Diagnosis and management of ADHD: a pediatric perspective on practice and challenges in Switzerland

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders in childhood. In Switzerland, the complex diagnosis and treatment are being carried out by adolescent-/child psychiatrists, and pediatricians. Guidelines recommend a multimodal therapy for patients with ADHD. However, it has been questioned whether health professionals follow this approach or favor drug therapy. This study aims to provide insights into the practice of pediatricians in Switzerland regarding diagnosis and treatment of ADHD and their perceptions of these processes.

METHOD

An online survey (self-report) about current practices of diagnosis and management as well as challenges regarding ADHD was distributed to office-based pediatricians in Switzerland. One hundred fifty-one pediatricians participated. Results show that therapy options were almost always discussed with parents and older children. Exchange with parents (81%) and level of child's suffering (97%) were central when selecting therapy options.

RESULTS

Therapies about which pediatricians informed most often were: pharmacological therapy, psychotherapy, and multimodal therapy. Challenges voiced were the subjectivity of diagnostic criteria and dependence on third parties, low availability of psychotherapy, and a rather negative public attitude towards ADHD. Needs that were expressed were further education for all professionals, support for coordination with specialists and schools as well as improvement of information on ADHD.

CONCLUSIONS

Pediatricians do consider a multimodal approach when treating ADHD and take the families` and children's opinions into account. Improvements of the availability of child and youth psychotherapy, the strengthening of the interprofessional cooperation with therapists and schools, and efforts to increase public knowledge about ADHD are proposed.

Teachers’ mental health literacy and action competencies

Background

Teachers are very important in mental health promotion and early recognition of mental health burden (disorder, illness). Teachers’ surrogate mental health literacy (MHL) may be key to improving mental health in youth but has been little investigated. We assessed surrogate MHL in Swiss teachers and tested a measure of mental health action competencies (MHAC).

Methods

In 2020, all teaching and support staff at compulsory school level were invited to an online survey covering individual and professional characteristics, MHL (finding, understanding, critical appraisal of information) and action competencies (adapted scale Ahnert et al. 2016, range 17 - 68) personal experience with students’ MHB. Data was explored descriptively and with multivariate regression. Item response theory analyses were conducted to examine internal psychometric MHAC scale properties, and group-mean differences tested between school levels.

Results

Participation rate was 38% (N = 459). Nearly all participants had taught at least 1 mentally burdened student in the past year (average 4.7). 77% felt experienced to very experienced regarding these students. Only 32% felt they had sufficient tools and teaching resources. Participants felt it was difficult to very difficult to find (47%), understand (53%) and appraise (90%) information on students’ mental health. Kindergarden teachers and teachers without class responsibility showed significantly lower MHL. Internal psychometric properties of the MHAC measure support the use of a 1-factor scale and indicates discriminant validity with respect to age; experience and school level, median score was high (P50 48, P25 44, P75 53), but single items, e.g. on suicide signs, were rated low.

Conclusions

While overall subjective MHAC are high, teachers are insecure regarding MHL and report a lack of tools and resources. Targeted training could strengthen surrogate mental health literacy with a focus on critical appraisal and certain action competencies.

Toward a digital child health booklet

Public health, paediatrics as well as other health professionals share the interest in providing services and improving conditions to ensure life-long health and well-being of children and adolescents. In this interprofessional setting and aim, parents are central partners, as are adolescents when they take over the responsibility of their own health. Ensuring the availability of health data for parents and adolescents at any given time and place is a key factor to empower and improve health management and literacy, providing continuity of health information along the care chain, and analysing health data of healthy and sick children is of high importance. The digital booklet will have a positive impact on sharing of health information among care professionals, thus ensuring continuity of care and limiting redundancy of investigation, and in addition provide data for public health research and monitoring of health and determinants. The Swiss Society of Paediatrics, the ZHAW/Institute of Public Health and the Kollegium of Hausarztmedizin (general practices) founded an association to digitalize the current paper child and adolescent health booklet with the aims:

1. Empower parents as ‘owners’ of health data to take responsibility and have greater autonomy in managing their child's health and illness

2. Provide a digital infrastructure for

– low-threshold and reliable source of advice

– easy update of data/information, digital communication with parents

– sharing of data with professionals and non-professionals involved in care of child.

