sessions. Our primary outcome was SHS exposure at two months post randomization, verified by children’s salivary cotinine. The trial is registered at ISRCTN.com; ISRCTN68690577.

Results

Between April 1, 2015 and June 30, 2015, we recruited 12 schools. Of the 484 children present in Year-5, 481 consented. Six schools were allocated to both SFI (n = 245) and to usual education only (n = 236). Of them, 450 children (SFI = 229; control = 221) who had cotinine levels indicative of SHS exposure were followed-up. All schools were retained, 91% children (208/229) in SFI and 88% (194/221) in the control arm completed primary outcome assessment. Their mean cotinine at the cluster level was 0.53 ng/ml (SD 0.36) in SFI and 1.84 ng/ml (SD 1.49) in the control arm—a mean difference of −1.31 ng/ml (95% CI = −2.86 to 0.24).

Conclusion

It was feasible to recruit, randomize, and retain primary schools and children in our trial. Our study, though not powered to detect differences in mean cotinine between the two arms, provides estimates to inform the likely effect size for future trials.

Implications

In countries with high smoking prevalence, children remain at risk of many conditions due to secondhand smoke exposure. There is little empirical evidence on the effectiveness and cost-effectiveness of interventions that can reduce their exposure to secondhand smoke at homes. CLASS II trial found that a school-based intervention (SFI) has the potential to reduce children’s exposure to SHS—an approach that has been rarely used, but has considerable merit in school-based contexts. CLASS II trial provides key information to conduct a future definitive trial in this area of public health, which despite its importance has so far received little attention.

Children Learning About Secondhand Smoke (CLASS II): protocol of a pilot cluster randomised controlled trial

INTRODUCTION

Exposure to secondhand smoke (SHS) increases children's risk of acquiring chest and ear infections, tuberculosis, meningitis and asthma. Smoking bans in public places (where implemented) have significantly reduced adults' exposure to SHS. However, for children, homes remain the most likely place for them to be exposed to SHS. Additional measures are therefore required to protect children from SHS. In a feasibility study in Dhaka, Bangladesh, we have shown that a school-based smoke-free intervention (SFI) was successful in encouraging children to negotiate and implement smoking restrictions in homes. We will now conduct a pilot trial to inform plans to undertake a cluster randomised controlled trial (RCT) investigating the effectiveness and cost-effectiveness of SFI in reducing children's exposure to SHS.

METHODS AND ANALYSIS

We plan to recruit 12 primary schools in Dhaka, Bangladesh. From these schools, we will recruit approximately 360 schoolchildren in year 5 (10-12 years old), that is, 30 per school. SFI consists of six interactive educational activities aimed at increasing pupils' knowledge about SHS and related harms, motivating them to act, providing skills to negotiate with adults to persuade them not to smoke inside homes and helping families to 'sign-up' to a voluntary contract to make their homes smoke-free. Children in the control arm will receive the usual education. We will estimate: recruitment and attrition rates, acceptability, fidelity to SFI, effect size, intracluster correlation coefficient, cost of intervention and adverse events. Our primary outcome will consist of SHS exposure in children measured by salivary cotinine. Secondary outcomes will include respiratory symptoms, lung function tests, healthcare contacts, school attendance, smoking uptake, quality of life and academic performance.

ETHICS AND DISSEMINATION

The trial has received ethics approval from the Research Governance Committee at the University of York. Findings will help us plan for the definitive trial.

TRIAL REGISTRATION NUMBER

ISRCTN68690577.

Social and academic impairment in youth with ADHD, predominately inattentive type and sluggish cognitive tempo

Sluggish cognitive tempo (SCT) was originally identified as a construct that characterized the inattention problems of some children with attention deficit disorder (ADD). Research has indicated that using SCT symptoms to identify a subset of youth with attention-deficit/hyperactivity disorder, predominately inattentive type (ADHD-IT) may elucidate distinct patterns of impairment and thereby improve the external validity of ADHD subtypes. The objective of the current study was to investigate whether youth with clinically-assessed ADHD-IT and high levels of SCT exhibit unique social and academic impairments. In a clinic-referred sample of youth (N = 209; 23 % female) aged 6 to 17 years, participants who met criteria for three different groups were identified: ADHD, Combined Type (ADHD-CT; n = 80), ADHD-IT with low SCT symptoms (n = 74), and ADHD-IT with high SCT symptoms (n = 55). These groups were compared on indicators of social and academic functioning while considering the effects of co-occurring internalizing and disruptive behavior disorders. Youth with ADHD-IT high in SCT exhibited uniquely elevated withdrawal, as well as low leadership and low peer-directed relational and overt aggression, which were not accounted for by co-occurring disorders. This high-SCT group was also the only group to have more homework problems than the ADHD-CT group, but only when other disruptive behavior disorders were absent. The distinctiveness of the high-SCT group, which was primarily evident in social as opposed to academic functioning, provides partial support for the external validity and clinical utility of SCT.

Clinical utility of the Vanderbilt ADHD Rating Scale for ruling out comorbid learning disorders

OBJECTIVE

The goal was to examine the clinical utility of using the Vanderbilt Attention-Deficit/Hyperactivity Disorder (ADHD) Rating Scale (VARS) to determine when to refer children with ADHD for learning disorder (LD) evaluations.

METHODS

A total of 128 stimulant-naive children with ADHD, 7 to 11 years of age, were included in the study. The parents and teachers of 128 children with diagnosed ADHD completed the VARS. The reading, numerical operations, and spelling subtests from the Wechsler Individual Achievement Test, Second Edition, were used to identify children with a comorbid LD. We examined the predictive validity and clinical utility of the VARS performance items for ruling in/out the presence of a comorbid LD.

RESULTS

Thirty-eight percent of the samples met the criteria for a comorbid LD. A cutoff score of 7.5 for the sum of the VARS parent and teacher reading items had excellent clinical utility for ruling out both reading and spelling LDs. Cutoff scores of 4 for the VARS teacher reading and writing items had excellent utility for ruling out comorbid reading and spelling LDs, respectively. None of the VARS performance items effectively identified or ruled out math LDs.

CONCLUSION

The VARS performance items should be used with an interview about school functioning and a review of school records to rule out the presence of a comorbid reading or spelling LD for children with diagnosed ADHD.