Receipt of Behavioral Therapy in Preschool-Age Children with ADHD and Coexisting Conditions: A DBPNet Study

OBJECTIVE

Practice guidelines from the American Academy of Pediatrics and Society for Developmental and Behavioral Pediatrics recommend evidence-based behavioral therapy (BT) as first-line treatment for preschool-age children with ADHD, prior to medication initiation. Thus, this study's objective is to present the frequency of physician-documented receipt of BT in preschool-age children with ADHD prior to medication initiation and to determine factors associated with receipt BT receipt.

METHODS

This retrospective medical record review was conducted across 7 Developmental Behavioral Pediatrics Research Network (DBPNet) sites. Data were abstracted for children <72 months old seen by a DBP clinician and initiated on ADHD medication between 1/1/2013-7/1/2017. From narrative text of the medical records, BT receipt was coded as: parent training in behavior management (PTBM), Applied Behavior Analysis (ABA), other, or did not receive.

RESULTS

Of the 497 children in this study; 225 children (45%) had reported receipt of any BT prior to ADHD medication initiation, with 15.9% (n = 79) receiving PTBM. Children with co-existing diagnoses of ASD or disruptive behavior disorder were more likely to receive BT than children without co-existing conditions (59.3% vs 69.0% vs 30.6%). There was significant site variability in reported receipt of BT, ranging from 22.4% to 74.1%, and sex and insurance were not associated with BT rates.

CONCLUSION

The percentage of children with documented receipt of any BT, and particularly PTBM, was low across all sites and co-existing conditions. These findings highlight the universal need to increase receipt of evidence-based BT for all young children with ADHD.

Do Externalizing and Internalizing Symptoms Moderate Medication Response in Preschool Attention-Deficit/Hyperactivity Disorder? A DBPNet Study

OBJECTIVES

This study aimed to determine whether parent ratings of attention-deficit/hyperactivity disorder (ADHD) symptom severity or externalizing symptoms (EXT) or internalizing symptoms (INT) moderate response to stimulants (STIM) and alpha-2 adrenergic agonists (A2As) in preschool ADHD.

METHODS

Health records for children treated with medication for ADHD and with parent rating scale data available (N = 309; age <72 months) were reviewed at 7 Developmental-Behavioral Pediatric Research Network sites. Severity of ADHD was defined as the number of ADHD symptoms occurring often or very often on DSM-IV-based parent rating scales. EXT or INT from standardized rating scales were categorized as T score <60, 60 to <70, or ≥70. Ordinal logistic regression models predicting response to medication were calculated.

RESULTS

The median (interquartile range) age at ADHD diagnosis was 59 (54-65) months. One hundred eighty-three participants had ADHD symptom severity, and 195 had EXT or INT data. ADHD severity was not associated with medication response. Both EXT and INT were associated with medication response but with significant medication class by EXT/INT interactions. Children with higher EXT were less likely to respond to STIM, with percentage of nonresponders for T-score categories <60, 60 to <70, and ≥70 being 3.6%, 25.7%, and 33.3% (p = 0.016) and, for A2As, being 60%, 50%, and 33.3% (p = 0.55), respectively. A similar pattern was observed for INT categories: STIM 19.4%, 22.5%, and 50.0% (p = 0.002) and A2As 42.3%, 30%, and 42.3% (p = 0.48), respectively.

CONCLUSION

For preschool ADHD, low ratings of EXT or INT are associated with a high likelihood of response to STIM. By contrast, response rates to STIM and A2As are more similar for children with high levels of EXT or INT.

Adverse Effects of α-2 Adrenergic Agonists and Stimulants in Preschool-age Attention-deficit/Hyperactivity Disorder: A Developmental-Behavioral Pediatrics Research Network Study

OBJECTIVES

To characterize and compare the type and frequency of a range of common and uncommon adverse effects (AEs) associated with α-2 adrenergic agonist (A2A) and stimulant treatment of attention-deficit/hyperactivity disorder at preschool-age as well as to evaluate the impact of age on common AEs.

STUDY DESIGN

This was a retrospective electronic medical record review of children <72 months of age (n = 497) evaluated at outpatient developmental-behavioral pediatric practices at 7 US academic medical centers within the Developmental-Behavioral Pediatrics Research Network. Data on AEs were abstracted for children who had treatment initiated by a developmental-behavioral pediatrician with an A2A or stimulant medication between January 2013 and July 2017; follow-up was complete by February 2019.