3. Monitoring of children's health data (parental consent provided)

The speakers with present their collaboration and project, its current status, as well challenges and solutions found.

COVID-19 containment measures impact utilization and provision of healthcare in Europe

Background

The COVID-19 containment measures, implemented to curb the pandemic, impacted health of children and adolescents by numerous pathways. We present the impact on health care utilization and provision.

Methods

A systematic review on secondary health impact is ongoing (PubMed, PsychInfo, Embase). Literature is screened (title, abstract, full-text) by 2 researchers, and data of interest extracted systematically.. Inclusion criteria are age (0 - 25 yrs.), exposure: containment measures, outcome: secondary health outcome, and European data origin.

Results

Jan. 2020 - Aug. 2021 10112 studies were identified, 337 were included. n = 60 were on health care utilization and provision. Utilization studies relied on objective hospital or registry data, care provision studies more often on survey data (professionals, parents). Data yields a large but varying decrease in emergency department visits during the lockdown: Italy ∼75%, Spain ∼65%, France ∼60%, and Germany ∼64%, and a substantial change in case mix and severity compared to comparable pre-COVID. Specialized and primary pediatric practices report that elective interventions were postponed, state of the art diagnostics withheld, and rehabilitation services disrupted. Vaccinations in infants, children, and adolescents dropped during the lockdown inversely proportional to children's age. Studies repeatedly suggest patients’ health services avoidance out of fear of infection and stay-at-home rules.Results on catch-up utilization and provision to follow (ongoing study).

Conclusions

COVID-19 measures exerted a measurable impact on health utilization and provision in children and adolescents. The utilization was comparatively lower and service provision disrupted across Europe. So far little can be said about a potential recovery in terms of catch-up of visits, diagnostics, or treatments. Analyses of the long-term health impact of the observed effects is recommended and can serve to improve future pandemic preparedness.

Key messages

• COVID-19 confinement measures had measurable secondary health impact on children and adolescents.

• Data on catch-up healthcare is important to establish long term impact and learnings.

Preventive and risky health behavior of Swiss university students during the COVID-19 pandemic

Background

Young adults are not considered a risk group for contracting COVID-19, but they are disproportionately affected by pandemic containment measures compared to other age groups. University students were confronted with abrupt changes both in their personal and academic lives. The “Health in Students during the Corona pandemic” study (HES-C) investigated the health and health behavior, concerns and views in students of the Zurich University of Applied Sciences. In the current analyses, we focused on COVID-19 related preventive behaviors, alcohol and marijuana consumption during the pandemic.

Methods

All students of the Zurich University of Applied Sciences (N = 12,429) were invited to a voluntary repeated cross-sectional open cohort survey which took place from the April 3 2020 (T0) to January 25 (T5), covering two university semesters with overall 6 surveys. Participation rates varied from T0 20% to T5 13%.

Results

While overall adherence to containment measures was high, men yielded lower adjusted odds (OR; 95%-CI) of adherence regarding the following measures: social distancing (0.68; 0.53-0.87), non-utilization of public transport (0.74; 0.56-0.97), 5-person limit for social gatherings (0.47; 0.35-0.64) and the stay at home rule (0.64; 0.51-0.82). In addition to gender, factors associated with adherence were information source and perceived susceptibility to the virus. Out of 80% who reported having drunk alcohol during the last 30 days at T0, 31% engaged at least once in binge drinking (>5 beverages) and 18% consumed more than usual. Marijuana was consumed by 11%, of which 27% reported higher use during the lock-down than before. Longitudinal data on risk behavior and factors associated with risk behavior and changes in behavior are currently being analyzed and will be presented.

Conclusions

Public health communication targeting university students should not only address pandemic related preventive behavior but also risk behavior during the pandemic.

Key messages

The pandemic has led to increased risky health behavior among certain students.

Public health communication targeting university students should not only address pandemic related preventive behavior but also risk behavior during the pandemic.

