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

Relationship Between Attention-Deficit/Hyperactivity Disorder Care and Medication Continuity

OBJECTIVE

To describe the relationships between attention-deficit/hyperactivity disorder (ADHD) care practices and subsequent medication use.

METHOD

A retrospective cohort from a random sample of medical records in 50 pediatric practices with 188 providers, including 1,352 children who started ADHD medication, was studied. Independent variables included physician behaviors related to medication titration and monitoring of treatment response. Primary outcomes were number of days covered with ADHD medication during the first year of treatment and time from starting medicine to the first 30-day gap in medication supply. Multilevel modeling and Cox proportional hazards regression models were conducted.

RESULTS

Children had an average medication supply of 217 days in the first year. Half experienced a 30-day gap in medication supply in the first 3 months. Nearly three-fourths had a medication adjustment in the first year with the first adjustment usually being a dosage change. The average time to the first medication adjustment was over 3 months. Physician's first contact with parents occurred in the first month of treatment for less than half, with the average time being over 2 months. Little variation related to ADHD care quality was accounted for at the physician level. Early titration and early contact were related to greater medication supply and continuity of treatment.

CONCLUSION

Earlier physician-delivered ADHD care (e.g., contact with parent after starting medication and medication adjustment) is related to greater medication supply and continuity. It remains to be determined whether interventions that improve the quality of titration and monitoring practices for children with ADHD would also improve medication continuity.

Adolescent Perceptions of Outgrowing Childhood Attention-Deficit Hyperactivity Disorder: Relationship to Symptoms and Quality of Life

OBJECTIVE

Parental and self-perceptions about outgrowing attention-deficit hyperactivity disorder (ADHD) likely impact treatment decisions; however, little is known about these perceptions. The aim of this study was to assess adolescent and parent perceptions of outgrowing childhood ADHD and evaluate how these perceptions relate to ADHD symptoms and quality of life (QoL).

METHOD

Cross-sectional survey of adolescents (13-18 years) with a childhood diagnosis of ADHD and their parents. Participants were contacted by mail and completed questionnaires about: perceptions of outgrowing ADHD, current ADHD symptoms (the Conners' Scales), and QoL (PedsQL). ANCOVAs were conducted to assess the relationship between the perception of outgrowing ADHD and: (1) current ADHD symptoms and (2) QoL, controlling for co-morbidities and medication use.

RESULTS

115 adolescent-parent dyads were enrolled. Mean age was 15.5 ± 1.7 years, 73% were male, and 63% were taking ADHD medication. Only 16% of adolescents and 9% of parents reported outgrowing ADHD, with little correlation between parent and adolescent responses (kappa 0.3). Adolescents who reported Yes or Don't Know to outgrowing ADHD, compared to those who reported No, had lower scores on the inattention (IA) and hyperactivity (H) scales of both parent report and adolescent self-report Conners' scales and higher scores on the adolescent self-report PedsQL.

CONCLUSION

A majority of adolescents do not endorse outgrowing their ADHD diagnosis, but those that do demonstrate fewer ADHD symptoms and better QoL than those who don't, suggesting that adolescents have insight about their level of impairment and should have a valued role in making treatment decisions.

Single-dose Pharmacokinetic Properties and Relative Bioavailability of a Novel Methylphenidate Extended-release Chewable Tablet Compared With Immediate-release Methylphenidate Chewable Tablet

PURPOSE

A novel methylphenidate hydrochloride extended-release chewable tablet (MPH ERCT) was developed to potentially address an unmet need for patients with attention-deficit/hyperactivity disorder, especially children, who cannot or will not swallow tablets or would prefer the convenience of a chewable tablet. This randomized, open-label, crossover trial compared the pharmacokinetic properties and relative bioavailability of MPH ERCT with an MPH chewable immediate-release tablet (IR MPH) formulation in healthy adults.

METHODS

Healthy men and women 18 to 55 years of age were randomly assigned to MPH ERCT 40 mg or 40 mg IR MPH administered in 2 equal doses of 20 mg 6 hours apart with a 7-day washout period. Plasma concentrations of MPH at selected time points up to 24 hours were measured, and pharmacokinetic parameters were determined using a noncompartmental approach in the SAS (Version 9.2) PROC general linear model procedure.