RESULTS

A2A and stimulants had distinctive AE profiles. A2A compared with stimulants had a greater proportion with daytime sleepiness and headaches; stimulants had significantly greater proportions for most other AE, including moodiness/irritability, difficulty with sleep, appetite suppression, stomachaches, skin picking/repetitive behaviors, withdrawn behavior, and weight loss. Younger age was associated with disruptive behavior and difficulty with sleep.

CONCLUSIONS

Stimulants had a greater rate of most AEs compared with A2A. AE profiles, together with efficacy, should inform clinical decision-making. Prospective randomized clinical trials are needed to fully compare efficacy and AE profiles of A2A and stimulants.

Disproportionate Representation of Children of Color and Parents with Disabilities in the Child Welfare System: The Intersection of Race/Ethnicity, Immigration Status, and Disability

CASE

An almost 5-year-old girl is referred to a developmental-behavioral clinician for developmental evaluation because of language and learning concerns. Her developmental screening in the primary pediatrics office showed scores concerning for delays in communication, social-emotional, gross, and fine motor domains. Her mother has concerns about her language. Her mother's primary language is Spanish, but the patient and her siblings speak primarily English. She speaks in short phrases and sentences with grammatical errors. Her mother understands approximately 75% of what she says, and strangers understand approximately 50%. She uses gestures and facial expression, is social and friendly, demonstrates pretend play, and plays well with her siblings and other children her age. She has occasional meltdowns, but there are no other major behavioral concerns. She feeds herself with utensils and is able to dress herself. She toilet trained recently, at about age 4.5 years.She did not receive early intervention before age 3 years and had no previous evaluations. She did not attend preschool or child care. Her mother reported that they were referred to the school district twice, but she had trouble requesting the evaluation.She lives with her parents and 2 brothers. The patient's parents immigrated to the United States from Mexico 7 years ago. They are both farm workers, and extended family members are in Mexico. On reviewing family history, the clinician learns that the patient's mother had trouble learning and attended school until she was 12 years old. She did not receive extra help at school. The child's mother said that she forgets things and "has trouble with reading and writing fast." The patient's 10-year-old brother has an individualized education plan and is in a substantially separate classroom. He has inclusion activities of recess, art, and music. He receives speech-language therapy and academic support for reading and writing. The patient's mother becomes tearful and shares that Child Protective Services was notified because of her inability to request the school evaluation, but a case was not opened.Developmental evaluation reveals expressive language at a 33-month-old level and receptive language at a 39-month-old level. Cognitive testing shows extremely low verbal comprehension, borderline visual spatial skills, and fluid reasoning in the low average range. Working memory and processing speed fall in the borderline range. The clinician learns at a follow-up visit that the patient's mother was evaluated by state disability services and has mild intellectual disability.What is your next step in management? What feedback or resources would you provide to the pediatric clinician and family?

Racism as an Adverse Childhood Experience: An Interactive Workshop to Train Pediatricians to Address Racism in Clinical Care

OBJECTIVE

The objective of this study was to address critical gaps in pediatric medical education by developing and evaluating an interactive educational workshop on racism as an adverse childhood experience (ACE).

METHODS

A team of developmental-behavioral pediatrics professionals used a best-practice curriculum development model of Kern's 6 steps to develop the workshop curriculum. Based on a targeted needs assessment, goals and objectives to address the topics of race and racism in clinical practice were developed. A variety of educational strategies (e.g., audience polls, videos, didactic presentations, experiential activities, and peer-guided case-based discussion and practice) were used to appeal to varied learning styles. Selection of strategies was guided by self-determination theory, an adult learning model that addresses the needs of autonomy, competence, and relatedness. The workshop was implemented at 2 national pediatric meetings and evaluated using participant polls and written program evaluation.

RESULTS

The workshop curriculum was well-received. Participants endorsed improvements in comfort level in talking about race/racism and demonstrated a significant change in preparation or comfort level for skills-based activities, including counseling families and offering resources to address experiences with racism, postworkshop. Participants endorsed intent to change clinical practice by discussing the issues of race and indicated a desire to receive additional training.

