Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011

Effect of General Anesthesia on Neurodevelopmental Abnormalities in Children Undergoing Treatment of Vascular Anomalies With Laser Surgery: A Retrospective Review

BACKGROUND

Multiple exposures to general anesthesia may be neurotoxic to the developing brain. This relationship has not been evaluated in children undergoing laser surgery for vascular anomalies.

OBJECTIVE

To evaluate the prevalence of neurodevelopmental abnormalities in children who received multiple laser procedures under general anesthesia before the age of 4 years for the treatment of vascular anomalies.

METHODS AND MATERIALS

Retrospective chart review of patients with contact of parents for telephone interview.

RESULTS

Thirty-three patients were eligible. Average age at the time of survey was 7.8 years. Twenty-three (84.8%) patients were female, with average age at the time of first treatment at 1.9 years. Average number of treatments received before the age of 4 years was 6.7. Anesthetics included inhalational nitrous oxide and isoflurane and intravenous propofol. Seven patients carried one or more of the following diagnoses: attention-deficit hyperactivity disorder (3.0%), anxiety (6.1%), behavioral disorder (3.0%), language disorder (3.0%), speech disorder (3.0%), and motor disorder (6.1%). These prevalence rates are similar to those found in the US population.

CONCLUSION

This is the first report on the prevalence of neurodevelopmental disorders in children undergoing multiple laser treatments under general anesthesia. Although the study sample is small, no increased risks when comparing with prevalence rates reported in the literature were noted.

Trends in ADHD medication use in children and adolescents in five western countries, 2005-2012

Over the last two decades, the use of ADHD medication in US youth has markedly increased. However, less is known about ADHD medication use among European children and adolescents. A repeated cross-sectional design was applied to national or regional data extracts from Denmark, Germany, the Netherlands, the United Kingdom (UK) and the United States (US) for calendar years 2005/2006-2012. The prevalence of ADHD medication use was assessed, stratified by age and sex. Furthermore, the most commonly prescribed ADHD medications were assessed. ADHD medication use prevalence increased from 1.8% to 3.9% in the Netherlands cohort (relative increase: +111.9%), from 3.3% to 3.7% in the US cohort (+10.7%), from 1.3% to 2.2% in the German cohort (+62.4%), from 0.4% to 1.5% in the Danish cohort (+302.7%), and from 0.3% to 0.5% in the UK cohort (+56.6%). ADHD medication use was highest in 10-14-year olds, peaking in the Netherlands (7.1%) and the US (8.8%). Methylphenidate use predominated in Europe, whereas in the US amphetamines were nearly as common as methylphenidate. Although there was a substantially greater use of ADHD medications in the US cohort, there was a relatively greater increase in ADHD medication use in youth in the four European countries. ADHD medication use patterns in the US differed markedly from those in western European countries.

Adverse Childhood Experiences and ADHD Diagnosis at Age 9 Years in a National Urban Sample

OBJECTIVE

To examine associations between adverse childhood experiences (ACEs) and attention-deficit/hyperactivity disorder (ADHD) at age 9 years using longitudinal data and assess the extent to which ACEs during middle childhood are independently associated with ADHD at age 9 years.

METHODS

We conducted a secondary analysis of data from the Fragile Families urban birth cohort 5- and 9-year interviews. The sample was limited to children for whom mothers were the primary caregiver and mother-reported information on 8 ACEs and ADHD were available at age 5 and 9 years. We examined associations between ACEs and parent-reported ADHD at age 9 years using logistic regression and controlling for potential confounders.

RESULTS

We included 1572 children; 48% were African American, 11% had parent-reported ADHD at age 9 years, 41% and 42% experienced ≥1 ACE by age 5 years and between the ages of 5 and 9 years, respectively. ACEs before age 5 years were associated with ADHD at age 9 years. One, 2, and ≥3 ACEs between age 5 and 9 years were associated with ADHD at age 9 years even after controlling for ACEs before age 5 years and ADHD at age 5 years (adjusted odds ratio [AOR], 1.9; 95% confidence interval [CI], 1.2-3; AOR, 2.1; 95% CI, 1.2-3.8; and AOR, 2.2; 95% CI, 1.1-4.3).

CONCLUSIONS

In this study of urban children, ACEs occurring before age 5 years as well as between the ages of 5 and 9 years were associated with ADHD at age 9 years. Even after controlling for early childhood ACEs and ADHD at age 5 years, the association between ADHD and ACEs in middle childhood remained significant, highlighting the importance of screening and intervention throughout childhood.

Chronic oral methylphenidate treatment reversibly increases striatal dopamine transporter and dopamine type 1 receptor binding in rats

Previously, we created an 8-h limited-access dual bottle drinking paradigm to deliver methylphenidate (MP) to rats at two dosages that result in a pharmacokinetic profile similar to patients treated for attention deficit hyperactivity disorder. Chronic treatment resulted in altered behavior, with some effects persisting beyond treatment. In the current study, adolescent male Sprague-Dawley rats were split into three groups at four weeks of age: control (water), low-dose MP (LD), and high-dose MP (HD). Briefly, 4 mg/kg (low dose; LD) or 30 mg/kg (high dose; HD) MP was consumed during the first hour, and 10 mg/kg (LD) or 60 mg/kg (HD) MP during hours two through eight. Following three months of treatment, half of the rats in each group (n = 8-9/group) were euthanized, and remaining rats went through a 1-month abstinence period, then euthanized. In vitro receptor autoradiography was performed to quantify binding levels of dopamine transporter (DAT), dopamine type 1 (D1R)-like receptors, and dopamine type 2 (D2R)-like receptors using [3H] WIN35,428, [3H] SCH23390, and [3H] Spiperone, respectively. Immediately following treatment, HD MP-treated rats had increased DAT and D1R-like binding in several subregions of the basal ganglia, particularly more caudal portions of the caudate putamen, which correlated with some previously reported behavioral changes. There were no differences between treatment groups in any measure following abstinence. These findings suggest that chronic treatment with a clinically relevant high dose of MP results in reversible changes in dopamine neurochemistry, which may underlie some effects on behavior.

Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity

OBJECTIVE

Although identifying adverse childhood experiences (ACEs) among children with behavioral disorders is an important step in providing targeted therapy and support, little is known about the burden of ACEs among children with attention deficit-hyperactivity disorder (ADHD). We described the prevalence of ACEs in children with and without ADHD, and examined associations between ACE type, ACE score, and ADHD diagnosis and severity.

METHODS

Using the 2011 to 2012 National Survey of Children's Health, we identified children aged 4 to 17 years whose parents indicated presence and severity of ADHD, and their child's exposure to 9 ACEs. Multivariate logistic regression was used to estimate associations between ACEs, ACE score, and parent-reported ADHD and ADHD severity, adjusted for sociodemographic characteristics.

RESULTS

In our sample (N = 76,227, representing 58,029,495 children), children with ADHD had a higher prevalence of each ACE compared with children without ADHD. Children who experienced socioeconomic hardship (adjusted odds ratio [aOR], 1.39; 95% confidence interval [CI], 1.21-1.59), divorce (aOR, 1.34; 95% CI, 1.16-1.55), familial mental illness (aOR, 1.55; 95% CI, 1.26-1.90), neighborhood violence (aOR, 1.47; 95% CI, 1.23-1.75), and incarceration (aOR, 1.39; 95% CI, 1.12-1.72) were more likely to have ADHD. A graded relationship was observed between ACE score and ADHD. Children with ACE scores of 2, 3, and ≥4 were significantly more likely to have moderate to severe ADHD.

CONCLUSIONS

Children with ADHD have higher ACE exposure compared with children without ADHD. There was a significant association between ACE score, ADHD, and moderate to severe ADHD. Efforts to improve ADHD assessment and management should consider routinely evaluating for ACEs.