Mental health in Swiss university students during the COVID-19 pandemic

Background

University students were confronted with abrupt changes by the COVID-19 lock-down in their personal and academic lives. The “Health in Students during the Corona pandemic” study investigated the impact on mental health and health behaviors of Swiss university students.

Methods

April 2020 all students of the Zurich University of Applied Sciences (N = 12,431) were invited to a repeated cross-sectional open cohort survey, participation ranged from T0 20% - T5 13%. Generalized anxiety (GAD-7), stress (PSS) and depression (PHQ-9) were investigated with descriptive and multivariate analyses. Latent class analyses (LCA) was applied to identify groups who differed in perception of impact on daily and student life. PHQ-9 results were compared with pre-pandemic data matched for age, sex and education.

Results

At T0 mean age was 26.5 (sd 5.6), 69% were female. Participants were similar across all surveys. LCA yielded three classes of perceived impact: 1 (low, n = 675), 2 (moderate, n = 1098), and 3 (strong, n = 656). At T0 adjusted proportion of moderate to severe anxiety was significantly higher in class 3 (45% (95% CI: 28.0-62.0), compared to 2 (15.5%, 95% CI: 13.1-17.9) and 1 (5.1%, 95% CI: 4.7-5.6). Class 3 showed significantly higher odds of high stress levels (class 3: OR = 28.4; 95% CI: 15.5 - 52.0; p = 0.000; class 2: OR = 2.8; 95% CI: 1.5 - 5.3; p = 0.002) compared to other students. Anxiety and stress levels declined with time. The adjusted prevalence of depressive symptoms in females (30.8% (95% CI: 28.6-33.0)) and males (24.8% (95% CI: 21.7-28.1) was substantially higher than in a matching pre-pandemic national sample of young women (10.9% (95% CI: 8.9-13.2)) and men (8.5% (6.6-11.0)). Depressive symptoms between T0 and T3 did not decline.

Conclusions

Students reported high anxiety, stress and depressive symptoms during the pandemic. Depressive symptoms did not decline with time, indicating a continuing impact on mental health throughout the pandemic.

Health status and labour force participation among older workers: a growth curve analysis

Objectives

We investigate how individual trajectories of health status and labor force participation among older workers in Switzerland are interrelated and how this relationship varies by occupation.

Methods

We use data from the Swiss Household Panel (SHP) to analyze the long-term trajectories of older workers, measured in terms of working hours and general health status. The sample includes more than 7,000 workers aged 50 to 65(men)/64(women). We run a bivariate response multilevel model for growth that allows examining between- and within-individual changes over time.

Results

All occupational groups become more heterogeneous in terms of health status with increasing age. At the same time, working hours decrease in all occupational groups with increasing age. A look at the individual level indicates that the working hours of manual workers seem to be more dependent on their health status compared to those of non-manual workers and that this dependence increases over time. This result confirms our hypothesis that the labor market participation of manual workers is more sensitive to their health status.

Conclusions

Our findings contribute to the debate about the importance of older workers' health in the context of working life extension.

Key messages

All occupational groups become more heterogenous in terms of health status with increasing age, however working hours of manual workers seem to be more dependent on their health status. Manual workers experience a stronger effect of health on working hours and that this effect increases over time, therefore prevention of ill health may be particularly beneficial in manual workers.

Digital health information seeking of migrant populations – a scoping review

Background

As societies and health systems are increasingly digitally transformed, many health information are provided digitally. Digital health information may reduce barriers to health systems known to be more common in persons with a migrant than native origin. We performed a scoping literature to evaluate evidence on digital information seeking by migrant populations.

Methods

In January 2020 we conducted a literature search (Web of Science, MEDLINE, CINAHL) using terms and synonyms for migrants, health, digital media and information seeking, limited to publications in English. Two researchers independently rated first titles and then abstracts for suitability, obtaining consensus at each step. Primary target group, health topic and related life phase, country, and primary study question were extracted from remaining manuscripts. Data on digital health information seeking will be extracted from full texts.