CONCLUSION

An interactive educational workshop on racism as an ACE was effective in improving pediatric professionals' comfort level and self-rated skills. Desire for a longer educational session suggests receptivity to longitudinal approaches. Replication and refinement of the educational workshop could clarify effective components of this approach. We advocate for longitudinal training curricula that incorporate observable behavior change and skills to increase and further evaluate the impact. Health care provider education and training to implement antiracism efforts in clinical encounters with patients and families can serve as an entry point to the complex process of addressing racism at multiple levels in health care.

Responding to Discriminatory Patient Requests

CASE

Julia is a 13-year-old White adolescent girl who was referred for psychological counseling given concerns related to mood, nonadherence, and adjustment secondary to her new diagnosis of type 1 diabetes. The family lives in a rural town located several hours from the academic medical center where she was diagnosed. After several months on a waitlist, the family was contacted to schedule a telehealth appointment with a predoctoral psychology trainee. When the scheduler informed the mother that her daughter would be scheduled with Ms. Huang, the mother abruptly stopped the conversation stating, "I do not want to waste everyone's time" and initially declined the appointment offered. When the scheduler asked about her hesitance, the mother disclosed previous interactions with doctors at the hospital who were "not born in the United States" that she felt were "textbook" (e.g., smiling even when discussing a new chronic medical condition) and "hard to understand" (i.e., because of different dialect/accent). The mother shared that she found these experiences to be stressful and felt the interactions had negatively affected Julia's care. When informed about the length of the waitlist for another clinician, the mother agreed to initiate services with the trainee.The supervising psychologist shared the mother's concerns and comments with Ms. Huang. After discussion, Ms. Huang agreed to provide intervention services, "as long as the family was willing." During the initial telehealth sessions, Ms. Huang primarily focused on building rapport and strengthening the therapeutic alliance with the family. During this time, Julia's mother was reluctant to incorporate suggested parent management strategies at home. Julia also made minimal improvement in her medical management (i.e., A1c levels remained high), had difficulty using behavioral coping strategies, and experienced ongoing mood symptoms (i.e., significant irritability, sleep difficulties, and depressive symptoms). Ms. Huang began to wonder whether the family's resistance and inability to implement recommendations were in some part because of the family's initial concerns and reluctance to engage in therapy with her as a clinician.Should Ms. Huang address the previously identified concerns with the patient and her family? What should be considered when determining how to approach this situation to ensure provision of both the best care for this patient and support for this trainee?

α2-Adrenergic Agonists or Stimulants for Preschool-Age Children With Attention-Deficit/Hyperactivity Disorder

IMPORTANCE

Attention-deficit/hyperactivity disorder (ADHD) is diagnosed in approximately 2.4% of preschool-age children. Stimulants are recommended as first-line medication treatment. However, up to 25% of preschool-age children with ADHD are treated with α2-adrenergic agonist medications, despite minimal evidence about their efficacy or adverse effects in this age range.

OBJECTIVE

To determine the frequency of reported improvement in ADHD symptoms and adverse effects associated with α2-adrenergic agonists and stimulant medication for initial ADHD medication treatment in preschool-age children.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective electronic health record review. Data were obtained from health records of children seen at 7 outpatient developmental-behavioral pediatric practices in the Developmental Behavioral Pediatrics Research Network in the US. Data were abstracted for 497 consecutive children who were younger than 72 months when treatment with an α2-adrenergic agonist or stimulant medication was initiated by a developmental-behavioral pediatrician for ADHD and were treated between January 1, 2013, and July 1, 2017. Follow-up was complete on February 27, 2019.

EXPOSURES

α2-Adrenergic agonist vs stimulant medication as initial ADHD medication treatment.

MAIN OUTCOMES AND MEASURES

Reported improvement in ADHD symptoms and adverse effects.

RESULTS

Data were abstracted from electronic health records of 497 preschool-age children with ADHD receiving α2-adrenergic agonists or stimulants. Median child age was 62 months at ADHD medication initiation, and 409 children (82%) were males. For initial ADHD medication treatment, α2-adrenergic agonists were prescribed to 175 children (35%; median length of α2-adrenergic agonist use, 136 days) and stimulants were prescribed to 322 children (65%; median length of stimulant use, 133 days). Improvement was reported in 66% (95% CI, 57.5%-73.9%) of children who initiated α2-adrenergic agonists and 78% (95% CI, 72.4%-83.4%) of children who initiated stimulants. Only daytime sleepiness was more common for those receiving α2-adrenergic agonists vs stimulants (38% vs 3%); several adverse effects were reported more commonly for those receiving stimulants vs α2-adrenergic agonists, including moodiness/irritability (50% vs 29%), appetite suppression (38% vs 7%), and difficulty sleeping (21% vs 11%).