Potential short-term neurobehavioral alterations in children associated with a peak pesticide spray season: The Mother's Day flower harvest in Ecuador

BACKGROUND

Exposures to cholinesterase inhibitor pesticides (e.g. organophosphates) have been associated with children's neurobehavioral alterations, including attention deficit and impulsivity. Animal studies have observed transient alterations in neurobehavioral performance in relation to cholinesterase inhibitor pesticide exposures; however, limited evidence exists regarding transient effects in humans.

METHODS

We estimated the associations between neurobehavioral performance and time after Mother's Day flower harvest (the end of a heightened pesticide usage period) among 308 4-to 9-year-old children living in floricultural communities in Ecuador in 2008 who participated in the ESPINA study. Children's neurobehavior was examined once (NEPSY-II: 11 subtests covering 5 domains), between 63 and 100days (SD: 10.8days) after Mother's Day harvest (blood acetylcholinesterase activity levels can take 82days to normalize after irreversible inhibition with organophosphates).

RESULTS

The mean (SD) neurobehavioral scaled scores across domains ranged from 6.6 (2.4) to 9.9 (3.3); higher values reflect greater performance. Children examined sooner after Mother's Day had lower neurobehavioral scores than children examined later, in the domains of (score difference per 10.8days, 95%CI): Attention/Inhibitory Control (0.38, 0.10-0.65), Visuospatial Processing (0.60, 0.25-0.95) and Sensorimotor (0.43, 0.10-0.77). Scores were higher with longer time post-harvest among girls (vs. boys) in Attention/Inhibitory Control.

CONCLUSIONS

Our findings, although cross-sectional, are among the first in non-worker children to suggest that a peak pesticide use period may transiently affect neurobehavioral performance, as children examined sooner after the flower harvest had lower neurobehavioral performance than children examined later. Studies assessing pre- and post-exposure measures are needed.

Crowdsourced validation of a machine-learning classification system for autism and ADHD

Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) together affect >10% of the children in the United States, but considerable behavioral overlaps between the two disorders can often complicate differential diagnosis. Currently, there is no screening test designed to differentiate between the two disorders, and with waiting times from initial suspicion to diagnosis upwards of a year, methods to quickly and accurately assess risk for these and other developmental disorders are desperately needed. In a previous study, we found that four machine-learning algorithms were able to accurately (area under the curve (AUC)>0.96) distinguish ASD from ADHD using only a small subset of items from the Social Responsiveness Scale (SRS). Here, we expand upon our prior work by including a novel crowdsourced data set of responses to our predefined top 15 SRS-derived questions from parents of children with ASD (n=248) or ADHD (n=174) to improve our model's capability to generalize to new, 'real-world' data. By mixing these novel survey data with our initial archival sample (n=3417) and performing repeated cross-validation with subsampling, we created a classification algorithm that performs with AUC=0.89±0.01 using only 15 questions.

QT prolongation by dexamphetamine: Does experience matter?

INTRODUCTION

Case reports of life-threatening cardiac arrhythmias and sudden cardiac arrest (SCA) among amphetamine users have raised serious concerns about the cardiac safety of this class of drugs. This is important in light of the high prevalence of dexamphetamine (dAMPH) prescription for attention-deficit/hyperactivity disorder (ADHD), and its rising use as a recreational drug. The objective was to investigate electrocardiogram (ECG) parameters upon intravenous administration of a single dAMPH dose in habitual recreational dAMPH users (users) and healthy gender/age/ intelligence-quotient-matched controls (non-users).

METHODS AND RESULTS

ECG recordings were made in 18 users and 18 non-users during administration of dAMPH (0.3 mg/kg body weight). Baseline ECG was normal in both groups. dAMPH elicited increased heart rate and corrected QT time (QTc) prolongation in both groups (all P < 0.001, QTc = 502 in one individual). QTc prolongation was attenuated in users compared to non-users, exhibiting a significant interaction effect (P = 0.04).

CONCLUSION

SCA associated with amphetamine use may be related to its QTc prolonging effects, particularly during first-time use. These observations may provide a rationale for conducting ECG analysis immediately after the first-time use of amphetamines, as this could potentially unmask vulnerable individuals.

Hispanic Residential Isolation, ADHD Diagnosis and Stimulant Treatment among Medicaid-Insured Youth

OBJECTIVE

This study aimed to evaluate a conceptual framework that assessed the effect of Hispanic residential isolation on Attention Deficit Hyperactivity Disorder (ADHD) health service utilization among 2.2 million publicly insured youth.

DESIGN

Cross-sectional.

SETTING

Medicaid administrative claims data for ambulatory care services from a US Pacific state linked with US census data.

PARTICIPANTS

Youth, aged 2-17 years, continuously enrolled in 2009.

MAIN OUTCOME MEASURES

The percent annual prevalence and odds of ADHD diagnosis and stimulant use according to two measures of racial/ethnic residential isolation: 1) the county-level Hispanic isolation index (HI) defined as the population density of Hispanic residents in relation to other racial/ethnic groups in a county (<.5; .5-.64; ≥.65); and 2) the proportion of Hispanic residents in a ZIP code tabulation area (<25%; 25%-50%; >50%).

RESULTS

Among the 47,364 youth with a clinician-reported ADHD diagnosis, 60% received a stimulant treatment (N = 28,334). As the county level HI increased, Hispanic residents of ethnically isolated locales were significantly less likely to receive an ADHD diagnosis (adjusted odds ratio [AOR]=.92 [95% CI=.88-.96]) and stimulant use (AOR=.61 [95% CI=.59-.64]) compared with Hispanic youth in less isolated areas. At the ZIP code level, a similar pattern of reduced ADHD diagnosis (AOR=.81 [95% CI=.77-.86]) and reduced stimulant use (AOR=.65 [95% CI=.61-.69]) was observed as Hispanic residential isolation increased from the least isolated to the most isolated ZIP code areas.

CONCLUSIONS

These findings highlight the opportunity for Big Data to advance mental health research on strategies to reduce racial/ethnic health disparities, particularly for poor and vulnerable youth. Further exploration of racial/ethnic residential isolation in other large data sources is needed to guide future policy development and to target culturally sensitive interventions.

Lens opacities in children using methylphenidate hydrochloride

PURPOSE

To assess clinical findings of eye examination in children having attention deficit hyperactivity disorder (ADHD) administered with methylphenidate hydrochloride.

METHODS

Fifty-seven consecutive patients diagnosed of ADHD and administered with oral methylphenidate hydrochloride treatment for at least one year were involved in this study (Group 1). Sixty healthy subjects (Group 2) having demographic features similar to group 1 were involved as a control group. All patients underwent detailed ophthalmological examination.

RESULTS

One hundred and seventeen consecutive subjects with a mean age of 11.2 ± 2.4 years (7-18 years) were enrolled. Fifty-seven consecutive patient (32 males, 25 females) under oral methylphenidate hydrochloride treatment (Group 1) and 60 healthy control subjects (30 males, 30 females) (Group 2)) were recruited for this prospective study. The mean methylphenidate hydrochloride dosage was 0.9 ± 0.1 mg/kg/day and the mean duration of methylphenidate hydrochloride usage was for 2.73 ± 0.73 years (1-7 years). High intraocular pressure was not observed in any of the patients in our study. We detected lens opacities in five eyes of five patients in group 1 (p = 0.019). The patient with the highest degree of cataract formation had been using MPH for 84 months and this patient's cataract score was P4.

CONCLUSION

Long-term use of methylphenidate may cause lens opacities. In particular, patients who have been using methylphenidate for more than two years should go for regular eye examination.