FINDINGS

A total of 33 participants were enrolled in the study; 31 participants were included in the pharmacokinetic analysis. The exposure ratios for MPH ERCT and IR MPH (MPH ERCT/IR MPH) for area under the analyte concentration versus time curves (AUC) from time zero to the last measurable analyte concentration (AUC0-last) (87.64%; 95% CI, 84.96-90.41) and AUC0-∞ (89.11%; 95% CI, 86.57-91.73) were within the standard 80% to 125% bioequivalence acceptance criteria. Mean Cmax for MPH ERCT and IR MPH was 12.51 ng/mL and 15.57 ng/mL, respectively; mean time to Cmax was 4.16 hours and 6.43 hours, respectively. The mean Cmax of MPH ERCT was 80% of the Cmax of IR MPH due to a higher peak concentration that occurs after the second dose of IR MPH. All adverse events were mild in severity.

IMPLICATIONS

The relative bioavailability of MPH ERCT 40 mg, based on the exposure (AUC), was comparable to that of IR MPH 40 mg administered in 2 equal doses of 20 mg 6 hours apart. Both formulations were generally well tolerated.

Population impact of preterm birth and low birth weight on developmental disabilities in US children

PURPOSE

Although previous studies demonstrate associations between adverse perinatal outcomes and developmental disabilities (DDs), study of population impacts is limited.

METHODS

We computed relative risks adjusted (aRRs) for sociodemographic factors and component and summary population attributable fractions (PAFs) for associations between very low birth weight (VLBW, all preterm births), moderately low birth weight (MLBW) + Preterm, MLBW at term, and normal birth weight (NBW) + Preterm and seven DDs (cerebral palsy [CP], autism spectrum disorder [ASD], intellectual disability [ID], behavioral-conduct disorders, attention-deficit-hyperactivity disorder [ADHD], learning disability [LD], and other developmental delay) among children aged 3-17 years in the 2011-2012 National Survey of Children's Health.

RESULTS

VLBW-Preterm, MLBW-Preterm and NBW-Preterm were strongly to moderately associated with CP (aRRs: 43.5, 10.1, and 2.2, respectively; all significant) and also associated with ID, ASD, LD, and other developmental delay (aRR ranges: VLBW-Preterm 2.8-5.3; MLBW-Preterm 1.9-2.8; and NBW-Preterm 1.6-2.3). Summary PAFs for preterm birth and/or LBW were 55% for CP, 10%-20% for ASD, ID, LD, and other developmental delay, and less than 5% for ADHD and behavioral-conduct disorders. Findings were similar whether we assessed DDs as independent outcomes or within mutually exclusive categories accounting for DD co-occurrence.

CONCLUSIONS

Preterm birth has a sizable impact on child neurodevelopment. However, relative associations and population impacts vary widely by DD type.

A new performance measurement system for maternal and child health in the United States

Objective

The Title V Maternal and Child Health (MCH) Block Grant is the linchpin for US MCH services. The first national performance measures (NPMs) for MCH were instituted in 1997. Changing trends in MCH risk factors, outcomes, health services, data sources, and advances in scientific knowledge, in conjunction with budgetary constraints led the Maternal and Child Health Bureau (MCHB) to design a new performance measurement system.

Methods

A workgroup was formed to develop a new system. The following guiding principles were used: (1) Afford States more flexibility and reduce the overall reporting burden; (2) Improve accountability to better document Title V’s impact; (3) Develop NPMs that encompass measures in: maternal and women’s health, perinatal health, child health, children with special health care needs, adolescent health, and cross-cutting areas.

Results

A three-tiered performance measurement system was proposed with national outcome measures (NOMs), NPMs and evidence-based/informed strategy measures (ESMs). NOMs are the ultimate goals that MCHB and States are attempting to achieve. NPMs are measures, generally associated with processes or programs, shown to affect NOMs. ESMs are evidence-based or informed measures that each State Title V program develops to affect the NPMs. There are 15 NPMs from which States select eight, with at least one from each population area. MCHB will provide the data for the NOMs and NPMs, when possible.

Conclusions

The new performance measurement system increases the flexibility and reduces the reporting burden for States by allowing them to choose 8 NPMs to target, and increases accountability by having States develop actionable ESMs.