CONCLUSIONS AND RELEVANCE

In this retrospective review of health records of preschool-age children with ADHD treated in developmental-behavioral pediatric practices, improvement was noted in the majority of children who received α2-adrenergic agonists or stimulants, with differing adverse effect profiles between medication classes. Further research, including from randomized clinical trials, is needed to assess comparative effectiveness of α2-adrenergic agonists vs stimulants.

School Readiness in Preschoolers With Symptoms of Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To compare school readiness in preschoolers with and without attention-deficit/hyperactivity disorder (ADHD) symptoms using a comprehensive framework. We hypothesized that preschoolers with ADHD symptoms have higher odds of school readiness impairment.

METHODS

Children ages 4 to 5 years (n = 93) were divided into 2 groups on the basis of presence of ADHD symptoms (ADHD group, n = 45; comparison group, n = 48). School readiness was assessed through 10 component measures, including direct assessments and standardized questionnaires, regarding 5 school readiness domains: physical well-being and motor development, social and emotional development, approaches to learning, language, and cognition and general knowledge. Analysis of covariance compared group mean scores on component measures. Domain impairment was defined as score ≥1 SD from the test population mean in the unfavorable direction on ≥1 measure in the domain. School readiness impairment was defined as impairment in ≥2 of 5 domains. Logistic regression predicted impairment within domains and overall readiness.

RESULTS

The ADHD group demonstrated significantly worse mean scores on 8 of 10 component measures and greater odds of impairment in all domains except for cognition and general knowledge. Overall, 79% of the ADHD group and 13% of the comparison group had school readiness impairment (odds ratio 21, 95% confidence interval 5.67-77.77, P < .001).

CONCLUSIONS

Preschoolers with ADHD symptoms are likely to have impaired school readiness. We recommend early identification of school readiness impairment by using a comprehensive 5-domain framework in children with ADHD symptoms paired with targeted intervention to improve outcomes.

Behavior problems and executive function impairments in preterm compared to full term preschoolers

BACKGROUND

Children born preterm (PT) are at high risk for behavior problems and deficits in executive function (EF), a set of cognitive processes that guide goal-directed behaviors. Behavior differences have been found as early as 2 years in PT children; EF differences have been found in infancy. Whether behavior problems and EF deficits co-occur at young ages has not been fully investigated.

AIMS

To determine whether (1) PT children have more behavior problems and EF impairment than full term (FT) children and (2) larger proportions of PT children show behavior problems or EF impairments.

DESIGN/METHODS

PT (≤34 wks, n = 82) and FT (n = 79) preschoolers (mean age 4.4 years) completed an EF battery. Parents completed rating scales of behavior problems and EF skills. Mean scores and proportions with impairment were compared between groups. Logistic regression predicting to impairment defined odds ratios for PT/FT groups.

RESULTS

PT compared to FT had more problems on most behavior and EF scales and poorer EF scores on all tasks and greater proportion with impairments on most behavior scales, all EF ratings, and all EF tasks, p < .05. PT had elevated odds for impaired performance-based EF, parent-rated EF and CBCL scores compared to FT, p < .05. Within the PT group, EF impairments were twice as common as behavior impairment.

CONCLUSIONS

We recommend early identification of EF impairments in PT children. Future research should evaluate whether EF impairments serve as better early markers for later functional difficulties compared to behavior problems, as well as targets for intervention.