Smartphones and Cognition: A Review of Research Exploring the Links between Mobile Technology Habits and Cognitive Functioning

While smartphones and related mobile technologies are recognized as flexible and powerful tools that, when used prudently, can augment human cognition, there is also a growing perception that habitual involvement with these devices may have a negative and lasting impact on users' ability to think, remember, pay attention, and regulate emotion. The present review considers an intensifying, though still limited, area of research exploring the potential cognitive impacts of smartphone-related habits, and seeks to determine in which domains of functioning there is accruing evidence of a significant relationship between smartphone technology and cognitive performance, and in which domains the scientific literature is not yet mature enough to endorse any firm conclusions. We focus our review primarily on three facets of cognition that are clearly implicated in public discourse regarding the impacts of mobile technology - attention, memory, and delay of gratification - and then consider evidence regarding the broader relationships between smartphone habits and everyday cognitive functioning. Along the way, we highlight compelling findings, discuss limitations with respect to empirical methodology and interpretation, and offer suggestions for how the field might progress toward a more coherent and robust area of scientific inquiry.

A Clinician's Guide to Co-occurring ADHD among Adolescent Substance Users: Comorbidity, Neurodevelopmental Risk, and Evidence-based Treatment Options

This article introduces neurodevelopmental and clinical considerations for treating adolescents with co-occurring Attention-Deficit/Hyperactivity Disorder (ADHD) and substance use (ASU) in outpatient settings. We first describe neurobiological impairments common to ADHD and ASU, including comorbidity with conduct disorder, that evoke a profile of multiplicative developmental risk. We then present two evidence-based options for targeting ADHD-related problems during ASU treatment. Medication integration interventions utilize family ADHD psychoeducation to prompt decision-making about ADHD medication and integrate medication management into behavioral services. Clinic-based academic training interventions utilize family interventions to improve the home academic environment and boost organization skills. We conclude with recommendations for ADHD assessment and intervention sequencing.

Prevalence and correlates of ADHD among adolescents in a Beirut community sample: results from the BEI-PSY Study

BACKGROUND

This study aims to investigate the prevalence, correlates and treatment seeking behavior related to ADHD among adolescents from Lebanon.

METHODS

Five hundred and ten adolescents were recruited through multistage stratified cluster sampling of households in Beirut, and separately interviewed along with one parent/legal guardian, using the DAWBA. All adolescents completed the PRQ and the SDQ; the parent/legal guardian also completed the SDQ and provided basic demographic information, including attitudes towards seeking mental health services.

RESULTS

10.20% of the adolescents were diagnosed with ADHD. Having ADHD was associated with having academic difficulties and being involved in bullying. Adolescents with ADHD also had higher odds of drinking alcohol, smoking cigarettes, and having comorbid emotional and conduct disorders (compared to those without ADHD). Adolescents with ADHD and their parents reported a higher burden of illness and were more likely to consider seeing a mental health professional than healthy adolescents and their parents.

CONCLUSION

ADHD among adolescents in Lebanon warrants closer attention, mainly increased awareness in the larger public, and stronger commitment to increase treatment resources to the community.

Motives for Prescription Stimulant Misuse in a College Sample: Characteristics of Users, Perception of Risk, and Consequences of Use

BACKGROUND

Prescription stimulant misuse is increasingly prevalent in college populations, with some misuse estimates over 40%. Stimulant use is associated with a variety of health and psychological problems. Motives for use may provide insight into problematic trajectories.

OBJECTIVES

The purpose of the current study was to evaluate characteristics of users and motives for prescription stimulant misuse in a large southeastern university.

METHOD

College students reported on prescription stimulant use, motives for use, consequences associated with use, perceptions of risk, and social norms. We specifically elicited participation from prescription stimulant misusers. Of the 199 participants, 86 reported misusing prescription stimulants in the past 60 days. We assessed motives for use, rates of substance use, risk perception, normative beliefs, and consequences associated with use. We evaluated differences between misusers and non-misusers, differentiate motives subscales, and identify relationships between motives subscales, rates of use, and consequences.

RESULTS

Misusers used more alcohol and other drugs, held different normative beliefs regarding stimulants, and had lower risk perceptions than non-misusers. We evaluated seven motives subscales among misusers: coping, social, enhancement, expansion, conformity, academic performance, and weight loss. Enhancement, social, weight loss, and expansion scales were correlated with negative consequences, while social motives were correlated with use. Results from regression analyses revealed positive associations between weight and expansion with negative consequences, and a negative association between conformity and consequences. Conclusions/Importance:Motives for prescription stimulant use and user characteristics may provide insight into prevention and treatment. Continued work is needed to refine item content and replicate findings.

Economic Burden of Attention-Deficit/Hyperactivity Disorder among Pediatric Patients in the United States

OBJECTIVES

To determine the adjusted incremental total costs (direct and indirect) for patients (aged 3-17 years) with attention-deficit/hyperactivity disorder (ADHD) and the differences in the adjusted incremental direct expenditures with respect to age groups (preschoolers, 0-5 years; children, 6-11 years; and adolescents, 12-17 years).

METHODS

The 2011 Medical Expenditure Panel Survey was used as the data source. The ADHD cohort consisted of patients aged 0 to 17 years with a diagnosis of ADHD, whereas the non-ADHD cohort consisted of subjects in the same age range without a diagnosis of ADHD. The annual incremental total cost of ADHD is composed of the incremental direct expenditures and indirect costs. A two-part model with a logistic regression (first part) and a generalized linear model (second part) was used to estimate the incremental costs of ADHD while controlling for patient characteristics and access-to-care variables.

RESULTS

The 2011 Medical Expenditure Panel Survey database included 9108 individuals aged 0 to 17 years, with 458 (5.0%) having an ADHD diagnosis. The ADHD cohort was 4.90 times more likely (95% confidence interval [CI] 2.97-8.08; P < 0.001) than the non-ADHD cohort to have an expenditure of at least $1, and among those with positive expenditures, the ADHD cohort had 58.4% higher expenditures than the non-ADHD cohort (P < 0.001). The estimated adjusted annual total incremental cost of ADHD was $949.24 (95% CI $593.30-$1305.18; P < 0.001). The adjusted annual incremental total direct expenditure for ADHD was higher among preschoolers ($989.34; 95% CI $402.70-$1575.98; P = 0.001) than among adolescents ($894.94; 95% CI $428.16-$1361.71; P < 0.001) or children ($682.71; 95% CI $347.94-$1017.48; P < 0.001).

CONCLUSIONS

Early diagnosis and use of evidence-based treatments may address the substantial burden of ADHD.

A Latent Class Analysis to Identify Variation in Caregivers' Preferences for their Child's Attention-Deficit/Hyperactivity Disorder Treatment: Do Stated Preferences Match Current Treatment?

OBJECTIVES

To investigate variation in caregiver preferences for their child's attention-deficit/hyperactivity disorder (ADHD) care and to determine if their stated preferences align with current care management.

METHODS

Caregivers of a child aged 4-14 years and in care for ADHD were recruited from pediatric outpatient clinics and advocacy groups across the state of Maryland. Participants completed a survey collecting demographics, the child's treatment, and caregiver preferences-elicited using a best-worst scaling experiment (case 2). Latent class analysis was used to identify distinct preference segments and bivariate analyses were used to compare the association between segment membership with what the child was currently receiving for their ADHD.

RESULTS

Participants (n = 184) were predominantly White (68%) and the child's mother (84%). Most children had ADHD for 2 or more years (79%). Caregiver preferences were distinguished by two segments: continuous medication (36%) and minimal medication (64%). The two groups had very different preferences for when medication was administered (p < 0.001), but they had similar preferences for provider-oriented and non-medication interventions (p > 0.05 for the caregiver behavior training, provider communication, provider specialty, and out-of-pocket costs). One third of the sample did not receive the preferred individualized education program and 42% of the minimal medication group reported using medication 7 days a week all year round.