Significance

The new national performance measure framework for maternal and child health will allow States more flexibility to address their areas of greatest need, reduce their data reporting burden by having the Maternal and Child Health Bureau provide data for the National Outcome and Performance Measures, yet afford States the opportunity to develop measurable strategies to address their selected performance measures.

Prescriptions, nonmedical use, and emergency department visits involving prescription stimulants

OBJECTIVE

Little is known regarding the temporal trends in prescriptions, nonmedical use, and emergency department (ED) visits involving prescription stimulants in the United States. Our aim was to examine these 3 national trends involving dextroamphetamine-amphetamine and methylphenidate in adults and adolescents.

METHOD

Three national surveys conducted between 2006-2011 were used: National Disease and Therapeutic Index, a survey of office-based practices; National Survey on Drug Use and Health, a population survey of substance use; and Drug Abuse Warning Network, a survey of ED visits. Ordinary least squares regression was used to examine temporal changes over time and the associations between the 3 trends.

RESULTS

In adolescents, treatment visits involving dextroamphetamine-amphetamine and methylphenidate decreased over time; nonmedical dextroamphetamine-amphetamine use remained stable, while nonmedical methylphenidate use declined by 54.4% in 6 years. ED visits involving either medication remained stable. In adults, treatment visits involving dextroamphetamine-amphetamine remained unchanged, while nonmedical use went up by 67.1% and ED visits went up by 155.9%. These 3 trends involving methylphenidate remained unchanged. Across age groups, the major source for nonmedical use of both medications was a friend or relative; two-thirds of these friends and relatives had obtained the medication from a physician.

CONCLUSIONS

Trends in prescriptions for stimulants do not correspond to trends in reports of nonmedical use and ED visits. Increased nonmedical stimulant use may not be simply attributed to increased prescribing trends. Future studies should focus on deeper understanding of the proportion of, risk factors for, and motivations for drug diversions.

Prenatal Triptan Exposure and Internalising and Externalising Behaviour Problems in 3-Year-Old Children: Results from the Norwegian Mother and Child Cohort Study

BACKGROUND

Triptans are commonly prescribed for migraine, a pain condition that is highly prevalent in women of childbearing age. No prior studies have investigated associations between exposure to triptans during fetal life and risk of externalising and internalising behaviours in children.

METHODS

This study was set in the Norwegian Mother and Child Cohort study, a prospective birth cohort. A total of 41,173 live, singleton births without major malformations present at 36-month post-partum follow-up were included in this study; 396 used a triptan during pregnancy, 798 used a triptan prior to pregnancy only, 3291 reported migraine without triptan use, and 36,688 reported no history of migraine or triptan use. Marginal structural models were used to analyse the association between timing of triptan exposure and neurodevelopmental outcome.

RESULTS

Children exposed to triptans during pregnancy had a 1.39-fold increased risk of externalising behaviours compared with those whose mothers used triptans prior to pregnancy only (95% CI 0.97, 1.97), a 1.36-fold increased risk compared with the unmedicated migraine group (95% CI 1.02, 1.81), and a 1.41-fold increased risk compared with the population comparison group (95% CI 1.08, 1.85). The greatest risk was associated with first trimester exposure (RR 1.77, 95% CI 0.98, 3.14). Risk differences were small, ranging from 3-6%.

CONCLUSIONS

This study found an increased risk of clinically relevant externalising behaviours in children with prenatal exposure to triptans, and this risk was highest for first trimester exposure. Absolute risks were small, and the results may be due to confounding by underlying migraine severity.

Utilization of same- vs. mixed-sex dyads impacts the observation of sex differences in juvenile social play behavior

The study of juvenile social play behavior has gained popularity due to the disruption of social behaviors in several psychiatric illnesses. In contrast to many tests currently utilized in animal models of psychiatric illness, juvenile social play behavior is part of the normal behavioral repertoire in the laboratory rat and can be observed in a controlled setting but without evocation by the experimenter. Understanding sources of naturally occurring differences in the juvenile social play behavior of the rat is a fundamental first step to guide future research on identifying factors that disrupt this behavior. One of the most commonly found variations is a sex difference, with male rats displaying higher levels of rough-and-tumble play behavior relative to females. This sex difference is also observed in human play. In our recent paper published in Biology of Sex Differences, we investigated how the sex and familiarity of the play partner can impact different components of rough-and-tumble play behavior (pouncing, pinning, boxing, and chasing) and the observation of sex differences within each of these components. Our findings suggest that juvenile male rough-and-tumble play behavior is impacted by the sex of their play partner, while females are more sensitive to the familiarity of their play partner. In this review, we discuss our recent findings and provide a comprehensive comparison of methodology and the reporting of sex differences in the literature on this topic.