Executive Function in Relation to White Matter in Preterm and Full Term Children

Background: Executive function (EF) refers to cognitive abilities used to guide goal-directed behavior. Diffusion Tensor Imaging (DTI) provides quantitative characterization of white matter tracts in the brain. Children with preterm birth often have EF impairments and white matter injury. Aim: To examine the degree of association between EF scores and white matter fractional anisotropy (FA) as measured by DTI in children born preterm and term Study design: Cross-sectional study Subjects: Participants, 9-16 years of age, born preterm (n = 25; mean gestational age 28.6 weeks; mean birth weight 1,191 grams), and full term (n = 20) Outcome measures: White matter FA analyzed with Tract-Based Spatial Statistics, a technique that generates a skeleton representing the core of white matter tracts throughout the brain. Behavioral scores from EF tasks examining working memory, spatial memory capacity, and multiple skills from the Stockings of Cambridge. Results: The groups performed comparably on all tasks. In both groups, unfavorable working memory strategy scores were associated with lower FA. Other measures of EF were not associated with whole skeleton FA in either group in either direction. Conclusions: Strategy score on a spatial working memory task was associated with FA in preterm and full term children, suggesting common underlying neurobiology in both groups. Associations were found in frontal-parietal connections and other major tracts. Lack of associations between other EF tasks and FA may be due to variation in how children accomplish these EF tasks. Future research is required to fully understand the neurobiology of EF in children born preterm.

Sensory processing in preterm preschoolers and its association with executive function

BACKGROUND

Symptoms of abnormal sensory processing have been related to preterm birth, but have not yet been studied specifically in preterm preschoolers. The degree of association between sensory processing and other domains is important for understanding the role of sensory processing symptoms in the development of preterm children.

AIMS

To test two related hypotheses: (1) preterm preschoolers have more sensory processing symptoms than full term preschoolers and (2) sensory processing is associated with both executive function and adaptive function in preterm preschoolers.

STUDY DESIGN

Cross-sectional study.

SUBJECTS

Preterm children (≤34weeks of gestation; n=54) and full term controls (≥37weeks of gestation; n=73) ages 3-5years.

OUTCOME MEASURES

Sensory processing was assessed with the Short Sensory Profile. Executive function was assessed with (1) parent ratings on the Behavior Rating Inventory of Executive Function - Preschool version and (2) a performance-based battery of tasks. Adaptive function was assessed with the Vineland Adaptive Behavior Scales-II.

RESULTS

Preterm preschoolers showed significantly more sensory symptoms than full term controls. A higher percentage of preterm than full term preschoolers had elevated numbers of sensory symptoms (37% vs. 12%). Sensory symptoms in preterm preschoolers were associated with scores on executive function measures, but were not significantly associated with adaptive function.

CONCLUSIONS

Preterm preschoolers exhibited more sensory symptoms than full term controls. Preterm preschoolers with elevated numbers of sensory symptoms also showed executive function impairment. Future research should further examine whether sensory processing and executive function should be considered independent or overlapping constructs.

Impact of bilirubin-induced neurologic dysfunction on neurodevelopmental outcomes

Bilirubin-induced neurologic dysfunction (BIND) is the constellation of neurologic sequelae following milder degrees of neonatal hyperbilirubinemia than are associated with kernicterus. Clinically, BIND may manifest after the neonatal period as developmental delay, cognitive impairment, disordered executive function, and behavioral and psychiatric disorders. However, there is controversy regarding the relative contribution of neonatal hyperbilirubinemia versus other risk factors to the development of later neurodevelopmental disorders in children with BIND. In this review, we focus on the empiric data from the past 25 years regarding neurodevelopmental outcomes and BIND, including specific effects on developmental delay, cognition, speech and language development, executive function, and the neurobehavioral disorders, such as attention deficit/hyperactivity disorder and autism.

Executive function mediates effects of gestational age on functional outcomes and behavior in preschoolers

OBJECTIVE

To investigate the role of executive function (EF) skills, measured by parent-rating and performance-based instruments, as mediators of the effects of gestational age (GA) on functional outcomes and behavior symptoms in preterm (PT) and full-term (FT) preschoolers.

PATIENTS AND METHODS

Children born PT (n = 70; mean GA, 29.6 weeks; mean birth weight, 1365 g) were compared to children born FT (n = 79) on composite measures of EF (using the Behavior Rating Inventory of Executive Function and a performance-based EF battery), adaptive function, prereading skills, and behavior symptoms. For the entire sample, mediation analyses examined the effect of GA on the outcomes with EF as mediator.