CONCLUSIONS

Although behavior management training and school accommodations aspects of an ADHD care plan are more important to caregivers than evidence-based medication, fewer families had access to educational accommodations. Further research is needed to clarify how stated preferences for care align with treatments used in actual practice settings.

Caregiver Treatment Preferences for Children with a New Versus Existing Attention-Deficit/Hyperactivity Disorder Diagnosis

OBJECTIVES

Parental experiences with managing their child's attention-deficit/hyperactivity disorder (ADHD) can influence priorities for treatment. This study aimed to identify the ADHD management options caregivers most prefer and to determine if preferences differ by time since initial ADHD diagnosis.

METHODS

Primary caregivers (n = 184) of a child aged 4-14 years old in care for ADHD were recruited from January 2013 through March 2015 from community-based pediatric and mental health clinics and family support organizations across the state of Maryland. Participants completed a survey that included child/family demographics, child clinical treatment, and a Best-Worst Scaling (BWS) experiment to elicit ADHD management preferences. The BWS comprised 18 ADHD management profiles showing seven treatment attributes, where the best and worst attribute levels were selected from each profile. A conditional logit model using effect-coded variables was used to estimate preference weights stratified by time since ADHD diagnosis.

RESULTS

Participants were primarily the mother (84%) and had a college or postgraduate education (76%) with 75% of the children on stimulant medications. One-on-one caregiver behavior training, medication use seven days a week, therapy in a clinic, and an individualized education program were most preferred for managing ADHD. Aside from caregiver training and monthly out-of-pocket costs, caregivers of children diagnosed with ADHD for less than two years prioritized medication use lower than other care management attributes and caregivers of children diagnosed with ADHD for two or more years preferred school accommodations, medication, and provider specialty.

CONCLUSIONS

Preferences for ADHD treatment differ based on the duration of the child's ADHD. Acknowledging that preferences change over the course of care could facilitate patient/family-centered care planning across a range of resources and a multidisciplinary team of professionals.

Annual Research Review: Quality of life and childhood mental and behavioural disorders - a critical review of the research

BACKGROUND

An individual's subjective perception of well-being is increasingly recognized as an essential complement to clinical symptomatology and functional impairment in children's mental health. Measurement of quality of life (QoL) has the potential to give due weight to the child's perspective.

SCOPE AND METHODOLOGY

Our aim was to critically review the current evidence on how childhood mental disorders affect QoL. First, the major challenges in this research field are outlined. Then we present a systematic review of QoL in children and adolescents aged 0-18 years formally diagnosed with a mental and behavioural disorder, as compared to healthy or typically developing children or children with other health conditions. Finally, we discuss limitations of the current evidence base and future directions based on the results of the systematic review and other relevant literature.

FINDINGS AND CONCLUSIONS

The systematic review identified 41 eligible studies. All were published after the year 2000 and 21 originated in Europe. The majority examined QoL in neurodevelopmental disorders, including attention-deficit hyperactivity disorder (k = 17), autism spectrum disorder (k = 6), motor disorders (k = 5) and intellectual disability (k = 4). Despite substantial heterogeneity, studies demonstrate that self-reported global QoL is significantly reduced compared to typical/healthy controls across several disorders and QoL dimensions. Parents' ratings were on average substantially lower, casting doubt on the validity of proxy-report. Studies for large diagnostic groups such as depressive disorders, anxiety disorders, (early onset) schizophrenia and eating disorders are largely lacking. We conclude that representative, well-characterized normative and clinical samples as well as longitudinal and qualitative designs are needed to further clarify the construct of QoL, to derive measures of high ecological validity, and to examine how QoL fluctuates over time and is attributable to specific conditions or contextual factors.

Sex Differences in the Physiological and Behavioral Effects of Chronic Oral Methylphenidate Treatment in Rats

Methylphenidate (MP) is a psychostimulant prescribed for Attention Deficit Hyperactivity Disorder. Previously, we developed a dual bottle 8-h-limited-access-drinking-paradigm for oral MP treatment of rats that mimics the pharmacokinetic profile of treated patients. This study assessed sex differences in response to this treatment. Male and female Sprague Dawley rats were assigned to one of three treatment groups at 4 weeks of age (n = 12/group): Control (water), low dose (LD) MP, and high dose (HD) MP. Rats drank 4 mg/kg MP (LD) or 30 mg/kg MP (HD) during the first hour, and 10 mg/kg (LD) or 60 mg/kg MP (HD) for the remaining 7 h each day. Throughout 3 months of treatment, rats were monitored for body weight, food intake, and fluid intake; as well as tested for open field behavior, circadian activity, novel object recognition, and social interaction. Chronic MP treated rats exhibited reduced fluid intake during distinct treatment weeks to a greater extent in males, and reduced total fluid intake in males only. HD MP treatment decreased body weight in both sexes, while HD MP increased total food intake in females only, likely to offset energy deficits resulting from MP-induced hyperactivity. LD and HD MP increased locomotor activity in the open field, particularly in females and during later treatment weeks. MP dose-dependently increased activity during the dark cycle of circadian testing in females, while in males hyperactivity was only exhibited by HD rats. HD MP increased center activity to a greater extent in males, while MP increased rearing behavior in females only. MP had no effect on social behavior or novel object recognition in either sex. This study concludes that chronic oral MP treatment at clinically-relevant dosages has significant effects on food intake, body weight, open field behavior, and wake cycle activity. Particularly marked sex differences were apparent for locomotor activity, with females being significantly more sensitive to the hyperactivating effects of the drug. These findings suggest that chronic MP exposure beginning in adolescence can have significant behavioral effects that are both dose- and sex-dependent, and raise concerns regarding the reversibility of these effects post-discontinuation of treatment.

Clinical and functional correlates of processing speed in pediatric Attention-Deficit/Hyperactivity Disorder: a systematic review and meta-analysis

It is well established that processing speed is negatively impacted in children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD). Unfortunately, exactly how processing speed vulnerabilities manifest in daily functioning has not been well established. To support clinical care of youth with ADHD, it is important to better understand the functional consequences and relevant outcomes associated with processing speed deficits. This systematic review and meta-analysis sought to identify the association between processing speed and clinical or functional correlates among children or adolescents diagnosed with ADHD. A total of 409 abstracts were screened, of which, 60 full-text articles were identified as potentially relevant, and 8 of these studies met inclusion criteria. Domains evaluated across these studies included reading skills, mathematics skills, written expression, anxiety, self-appraisals of competence, and adaptive functioning. Six studies reported an association between processing speed and reading skills, allowing for meta-analysis. Processing speed difficulties among youth with ADHD appear strongly associated with several clinical and functional correlates including weaker academic skills, poorer adaptive skills, increased self-reported anxiety, and overestimates of social competence. Meta-analytic results for studies reporting the association between processing speed and reading skills indicate a medium overall weighted mean effect size (r = 0.33, 95% CI = 0.28 -0.39) with minimal heterogeneity (I² = 0.17). Clinical implications of these findings, limitations in the current knowledge base, and suggestions for future research are discussed.