Results

After title and abstract screening 41 from 315 articles remained. 25 articles focused primarily on migrant populations, 16 ran analyses by migrant status or ethnicity. Dominant populations were Latinos, Hispanics and Asians. Studies were performed in North America (n = 32), Europe, Asia and Australia (each n = 3). Seven papers were on maternal and child health, four on child and adolescent and 30 on adult health. Use of digital technologies is very frequent in most migrant populations. Impact of digital health information vs. traditional information was seldom investigated. In Adults general health, HIV and Cancer were most frequent topics. Further data on impact, preferences, barriers, and context will be presented.

Conclusions

Studies indicate frequent use of digital health information both on general health and specific health topics. The many North American studies indicate an advanced digital transformation of health promotion and care. Full texts will further reveal potential and limitations of digital information seeking and services for migrants.

Key messages

Digital health information seeking is common in migrant populations. Data on digital health information seeking is as heterogenous as migrant populations themselves, current evidence is limited to allow recommendations on design and implementation of such services.

Digital health literacy of health care profession students

Background

Digital transformation in health and health systems is a chance and a challenge for health professionals irrespective of their field. To maximize the benefit for patients high digital health literacy is required. A requirement not represented in health professions’ curricula in Switzerland. Little is known on the digital health competencies of students, on their utilization and views of digital media in the context of health, thus a cross-sectional survey was performed at a School of Health Professsions in Switzerland.

Methods

All BSc. students (N = 1200; nursing, midwifery, occupational health, physiotherapy and health promotion) received an online questionnaire covering utilization of various information resources, views on digital health & media and the German eHealth Literacy Scale (eHEALS, score 0 - 40). Descriptive and group analyses were performed, further adjusted analyses will be run.

Results

453 students responded (female N = 368, male N = 26). Participation was 38% and highest in 1st students. Personal health information resources used most were: internet 82%, familiy&friends 70%, health professionals 66%, textbooks 40%. A majority rated digital media as important (66%) or rather important (30%) for their future professional activities. The overall eHeals-score was 28.6 (sd 4.93); critical evaluation and confidence in applying information scored lowest. Preliminary group analyses show significant increase by study year (1st 28.0, 2nd 28.9, 3rd 29.7, p = 0.01), while scores by gender or health profession were non-significantly different.

Conclusions

Almost all students in health professions use digital media for their own health information needs and consider digital media as highly relevant for their future career. Critical evaluation skills need to be strenghtend. Digital Health Literacy is only slightly higher in 3rd year students. Longitudinal data are needed to differentiate cohort from learning effects.

Key messages

Digital media are increasingly important in health systems, a view shared by future health professionals. Data indicate only a small increase of digital health literacy across three years of study. Curricula should include digital health competencies to ensure a highly digitally skilled health work force.

Clinical markers of asthma and IgE assessed in parents before conception predict asthma and hayfever in the offspring

BACKGROUND

Mice models suggest epigenetic inheritance induced by parental allergic disease activity. However, we know little of how parental disease activity before conception influences offspring's asthma and allergy in humans.

OBJECTIVE

We aimed to assess the associations of parental asthma severity, bronchial hyperresponsiveness (BHR), and total and specific IgEs, measured before conception vs. after birth, with offspring asthma and hayfever.

METHODS

The study included 4293 participants (mean age 34, 47% men) from the European Community Respiratory Health Survey (ECRHS) with information on asthma symptom severity, BHR, total and specific IgEs from 1991 to 1993, and data on 9100 offspring born 1972-2012. Adjusted relative risk ratios (aRRR) for associations of parental clinical outcome with offspring allergic disease were estimated with multinomial logistic regressions.

RESULTS

Offspring asthma with hayfever was more strongly associated with parental BHR and specific IgE measured before conception than after birth [BHR: aRRR = 2.96 (95% CI: 1.92, 4.57) and 1.40 (1.03, 1.91), respectively; specific IgEs: 3.08 (2.13, 4.45) and 1.83 (1.45, 2.31), respectively]. This was confirmed in a sensitivity analysis of a subgroup of offspring aged 11-22 years with information on parental disease activity both before and after birth.