RESULTS

Compared to children born FT, children born PT had significantly higher parent-rated EF scores and lower performance-based EF scores, both indicating more problems; furthermore, children born PT had lower adaptive function and prereading scores and more problematic behavior. GA contributed to adaptive function, prereading skills, and behavior symptoms for all children. EF acted as a mediator of GA for all 3 outcomes; different patterns emerged for parent-rated and performance-based EF evaluations. For adaptive function, both EF measures significantly mediated the effects of GA; for prereading skills, only performance-based EF was significant; for behavior symptoms, only parent-rated EF was significant.

CONCLUSIONS

We propose standard assessment of EF, using both parent-rating and performance-based EF measures, in young PT children and other children at the risk of EF impairments. EF skills are measurable, mediate important functional outcomes, and may serve as intervention targets.

Executive function is associated with social competence in preschool-aged children born preterm or full term

BACKGROUND

Executive function (EF), defined as higher-order cognitive processes used in planning and organizing actions and emotions, is often impaired in children born preterm. Few studies have assessed social competence, the processes and resources required to meet social demands and achieve social goals, in children born preterm. The relations between EF and social competence in preterm and full term preschoolers have not been well characterized.

AIMS

To characterize social competence and assess the relationship between EF and social competence in preschool-aged children born preterm or full term.

STUDY DESIGN

Cross-sectional study.

SUBJECTS

Study subjects had a history of preterm birth (≤34weeks of gestation) and birth weight <2500g (n=70). Controls were born full term (≥37weeks) (n=79).

OUTCOME MEASURES

Children completed a battery of EF tasks; a mean age-adjusted z-score for the battery was generated for each child. Parents rated child EF on one scale and child social competence on two standardized scales.

RESULTS

Compared to full term children, preterm children showed a lower mean EF battery z-score, poorer parent-rated EF, and poorer scores on the two social competence scales. In hierarchical multiple regression models, EF battery z-score and parent-rated EF made independent contributions to both measures of social competence. Preterm birth explained additional variance for one measure of social competence.

CONCLUSIONS

Standard assessment of EF skills and social competence in young preschool children, including children born preterm, may identify at-risk children for long-term social difficulties and may also provide targets for intervention.

Complementary assessments of executive function in preterm and full-term preschoolers

Executive functions (EFs) are interrelated cognitive processes that have been studied in relation to behavior, attention, academic achievement, and developmental disorders. Studies of EF skills assessed through parent report and performance-based measures show correlations between them ranging from none to modest. Few studies have examined the relationship between EF skills measured through parent report and performance-based measures in relation to adaptive function. The present study included preschool children born preterm as a population at high risk for EF impairments. Preschool children (N = 149) completed a battery of EF tasks that assess working memory, response inhibition, idea generation, and attention shifting or cognitive flexibility. Parents reported on children's EF and adaptive skills. Preterm children showed more parent-rated and performance-based EF impairments than did full-term children. The combined use of either parent report or performance-based measures resulted in the identification of a large number of children at risk for EF impairment, especially in the preterm group. Both parent report and performance-based EF measures were associated with children's adaptive function. EF skills are measurable in young child'ren, and we suggest that EF skills may serve as targets for intervention to improve functional outcomes. We recommend the use of both parent report and performance-based measures to characterize children's EF profiles and to customize treatment.

Effects of early language, speech, and cognition on later reading: a mediation analysis

This longitudinal secondary analysis examined which early language and speech abilities are associated with school-aged reading skills, and whether these associations are mediated by cognitive ability. We analyzed vocabulary, syntax, speech sound maturity, and cognition in a sample of healthy children at age 3 years (N = 241) in relation to single word reading (decoding), comprehension, and oral reading fluency in the same children at age 9-11 years. All predictor variables and the mediator variable were associated with the three reading outcomes. The predictor variables were all associated with cognitive abilities, the mediator. Cognitive abilities partially mediated the effects of language on reading. After mediation, decoding was associated with speech sound maturity; comprehension was associated with receptive vocabulary; and oral fluency was associated with speech sound maturity, receptive vocabulary, and syntax. In summary, all of the effects of language on reading could not be explained by cognition as a mediator. Specific components of language and speech skills in preschool made independent contributions to reading skills 6-8 years later. These early precursors to later reading skill represent potential targets for early intervention to improve reading.

Attention and internalizing behaviors in relation to white matter in children born preterm

OBJECTIVE

Diffusion tensor imaging (DTI) is a magnetic resonance imaging technique that provides quantitative characterization of white matter tracts in the brain. This study used DTI to examine the degree of association between parent-rated scores of attention, internalizing behaviors including anxiety symptoms, and externalizing behaviors and white matter fractional anisotropy (FA) in children born preterm.