Attention-deficit hyperactivity disorder in elementary school students in Shantou, China: prevalence, subtypes, and influencing factors

Attention-deficit hyperactivity disorder (ADHD) is a frequent childhood-onset psychiatric condition and categorized into three subtypes of predominantly inattentive (ADHD-I), hyperactive impulsive (ADHD-H), and combined (ADHD-C). The prevalence and subtypes of ADHD vary considerably. The primary aim of this study was to provide a prevalence estimate of ADHD in elementary school students living in Shantou, a district of China, and in addition to examine the influence of informants, age, and gender on the prevalence. A total of 3,497 students aged 7-12 years were enrolled by random and stratified sampling. In stage I, teachers and parents of all participating students in randomly selected schools were asked to complete Chinese versions of the Conners' 10-item scale. In stage II, students with high scores (>15) were interviewed by a psychiatrist for a diagnosis with or without ADHD. Parents rated many more students with high scores than teachers did in stage I. The prevalence of ADHD determined by Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) was 5.91% (5.27%-6.55%), which is comparable to the rates reported in previous studies with Chinese children. This hits the low border of the ADHD prevalence range from 5.9 to 7.1% worldwide, and is lower than that of Chinese children living in Hong Kong, suggesting an important influence of Chinese culture on the diagnosis of ADHD. The constituent ratios of ADHD-I, ADHD-C, and ADHD-H subtypes were 67.43, 24.57, and 8.00%, respectively. The rate of ADHD-H decreased with age, whereas that of ADHD-I remained at the highest levels in all age groups, suggesting that symptoms in the inattention domain are the most persistent and refractory.

Academic and Social Functioning Associated with Attention-Deficit/Hyperactivity Disorder: Latent Class Analyses of Trajectories from Kindergarten to Fifth Grade

Children with attention-deficit/hyperactivity disorder (ADHD) are known to exhibit significantly lower academic and social functioning than other children. Yet the field currently lacks knowledge about specific impairment trajectories experienced by children with ADHD, which may constrain early screening and intervention effectiveness. Data were analyzed from a nationally representative U.S. cohort in the Early Childhood Longitudinal Study, Kindergarten Class of 1998-1999 (ECLS-K) for 590 children (72.7 % male) whose parents reported a formal diagnosis of ADHD. Children's math, reading, and interpersonal skills were assessed at 5 time points between kindergarten and fifth grade. Growth mixture model analyses indicated 4 latent trajectory classes for reading, 8 classes for math, and 4 classes for interpersonal skills. Membership in reading and math trajectory classes was strongly related; overlaps with interpersonal skills classes were weaker. Trajectory class membership was correlated with demographic characteristics and behavioral functioning. Children with ADHD display substantial heterogeneity in their reading, math, and interpersonal growth trajectories, with some groups of children especially likely to display relatively severe levels of academic and social impairment over time. Early screening and intervention to address impairment, particularly reading difficulties, among kindergarten students with ADHD is warranted.

Financial Dependence of Young Adults with Childhood ADHD

This study used data from the Pittsburgh ADHD Longitudinal Study (PALS) to evaluate financial outcomes of young adults (YA) with ADHD relative to comparisons. Participants for this study included 309 individuals who had been diagnosed with ADHD (DSM-III-R or DSM-IV) in childhood and 208 comparison YA without childhood ADHD diagnoses (total N = 517) who were followed through age 25. Participants were predominately male (88 %) and Caucasian (84 %). Diagnostic interviews were conducted in childhood. Young adults and their parents reported on financial outcomes and a number of predictor variables. Young adults with ADHD experienced greater financial dependence on family members (p < 0.05) and the welfare system (p < 0.01) and had lower earnings (p < 0.05) than comparisons. ADHD diagnostic status, education attainment, and delinquency were significant predictors of financial outcomes. A projection of lifetime earnings indicated that ADHD group participants could expect to earn $543,000-$616,000 less over their lifetimes than comparisons. Due to the propensity of individuals with ADHD to underreport problems, the data are likely to be underestimates. These findings support the need for interventions to improve labor market outcomes as well as the development of interventions that target the management of personal finances for individuals with ADHD in young adulthood.

Legal Epidemiology: The Science of Law

The importance of legal epidemiology in public health law research has undoubtedly grown over the last five years. Scholars and practitioners together have developed guidance on best practices for the field, including: placing emphasis on transdisciplinary collaborations; creating valid, reliable, and repeatable research; and publishing timely products for use in decision-making and change. Despite the energy and expertise researchers have brought to this important work, they name significant challenges in marshalling the diverse skill sets, quality controls, and funding to implement legal epidemiology activities. The Centers for Disease Control and Prevention (CDC) has worked to develop cross-cutting research and translation on issues of national priority in legal epidemiology, and has explored ways to overcome some of these challenges. As such, this article describes a case study of the use of law to characterize states' prior authorization policies regarding medication used to treat attention-deficit/hyperactivity disorder (ADHD), a central component of a broader effort to improve behavior therapy options for young children with ADHD. This article highlights the types of legal epidemiology work we have undertaken, the application of this work to an emerging public health problem, and the lessons learned in creating impactful research for the field.

Adolescents' Prescription Stimulant Use and Adult Functional Outcomes: A National Prospective Study

OBJECTIVE

To assess the prospective 17-year relationship between the medical and nonmedical use of prescription stimulants during adolescence (age 18 years) and educational attainment and substance use disorder (SUD) symptoms in adulthood (age 35 years).

METHOD

A survey was self-administered by nationally representative probability samples of US high school seniors from the Monitoring the Future study; 8,362 of these individuals were followed longitudinally from adolescence (age 18, high school senior years 1976-1996) to adulthood (age 35, 1993-2013).

RESULTS

An estimated 8.1% reported medical use of prescription stimulants, and 16.7% reported nonmedical use of prescription stimulants by age 18 years. Approximately 43% of adolescent medical users of prescription stimulants had also engaged in nonmedical use of prescription stimulants during adolescence. Among past-year adolescent nonmedical users of prescription stimulants, 97.3% had used at least one other substance during the past year. Medical users of prescription stimulants without any history of nonmedical use during adolescence did not differ significantly from population controls (i.e., non-attention-deficit/hyperactivity disorder [ADHD] and non-stimulant-medicated ADHD during adolescence) in educational attainment and SUD symptoms in adulthood. In contrast, adolescent nonmedical users of prescription stimulants (with or without medical use) had lower educational attainment and more SUD symptoms in adulthood, compared to population controls and medical users of prescription stimulants without nonmedical use during adolescence.

CONCLUSION

Nonmedical use of prescription stimulants is common among adolescents prescribed these medications. The findings indicate youth should be carefully monitored for nonmedical use because this behavior is associated with lower educational attainment and more SUD symptoms in adulthood.

Use of cognitive enhancers among medical students in Lithuania

Aims

The purpose of this study is to analyse the use of cognitive enhancers among medical students in Lithuania, determine the reasons for usage and evaluate the contributing factors such as socio-demographic characteristics, stress levels, sleep quality and knowing somebody who has used a neuro-enhancing drug.

Design

A cross-sectional survey study was performed by analysing a convenience sample of n=579 in the two universities offering medical education in Lithuania, Vilnius University and the Lithuanian University of Health Sciences. In 2014, students were asked to fill in anonymous paper questionnaires consisting of 13 items on prevalence of substance use to enhance cognitive performance, and on reasons and correlates (response rate 95%) during lecture time.

Results

Of the respondents, 8.1% indicated that they had used cognitive enhancers. Among those who had used these drugs, nootropics were the most frequently mentioned (59.6%), while psychostimulants, such as modafinil, methylphenidate and amphetamine-derived drugs were mentioned less frequently (38.3%). Other substances were indicated by 23.4% of the respondents. Improvement of concentration and increased studying time were predominant purposes (55.3% and 48.9% of users, respectively). Male students reported three times higher prevalence rates than females (14.6% vs. 5.1%, p<0.05). Prevalence was also higher in students who knew someone using these substances than among those who did not know such persons (17.3% vs. 5.1%, p< 0.05). This was the most associated factor with cognitive-enhancing drug-taking behaviour. No correlation between cognitive enhancement usage and sleep quality or stress levels was found, nor between usage and belonging to a student organisation or having a job.