CONCLUSION & CLINICAL RELEVANCE

Parental BHR and specific IgE were associated with offspring asthma and hayfever, with the strongest associations observed with clinical assessment before conception as compared to after birth of the child. If the hypothesis is confirmed in other studies, parental disease activity assessed before conception may prove useful for identifying children at risk for developing asthma with hayfever.

The effects of growing up on a farm on adult lung function and allergic phenotypes: an international population-based study

RATIONALE

Evidence has suggested that exposure to environmental or microbial biodiversity in early life may impact subsequent lung function and allergic disease risk.

OBJECTIVES

To investigate the influence of childhood living environment and biodiversity indicators on atopy, asthma and lung function in adulthood.

METHODS AND MEASUREMENTS

The European Community Respiratory Health Survey II investigated ∼10 201 participants aged 26-54 years from 14 countries, including participants' place of upbringing (farm, rural environment or inner city) before age 5 years. A 'biodiversity score' was created based on childhood exposure to cats, dogs, day care, bedroom sharing and older siblings. Associations with lung function, bronchial hyper-responsiveness (BHR), allergic sensitisation, asthma and rhinitis were analysed.

MAIN RESULTS

As compared with a city upbringing, those with early-life farm exposure had less atopic sensitisation (adjusted OR 0.46, 95% CI 0.37 to 0.58), atopic BHR (0.54 (0.35 to 0.83)), atopic asthma (0.47 (0.28 to 0.81)) and atopic rhinitis (0.43 (0.32 to 0.57)), but not non-atopic outcomes. Less pronounced protective effects were observed for rural environment exposures. Women with a farm upbringing had higher FEV₁ (adjusted difference 110 mL (64 to 157)), independent of sensitisation and asthma. In an inner city environment, a higher biodiversity score was related to less allergic sensitisation.

CONCLUSIONS

This is the first study to report beneficial effects of growing up on a farm on adult FEV₁. Our study confirmed the beneficial effects of early farm life on sensitisation, asthma and rhinitis, and found a similar association for BHR. In persons with an urban upbringing, a higher biodiversity score predicted less allergic sensitisation, but to a lesser magnitude than a childhood farm environment.

Asthma and the menopause: a systematic review and meta-analysis

OBJECTIVE

To review the available literature to determine whether the menopausal transition is associated with asthma incidence.

METHODS

We performed a systematic review and meta-analysis of cohort and cross-sectional studies providing a definition/assessment of menopausal status, incidence or prevalence of a defined diagnosis of asthma, and providing a measure of the association or of menopausal state and asthma or enough data for a calculation of this association. Where possible these meta-analytic estimates were also stratified by intake of menopausal hormone therapy (MHT).

RESULTS

Of 76 potentially relevant articles, 8 studies met the inclusion criteria and were included in the review, and 6 in the meta-analysis. There was heterogeneity across studies: four studies reported slightly increased prevalence rates of asthma in post-menopause, one large cohort yielded a lower asthma incidence and one cross-sectional study a lower prevalence in post-menopause. Overall, the meta-analysis showed no significant association between menopause and asthma rates. When stratifying by use of MHT, the association between menopause and asthma rates was increased in women reporting use of MHT (RR 1.32, 95%CI 1.01-1.74), but not in women not using MHT.

CONCLUSION

We found no significant association of menopause with asthma prevalence or incidence except for women reporting use of MHT. However, these findings result from a small number of studies, including only 1 large cohort with incidence rates for pre- as well as post-menopause. Further studies are needed addressing more closely subgroup analyses and a possible modification of the association of menopause and asthma by MHT.

[Sexual health: variability in Switzerland and Europe]

Sexual Health is interrelated with both, sex and gender, through its biological dimension, its connection with cultural conventions, and its impact on women's health. Reproductive factors are presented from two cohorts, the Swiss SAPALDIA study and the European Community Respiratory Health Survey. Reproductive characteristics vary considerably across Switzerland and across Europe. A shift is observed towards lower ages at menarche and higher ages at menopause in younger cohorts. Smoking is the most important determinant of an early menopause. These secular trends imply that there will be changes also in the prevalence of diseases associated with age at menopause such as breast cancer and cardiovascular diseases.