METHODS

Participants were aged 9 to 16 years; 25 were born at <36 weeks of gestation (mean = 28.6 wk, birth weight = 1191 g) and 20 were full term. The authors analyzed the results using Tract-Based Spatial Statistics, a technique that generates a skeleton representing the core of white matter tracts throughout the brain. The authors examined the correlations between behavior scores and FA of (1) the whole skeleton and (2) the specific regions of interest.

RESULTS

In preterm children, scores on attention and internalizing behavior scales were each associated with whole skeleton FA and several regions of interest; unfavorable scores were consistently associated with lower FA. Externalizing behaviors were not associated with whole skeleton FA, but significant associations were found within a few regions of interest. The network of significant regions for attention and internalizing symptoms was widely distributed and overlapping. In full-term children, no associations of FA and behavior were significant.

CONCLUSIONS

Attention and internalizing behaviors in preterm children were associated with FA in a widely distributed overlapping network of white matter tracts, suggesting common underlying neurobiology. DTI contributes to understanding individual differences in attention and behavior characteristics in children born preterm.

Oculomotor assessments of executive function in preterm children

OBJECTIVE

To use objective, nonverbal oculomotor tasks to assess executive function and infer the neural basis of impairments in preterm children.

STUDY DESIGN

Cross-sectional study of preterm children age 9-16 years (n = 69; mean gestational age 29 weeks) and full-term controls (n = 43). Tasks assessed sensorimotor function (reflexive prosaccades); resistance to peripheral distracters (fixation); response inhibition, response preparation, and execution of a voluntary saccade (antisaccades); and spatial working memory (memory-guided saccades). Group differences were analyzed using ANOVA. We used linear regression to analyze the contributions of age, sex, gestational age, and white matter category to task performance.

RESULTS

Preterm children did not differ from controls on basic sensorimotor function, response inhibition, and working memory. Compared with controls, preterm children showed greater susceptibility to peripheral distracters (P = .008) and were slower to initiate an inhibitory response (P = .003). Regression models showed contributions of age and white matter category to task performance.

CONCLUSIONS

Preterm children show intact basic sensorimotor function and demonstrate difficulties in processes underlying executive control, including increased distractibility and prolonged response preparation. These limitations may reflect specific neural abnormalities in fronto-subcortical executive control of behavior.

Executive function skills are associated with reading and parent-rated child function in children born prematurely

BACKGROUND

Preterm children are at risk for executive function (EF) problems, which have been linked to behavior and learning problems in full term children. In this study, we examine the relationship between EF and functional outcomes in preterm children.

AIM

To evaluate (1) EF skills of 9- to 16-year-old children born across the spectrum of gestational age (GA), (2) relationship of degree of prematurity to EF skills, and (3) contributions of EF skills to two functional outcomes - reading scores and parent-rated child function.

METHOD

Preterm children <36 weeks gestation (n=72) were compared to full term children (n=42) of similar age, gender and SES, on measures of EF, reading, and parent-ratings of child function. Multiple regression models evaluated contributions to EF skills and functional outcomes.

RESULTS

Compared to full term controls, preterm children had poorer EF performance on a complex planning and organization task and did not increase planning time as task difficulty increased. Their spatial memory capacity was not different. GA contributed to EF skills, but was mediated by IQ. EF contributed to the variance in reading skills but did not add to the variance in reading when IQ was considered. EF skills significantly contributed to the variance in parent-rated child function, but IQ did not.

CONCLUSION

EF skills contribute to measures of functional outcome in this high-risk population. The use of EF skills as an early marker for learning and functional problems and as a target for intervention in children born preterm warrants future study.

Update on environmental risk factors for attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent neurobehavioral disorder affecting 5% to 10% of children. Although considered to be a highly familial disorder, ADHD heritability estimates of 60% to 80% highlight the considerable role that environmental factors may still play in disorder susceptibility. Proposed ADHD environmental risk factors include prenatal substance exposures, heavy metal and chemical exposures, nutritional factors, and lifestyle/psychosocial factors. This paper reviews the literature published in 2010 investigating the association between environmental risk factors and ADHD or related symptomatology. Sources of risk factor exposure and the proposed mechanism by which each exposure is linked to ADHD-related neurobehavioral changes are also reported. Methodologic limitations of the current literature are discussed, and guidelines for future study are proposed. An improved understanding of the role that environmental factors play in ADHD etiology is critical to future ADHD prevention efforts.