Conclusions

In Lithuania, 1 of 12 medical students admits to having used neuro-enhancing drugs. Our study results provide an overview of the actual situation on correlates and reasons for taking performance-enhancing substances.

Does Applied STEM Course Taking Link to STEM Outcomes for High School Students With Learning Disabilities?

Over the most recent two decades, federal policy has urged high schools to embed applied science, technology, engineering, and mathematics (STEM) courses into the curriculum to reinforce concepts learned in traditional math and science classes as well as to motivate students' interests and long-term pursuits in STEM areas. While prior research has examined whether these courses link to STEM persistence for the general student population, no work has examined the role of these courses for students with learning disabilities (LDs). This is a critical lapse, as these courses have been supported as being one path by which STEM material can become more accessible for students with diverse learning needs. Hence, this descriptive study examines the landscape of applied STEM course taking for students with LDs. The findings suggest students with LDs are less likely to take applied STEM courses in high school compared to the general population. Additionally, while the general population does benefit from taking these courses, there is a unique association between applied STEM course taking and advanced math and science course taking or math achievement for students with LDs. Hence, there is no evidence that applied STEM course taking is related to any closure of the STEM achievement gap for students with LDs.

Sex moderates the impact of birth weight on child externalizing psychopathology

Low birth weight (LBW) has consistently been associated with childhood attention deficit/hyperactivity disorder (ADHD), and a similar association has been found for childhood externalizing disorders, such as oppositional defiant disorder (ODD) and conduct disorder (CD), albeit to a lesser degree. Although the association between LBW and these disorders has been robustly replicated, few studies have adequately controlled for confounding variables, such as parental age at birth and prenatal tobacco use, examined the specificity of the risk of LBW for ADHD symptoms, or investigated potential nonlinear (i.e., quadratic) effects of birth weight (BW). Additionally, the extent to which LBW confers risk for these disorders depending on childhood sex has rarely been examined. The current study examined associations between BW and ADHD, ODD, and CD symptom dimensions as well as the extent to which such associations are moderated by child sex, while also controlling for confounding variables. Significant interactions between sex and BW emerged across all analyses predicting ADHD and externalizing psychopathology, such that associations were stronger in males relative to females. Results remained when controlling for a number of confounds, including parental age, prenatal tobacco use, comorbid psychopathology, as well as other indicators of maternal and child health during the pre- and perinatal period. Both linear and quadratic associations emerged between BW and both hyperactivity and CD symptoms, whereas BW predicted inattention and ODD symptoms in a linear fashion. Future research should continue to investigate the impact of BW on ADHD and externalizing psychopathology, in particular, the biological mechanisms underlying this association. (PsycINFO Database Record

Efficacy, Safety, and Tolerability of an Extended-Release Orally Disintegrating Methylphenidate Tablet in Children 6-12 Years of Age with Attention-Deficit/Hyperactivity Disorder in the Laboratory Classroom Setting

OBJECTIVE

Methylphenidate extended-release orally disintegrating tablets (MPH XR-ODTs) represent a new technology for MPH delivery. ODTs disintegrate in the mouth without water and provide a pharmacokinetic profile that is consistent with once-daily dosing. This study sought to determine the efficacy, safety, and tolerability of this novel MPH XR-ODT formulation in school-age children with attention-deficit/hyperactivity disorder (ADHD) in a laboratory classroom setting.

METHODS

Children aged 6-12 years with ADHD (n = 87) were enrolled in this randomized, multicenter, double-blind, placebo-controlled, parallel, laboratory classroom study. The MPH XR-ODT dose was titrated to an optimized dose during a 4-week open-label period and maintained on that dose for 1 week. Participants (n = 85) were then randomized to receive their optimized dose of MPH XR-ODT or placebo once daily for 1 week (double blind), culminating in a laboratory classroom testing day. Efficacy was evaluated using the Swanson, Kotkin, Agler, M-Flynn, and Pelham (SKAMP) Attention, Deportment, and Combined scores along with Permanent Product Measure of Performance (PERMP; Attempted and Correct) assessments. Onset and duration of drug action were also evaluated as key secondary endpoints. Safety assessments included adverse events (AEs), physical examinations, electrocardiograms (ECGs), and the Columbia Suicide Severity Rating Scale (C-SSRS).

RESULTS

The average SKAMP-Combined score on the classroom study day was significantly better for the MPH XR-ODT group (n = 43) than for the placebo group (n = 39; p < 0.0001). The effect was evident at 1 hour and lasted through 12 hours postdose. The average SKAMP-Attention, SKAMP-Deportment, PERMP-A, and PERMP-C scores were indicative of significantly greater ADHD symptom control for the MPH XR-ODT group. The most common AEs reported were decreased appetite, upper abdominal pain, headache, insomnia, upper respiratory tract infection, affect lability, irritability, cough, and vomiting.

CONCLUSIONS

MPH XR-ODT was effective and well tolerated for the treatment of children with ADHD in a laboratory classroom setting. Clinical Trial Registry: NCT01835548 ( ClinicalTrials.gov ).

Adolescent Patient Education Regarding ADHD Stimulant Diversion And Misuse

OBJECTIVES

Recent studies report that adolescents misuse and divert ADHD stimulants. This study evaluates the extent to which physicians educate adolescents with ADHD about stimulant misuse and diversion (M/D).

METHODS

Child/adolescent psychiatrists (CAP), child neurologists (CN), and developmental-behavioral pediatricians (DBP) in the US completed a questionnaire. Descriptive statistics were performed on the final sample (n=826); multivariate regressions were performed to identify education practice differences.

RESULTS

Only 46% and 44% of physicians educate patients "often" or "very often" on health risks and legal consequences, respectively, of stimulant M/D. CAP are more likely to educate on health and legal consequences than CN, and more likely to educate on legal consequences than DBP. Compared to physicians who prescribe stimulants to 1-10 patients (low prescribers), medium prescribers (11-30 patients) and high prescribers (30+ patients) are more likely to educate about M/D. 60% of physicians counsel patients at least "often" about M/D in a pre-college appointment; 8% have written materials regarding M/D available.

CONCLUSIONS

Many physcians currently don't educate adolescent patients with ADHD often enough about M/D. CN and DBP, and low prescribers, are less likely to educate about M/D.

PRACTICE IMPLICATIONS

Physicians who prescribe stimulants must educate patients more often to prevent stimulant M/D.

Improving homework performance among children with ADHD: A randomized clinical trial

OBJECTIVE

Evidence indicates that children with Attention Deficit Hyperactivity Disorder (ADHD) experience acute and prolonged academic impairment and underachievement including marked difficulty with completing homework. This study is the first to examine the effects of behavioral, psychostimulant, and combined treatments on homework problems, which have been shown to predict academic performance longitudinally.

METHOD

Children with ADHD (ages 5-12, N = 75, 71% male, 83% Hispanic/Latino) and their families were randomly assigned to either behavioral treatment (homework-focused parent training and a daily report card; BPT + DRC) or a waitlist control group. Children also participated in a concurrent psychostimulant crossover trial conducted in a summer treatment program. Children's objective homework completion and accuracy were measured as well as parent-reported child homework behaviors and parenting skills.

RESULTS

BPT + DRC had large effects on objective measures of homework completion and accuracy (Cohen's ds from 1.40 to 2.21, ps < .001). Other findings, including unimodal medication and incremental combined treatment benefits, were not significant.