Determinants of change in airway reactivity over 11 years in the SAPALDIA population study

We investigated determinants of change in bronchial reactivity in the Swiss Cohort Study on Air Pollution and Lung Diseases in Adults (SAPALDIA), a population-based cohort with wide age range (29-72 yrs at follow-up). The role of sex, age, atopic status, smoking and body mass index (BMI) on percentage change in bronchial reactivity slope from the baseline value was analysed in 3,005 participants with methacholine tests in 1991 and 2002, and complete covariate data. Slope was defined as percentage decline in forced expiratory volume in 1 s from its maximal value per micromole of methacholine. Bronchial hyperreactivity prevalence fell from 14.3 to 12.5% during follow-up. Baseline age was nonlinearly associated with change in reactivity slope: participants aged <50 yrs experienced a decline and those above an increase during follow-up. Atopy was not associated with change, but accentuated the age pattern (p-value for interaction = 0.038). Smoking significantly increased slope by 21.2%, as did weight gain (2.7% increase per BMI unit). Compared with persistent smokers, those who ceased smoking before baseline or during follow-up experienced a significant decrease in slope (-27.7 and -23.9%, respectively). Differing, but not statistically different, age relationships and effect sizes for smoking and BMI between sexes were found. Mean bronchial reactivity increases after 50 yrs of age, possibly due to airway remodelling or ventilation-perfusion disturbances related to cumulative lifetime exposures.

Vitamin D supplementation in Swiss infants

BACKGROUND

Various recent publications reported clinical manifestations of vitamin D deficiency in infants. Furthermore new research revealed additional properties of vitamin D for bone health and in the prevention of chronic diseases. However, prevalence data on actual supplementation rates are scarce. This study reports the prevalence of vitamin D supplementation in infants in Switzerland and presents risk factors for non-supplementation.

METHODS

In 2003, mothers of 2861 randomly selected infants aged 0-9 months received a questionnaire on infant feeding, including a question on vitamin D supplementation. The prevalence of vitamin D supplementation was calculated and its dependency on various factors analysed by multiple logistic regression.

RESULTS

64% of the infants had received vitamin D. The regression analysis yielded various significant risk factors for non-supplementation: young maternal age, German language region, Swiss nationality, siblings and breastfeeding. Protective factors were intake of folic acid during pregnancy and professional information on infant feeding. The protective effect of professional information varied significantly by region.

CONCLUSIONS

Given that the supplementation of vitamin D is recommended for all infants, the supplementation prevalence in Swiss infants is unsatisfactorily low. Various risk factors were identified and a positive impact of professional counselling on the supplementation rate could be demonstrated. In view of the new evidence emerging on additional preventive properties of vitamin D and the resurgence of rickets, the importance of vitamin D for infant health and ways to improve its promotion must be discussed anew.

Vitamin D supplementation in Swiss infants

BACKGROUND

Various recent publications reported clinical manifestations of vitamin D deficiency in infants. Furthermore new research revealed additional properties of vitamin D for bone health and in the prevention of chronic diseases. However, prevalence data on actual supplementation rates are scarce. This study reports the prevalence of vitamin D supplementation in infants in Switzerland and presents risk factors for non-supplementation.

METHODS

In 2003, mothers of 2861 randomly selected infants aged 0-9 months received a questionnaire on infant feeding, including a question on vitamin D supplementation. The prevalence of vitamin D supplementation was calculated and its dependency on various factors analysed by multiple logistic regression.

RESULTS

64% of the infants had received vitamin D. The regression analysis yielded various significant risk factors for non-supplementation: young maternal age, German language region, Swiss nationality, siblings and breastfeeding. Protective factors were intake of folic acid during pregnancy and professional information on infant feeding. The protective effect of professional information varied significantly by region.

CONCLUSIONS

Given that the supplementation of vitamin D is recommended for all infants, the supplementation prevalence in Swiss infants is unsatisfactorily low. Various risk factors were identified and a positive impact of professional counselling on the supplementation rate could be demonstrated. In view of the new evidence emerging on additional preventive properties of vitamin D and the resurgence of rickets, the importance of vitamin D for infant health and ways to improve its promotion must be discussed anew.