Behavior problems of 9-16 year old preterm children: biological, sociodemographic, and intellectual contributions

BACKGROUND

Preterm children are at risk for behavior problems. Studies examining contributions of intellectual and environmental factors to behavior outcomes in preterm children are mixed.

AIMS

(1) To identify the nature of maladaptive behaviors in preterm children age 9 to 16 years born across the spectrum of gestational age and birth weight (BW). (2) To examine contributions of BW as a biological factor, socioeconomic status as an environmental factor, and intelligence quotient (IQ) as indicative of intellectual ability to behavior outcomes.

METHOD

Using the Child Behavior Checklist, parent reports of behavior for 63 preterm children (gestational age 24 to <36 weeks) were compared to 29 full term children of similar age, gender and socioeconomic status. Multiple regression models evaluated effects of prematurity, socioeconomic status, and intellectual ability on behavioral symptom scores.

RESULTS

Preterm children had higher total and internalizing problem scores compared to full term children. They also had lower IQ. BW was a significant predictor of total and internalizing behavior problems. Among the syndrome scales, anxious/depressed and attention problems were elevated. Socioeconomic status did not contribute to behavior scores. IQ contributed to total, but not to internalizing or externalizing, scores. IQ contributed to attention problems, but not to anxious/depressed scores.

CONCLUSION

Preterm children had increased behavior problems, especially symptoms of inattention and anxiety. Lower BW predicted more behavior problems. IQ acted as a mediator between BW and attention scores, but not anxiety scores. These findings alert health care providers to assess anxiety in all preterm children regardless of intellectual ability and additional study on the influence of intellectual ability on behavioral outcomes in preterm children is needed.

Early histories of school-aged children with attention-deficit/hyperactivity disorder

In a prospective study of developmental outcomes in relation to early-life otitis media, behavioral, cognitive, and language measures were administered to a large, diverse sample of children at 2, 3, 4, 6, and 9-11 years of age (N = 741). At 9-11 years of age, 9% of the children were categorized as having attention-deficit/hyperactivity disorder (ADHD) based on parent report. Compared to the non-ADHD group, the ADHD group had higher (i.e., less favorable) scores on parent and teacher versions of the Child Behavior Checklist at all ages. Children in the ADHD group also had lower scores on cognitive and receptive language measures in preschool. The findings support the concept that ADHD is a cognitive as well as a behavioral disorder.

Academic and educational outcomes of children with ADHD

Attention-deficit/hyperactivity disorder (ADHD) is associated with poor grades, poor reading and math standardized test scores, and increased grade retention. ADHD is also associated with increased use of school-based services, increased rates of detention and expulsion, and ultimately with relatively low rates of high school graduation and postsecondary education. Children in community samples who show symptoms of inattention, hyperactivity, and impulsivity with or without formal diagnoses of ADHD also show poor academic and educational outcomes. Pharmacologic treatment and behavior management are associated with reduction of the core symptoms of ADHD and increased academic productivity, but not with improved standardized test scores or ultimate educational attainment. Future research must use conceptually based outcome measures in prospective, longitudinal, and community-based studies to determine which pharmacologic, behavioral, and educational interventions can improve academic and educational outcomes of children with ADHD.

Academic and educational outcomes of children with ADHD

Attention-deficit/hyperactivity disorder (ADHD) is associated with poor grades, poor reading and math standardized test scores, and increased grade retention. ADHD is also associated with increased use of school-based services, increased rates of detention and expulsion, and ultimately with relatively low rates of high school graduation and postsecondary education. Children in community samples who show symptoms of inattention, hyperactivity, and impulsivity with or without formal diagnoses of ADHD also show poor academic and educational outcomes. Pharmacologic treatment and behavior management are associated with reduction of the core symptoms of ADHD and increased academic productivity, but not with improved standardized test scores or ultimate educational attainment. Future research must use conceptually based outcome measures in prospective, longitudinal, and community-based studies to determine which pharmacologic, behavioral, and educational interventions can improve academic and educational outcomes of children with ADHD.