CONCLUSIONS

Behavioral treatment focused on homework problems results in clear benefits for children's homework completion and accuracy (the difference between passing and failing, on average), whereas long-acting stimulant medication resulted in limited and largely nonsignificant acute effects on homework performance. (PsycINFO Database Record

Utilization of Stimulants and Atomoxetine for Attention-Deficit/Hyperactivity Disorder among 5.4 Million Children Using Population-Based Longitudinal Data

Use of stimulants to treat attention-deficit/hyperactivity disorder (ADHD) has increased over the past two decades and varies substantially between countries. The objective of this multinational population-based study was to examine utilization of ADHD drugs (stimulants and atomoxetine) including comedication with other psychotropic drugs in the entire child population in the five Nordic countries. We included longitudinal data on dispensed ADHD drugs from five Nordic prescription registers during 2008-2012, which in 2012 comprised 48,296 individuals among 5.42 million inhabitants aged 0-17 years. Prevalence of filling ≥1 prescriptions of ADHD drugs among children aged 6-17 years increased during 2008-2012 from 5.9 to 11.2 and 19.4 to 31.0 per 1000 girls and boys, respectively. Prevalence by country showed that Iceland, Finland and Sweden had a steady increase during the study period, while in Norway the prevalence was quite stable and in Denmark it levelled off from 2010. Use in preschoolers (aged 0-5 years) was rare. Iceland had much higher prevalence and incidence than the other Nordic countries. The incidence of ADHD drug use increased during the study period, from 4.0 to 4.9 and from 1.5 to 2.3 per 1000 boys and girls, respectively. The increasing number of new users levelled off somewhat after 2010. Comedication with other psychotropic drugs was more common among girls (33.9%) than boys (27.0%) and was mainly melatonin, followed by antidepressants and antipsychotics. Overall prevalence of ADHD drug use increased among Nordic girls and boys aged 6-17 years, whereas the incidence increased slightly during 2008-2010 but levelled off through 2012. The substantial differences in ADHD drug use across the Nordic countries and high degree of comedication with other psychotropic drugs underscore the importance of close monitoring of treatment for ADHD among children.

Atomoxetine treatment for children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD): a comprehensive meta-analysis of outcomes on parent-rated core symptomatology

Attention-Deficit/Hyperactivity Disorder (ADHD) impacts a significant number of children and adolescents and often leads to deleterious functional impairment. Psychostimulant medication has historically been the first line of pharmacological intervention, though recent years have seen greater attention paid to non-stimulant alternatives. The objective of the present study was to conduct the most comprehensive meta-analysis to date evaluating the efficacy of atomoxetine in reducing core symptomatology of ADHD according to parent report. Selection criteria were applied, and studies were located by searching electronic databases, review of reference sections, and contact with expert researchers; article searching began on 10/01/2013, and the final search was conducted on 09/01/2014. A total of 42 studies met inclusion criteria-33 with control groups and 9 without-for a total sample of 8398 individuals. For those receiving atomoxetine, the summary pre-post (e.g., standardized mean gain) effect size estimate was 1.37 (95% CI [1.24, 1.51], p < .001); atomoxetine was found to statistically significantly outperform control conditions overall (Z = 4.07, p < .001), though results differed by the type of control group; for instance, when comparing atomoxetine to alternative medications as controls, significant differences were no longer present. The non-stimulant atomoxetine led to significant improvement in core ADHD symptomatology and should be considered as a viable pharmacological treatment option for ADHD.

The Effects of Stimulant Medication and Training on Sports Competence Among Children With ADHD

The current study examined the relative efficacy of behavioral sports training, medication, and their combination in improving sports competence among youth with attention deficit/hyperactivity disorder (ADHD). Participants were 73 youth (74% male; 81% Hispanic) between the ages of 5 and 12 diagnosed with Diagnostic and Statistical Manual of Mental Disorders (4th ed.) ADHD enrolled in a Summer Treatment Program (STP). The study consisted of a 2 (medication: methylphenidate, placebo) × 2 (sports training: instruction and practice, recreational play) between-groups design and was conducted over a 3-week period during the STP. Sports training was conducted with a novel sport, badminton, to limit previous sport knowledge and to differentiate it from concurrent sports training that occurred within the STP. Objective and subjective measures of sports skills, knowledge, and behavior were collected. Results indicated that, relative to recreational play, brief sports training improved observed and counselor-rated measures of sports competence including sports skills, knowledge, game awareness, effort, frustration, and enjoyment. During sports training, medication incrementally improved children's observed rule following behavior and counselor-rated sportsmanship relative to placebo. In the absence of sports training, medication improved behavior, effort, and sport knowledge. Training in sports skills and rules produced the largest magnitude effects on sports-related outcomes. Therefore, skills training, rather than medication alone, should be used in conjunction with behavioral intervention to teach sports to youth with ADHD. It is recommended that medication be used only as an adjunct to highly structured sports skills training for youth who display high rates of negative behavior during sports activities.

Parent-Reported Health Consequences and Relationship to Expenditures in Children with ADHD

OBJECTIVES

(1) To describe parents' report of special needs for children with ADHD on the Children with Special Health Care Needs (CSHCN) Screener; and (2) to assess the association between responses to Screener items and annual mental health and total health expenditures per child.

METHODS

In pooled 2002-2011 Medical Expenditure Panel Survey (MEPS) data, we identify children ages 4-17 years with ADHD. We use OLS and two-part regressions to model the relationship between CSHCN Screener items and mental health and total health expenditures. Based on these models we estimate adjusted, average total health expenditures for children with ADHD-both with and without a co-morbid mental health condition-and different combinations of endorsed Screener items. This research was conducted in accordance with prevailing ethical principles.

RESULTS

There were 3883 observations on 2591 children with ADHD. Without a co-morbid mental health condition, average total expenditures per year from adjusted, model-based estimates were $865 for those meeting no Screener items, $2664 for those meeting only the medication item, $3595 for those meeting the medication and counseling items, and $4203 for those meeting the medication, counseling, and use of more health services items. Children with a co-morbid mental health condition had greater total health expenditures for each combination of Screener items. The associations between Screener items and mental health expenditures were similar, but with a slightly lower marginal effect of the medication item (p < 0.001 for all comparisons).

CONCLUSIONS

Parents' responses on the CSHCN Screener are associated with meaningful variation in expenditures for children with ADHD. Though cross-sectional, this study suggests that the CSHCN Screener can be a useful categorization scheme for children with ADHD. It may be an efficient, standardized tool at the point of care for identifying children who need more resources and for targeting intensive interventions in the context of population health management.

Attention-deficit/hyperactivity disorder severity, diagnosis, & later academic achievement in a national sample

Although 11% (6.4 million) American children are diagnosed with attention deficit/hyperactivity disorder (ADHD), the role of ADHD severity in shaping the association between ADHD diagnosis and academic achievement is not understood. Using a nationally-representative sample of 7830 U.S. kindergartners from the Early Childhood Longitudinal Study-Kindergarten Cohort, we use regression and propensity score matching to compare diagnosed (N = 350) and undiagnosed children who are cognitively, behaviorally, and demographically similar. Diagnosed children with less severe ADHD-related behaviors on average scored lower in reading (-0.30 SD) and math (-0.22 SD) than their undiagnosed peers - a difference two times larger than that between diagnosed and undiagnosed children with more severe ADHD-related behaviors. Pharmacological treatment did not attenuate most of this "diagnostic labeling effect" among children with less severe ADHD-related behaviors. Negative factors associated with an ADHD diagnosis may outweigh potential benefits for achievement among children with less severe ADHD-related behaviors, even those receiving treatment.

Classifying sensory profiles of children in the general population

BACKGROUND

The aim of this study was to subtype groups of children in a community sample with and without developmental conditions, based on sensory processing patterns.

METHODS

We used latent profile analysis to determine the number of sensory subtypes in a sample of n = 1132 children aged 3-14 years with typical development and developmental conditions, including autism spectrum disorder (ASD), attention-deficit hyperactivity disorder and learning disabilities.

RESULTS

A five-subtype solution was found to best characterize the sample, which differed on overall degree and differential presentation of sensory processing patterns. Children with and without developmental conditions presented across subtypes, and one subtype was significantly younger in age than others (P < 0.05).

CONCLUSIONS

Our results show that sensory subtypes include both children with typical development and those with developmental conditions. Sensory subtypes have previously been investigated in ASD only, and our results suggest that similar sensory subtypes are present in a sample reflective of the general population of children including those largely with typical development. Elevated scores on sensory processing patterns are not unique to ASD but rather are reflections of children's abilities to respond to environmental demands.

Review of reviews on exposures to synthetic organic chemicals and children's neurodevelopment: Methodological and interpretation challenges

Environmental epidemiology data are becoming increasingly important in public health decision making, which commonly incorporates a systematic review of multiple studies. This review addresses two fundamental questions: What is the quality of available reviews on associations between exposure to synthetic organic chemicals and neurodevelopmental outcomes? What is the value (e.g., quality and consistency) of the underlying literature? Published reviews on associations between synthetic organic environmental chemical exposures and neurodevelopmental outcomes in children were systematically evaluated. Seventy-four relevant reviews were identified, and these were evaluated with respect to four methodological characteristics: (1) systematic inclusion/exclusion criteria and reproducible methods for search and retrieval of studies; (2) structured evaluation of underlying data quality; (3) systematic assessment of consistency across specific exposure-outcome associations; and (4) evaluation of reporting/publication bias. None of the 74 reviews fully met the criteria for all four methodological characteristics. Only four reviews met two criteria, and six reviews fulfilled only one criterion. Perhaps more importantly, the higher quality reviews were not able to meet all of the criteria owing to the shortcomings of underlying studies, which lacked comparability in terms of specific research question of interest, overall design, exposure assessment, outcome ascertainment, and analytic methods. Thus, even the most thoughtful and rigorous review may be of limited value if the underlying literature includes investigations that address different hypotheses and are beset by methodological inconsistencies and limitations. Issues identified in this review of reviews illustrate considerable challenges that are facing assessments of epidemiological evidence.

An Ultraconserved Brain-Specific Enhancer Within ADGRL3 (LPHN3) Underpins Attention-Deficit/Hyperactivity Disorder Susceptibility

BACKGROUND

Genetic factors predispose individuals to attention-deficit/hyperactivity disorder (ADHD). Previous studies have reported linkage and association to ADHD of gene variants within ADGRL3. In this study, we functionally analyzed noncoding variants in this gene as likely pathological contributors.

METHODS

In silico, in vitro, and in vivo approaches were used to identify and characterize evolutionary conserved elements within the ADGRL3 linkage region (~207 Kb). Family-based genetic analyses of 838 individuals (372 affected and 466 unaffected patients) identified ADHD-associated single nucleotide polymorphisms harbored in some of these conserved elements. Luciferase assays and zebrafish green fluorescent protein transgenesis tested conserved elements for transcriptional enhancer activity. Electromobility shift assays were used to verify transcription factor-binding disruption by ADHD risk alleles.

RESULTS

An ultraconserved element was discovered (evolutionary conserved region 47) that functions as a transcriptional enhancer. A three-variant ADHD risk haplotype in evolutionary conserved region 47, formed by rs17226398, rs56038622, and rs2271338, reduced enhancer activity by 40% in neuroblastoma and astrocytoma cells (p_Bonferroni < .0001). This enhancer also drove green fluorescent protein expression in the zebrafish brain in a tissue-specific manner, sharing aspects of endogenous ADGRL3 expression. The rs2271338 risk allele disrupts binding of YY1 transcription factor, an important factor in the development and function of the central nervous system. Expression quantitative trait loci analysis of postmortem human brain tissues revealed an association between rs2271338 and reduced ADGRL3 expression in the thalamus.

CONCLUSIONS

These results uncover the first functional evidence of common noncoding variants with potential implications for the pathology of ADHD.

The use of modified-release methylphenidate in the treatment of attention-deficit/hyperactivity disorder

INTRODUCTION

Since Ritalin® (Methylphenidate-Immediate release or MPH-IR) was introduced for the treatment of attention-deficit/hyperactivity disorder, multiple formulations of MPH have been developed. The specific formulation determines the pharmacokinetic (PK) profile and the onset and duration of action for the compound. Areas covered: Aptensio XR® is a multilayer-release MPH (MPH-MLR) consisting of an MPH-IR layer (40%) and an extended-release (ER) portion of 60% of MPH. It has an initial maximum MPH concentration at about two hours (h) and a second concentration peak at approximately 8 h. This formulation allows for a rapid onset of effect by 1 h and a duration of action through 12 h after dosing. The chemistry, PK, efficacy and adverse event profile of MPH-MLR will be reviewed. Expert commentary: Although the PK profile may prove beneficial to patients in the late afternoon and early evening, it is not clear if this is a significant advantage compared with other MPH-ER formulations.

The Comorbidity of ADHD and Eating Disorders in a Nationally Representative Sample

Evidence suggests a comorbidity of childhood attention-deficit/hyperactivity disorder (ADHD) and subsequent eating disorders. However, most studies have assessed this comorbidity among patient populations as opposed to nationally representative samples and have not explored differences by subtype of each disorder. The current study aims to investigate the association between both clinical (i.e., diagnosed) and subclinical (i.e., presence of behaviors but not all diagnostic criteria) ADHD and eating disorders via a secondary data analysis of the National Longitudinal Study of Adolescent Health (n = 12,262). Results reveal that those with clinical ADHD are more likely to experience (a) clinical eating disorder, (b) clinical-level binging and/or purging behaviors, and (c) clinical-level restrictive behaviors. Those with subclinical ADHD (both inattentive and hyperactive/impulsive) were more likely to experience subclinical binging and/or purging behaviors but not subclinical restrictive behaviors. Implications of study findings pertain to both secondary/targeted prevention of eating disorders and tertiary prevention via patient-specific treatment plans.

Effect of vitamin D supplementation as adjunctive therapy to methylphenidate on ADHD symptoms: A randomized, double blind, placebo-controlled trial

OBJECTIVES

Previous studies have shown that serum levels of vitamin D were lower in attention deficit hyperactivity disorder (ADHD) children compared to healthy controls. The aim of the study was to determine the effect of vitamin D supplementation as adjunctive therapy to methylphenidate on symptoms of children with ADHD.

METHODS

Sixty-two children aged 5-12 years with a diagnosis of ADHD based on DSM-IV criteria were randomly assigned into two groups to receive either 2000IU vitamin D or placebo in addition to methylphenidate for 8 weeks. Symptoms severity was assessed by Conner's Parent Rating Scale-Revised[S] (CPRS), ADHD rating scale-IV (ADHD-RS), and Weekly Parent Ratings of Evening and Morning Behavior (WPREMB) at weeks 0, 4, and 8. Serum levels of 25(OH)D were measured at baseline and after 8 weeks. Anthropometric variables, dietary intake, physical activity, sun exposure, and side effects were assessed.

RESULTS

Fifty-four participants completed the trial. After 8 weeks of supplementation, serum levels of 25(OH)D significantly increased in the vitamin D group. ADHD symptoms decreased significantly in both groups (P < 0.05). Evening symptoms and total score of WPREMB scale were significantly different at weeks 4 and 8 between the two groups (P = 0.013, 0.016, respectively), but no differences were found in symptoms by CPRS and ADHD-RS scales.

DISCUSSION

Vitamin D supplementation as adjunctive therapy to methylphenidate improved ADHD evening symptoms. Future research is needed to clarify vitamin D effects as monotherapy in ADHD and its mechanism. The trial was registered in www.irct.ir is (IRCT201404222394N10).