Trait and State Variance in Multi-Informant Assessments of ADHD and Academic Impairment in Spanish First-Grade Children

OBJECTIVE

We examined the stable trait and variable state components of ADHD-inattention (IN), ADHD-hyperactivity/impulsivity (HI), and academic impairment (AI) dimensions using mothers', fathers', primary and secondary teachers' ratings of children's behavior at home and school. We also examined between-informant agreement with regard to trait and state components.

METHOD

Mothers, fathers, primary and secondary teachers rated HI, IN, and AI in N = 758 Spanish first grade children (55% boys) over three measurement occasions across 12 months.

RESULTS

Latent state-trait analyses revealed that mothers', fathers', and primary teachers' (but not secondary teachers') ratings reflected more trait variance for ADHD-HI (M = 73%), ADHD-IN (M = 74%), and AI (M = 76%) than occasion-specific variance (M = 27%, M = 26%, and M = 24%, respectively). Fathers' ratings shared a meaningful level of trait variance with mothers' ratings of ADHD-HI and ADHD-IN (range 78% to 82%), whereas primary and secondary teachers' ratings shared lower levels of trait variance with mothers' ratings (range 41% to 63%). The trait components of fathers', primary teachers', and secondary teachers' ratings of AI showed high levels of convergence with mothers' ratings (88%, 70%, and 59% respectively).

CONCLUSIONS

ADHD symptom reports reflect both trait (48 to 86%) and state (14 to 53%) variance components. The lower amount of shared variability between home and school suggests the setting-specificity of trait and state components of ADHD symptoms. Our findings indicate that ADHD symptom reports may reflect context-specific traits, suggesting the importance of differentiating and targeting ADHD behaviors across different settings.

Recalled Initiation and Duration of Maternal Breastfeeding Among Children with and Without ADHD in a Well Characterized Case-Control Sample

Early environmental influences are increasingly of interest in understanding ADHD as a neurodevelopmental condition, particularly in light of recognition that gene by environment interplay are likely involved in this condition. Breastfeeding duration predicts cognitive development, as well as development of brain white matter connectivity, in areas similar to those seen in ADHD. Prior studies show an association between breastfeeding and ADHD but without adequate evaluation of ADHD. A case control cohort of 474 children aged 7-13 years was examined, 291 with well characterized ADHD (71.5 % male) and the rest typically developing controls (51.9 % male). Mothers retrospectively reported on breast feeding initiation and duration. Initiation of breastfeeding was not associated with child ADHD, but shorter duration of breastfeeding was associated with child ADHD with a medium effect size (d = 0.40, p < 0.05); this effect held after covarying a broad set of potential confounders, including child oppositional defiant and conduct problems and including maternal and paternal ADHD symptoms. Effects were replicated across both parent and teacher ratings of child ADHD symptoms. Shorter duration of breastfeeding is among several risk factors in early life associated with future ADHD, or else longer duration is protective. The direction of this effect is unknown, however. It may be that some children are more difficult to breastfeed or that breastfeeding provides nutrients or other benefits that reduce future chance of ADHD.

Impulsive Aggression as a Comorbidity of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

OBJECTIVE

This article examines the characteristics of impulsive aggression (IA) as a comorbidity in children and adolescents with attention-deficit/hyperactivity disorder (ADHD), focusing on its incidence, impact on ADHD outcomes, need for timely intervention, and limitations of current treatment practices.

METHODS

Relevant literature was retrieved with electronic searches in PubMed and PsycINFO using the search strategy of "ADHD OR attention deficit hyperactivity disorder" AND "impulsive aggression OR reactive aggression OR hostile aggression OR overt aggression" AND "pediatric OR childhood OR children OR pre-adolescent OR adolescent" with separate searches using review OR clinical trial as search limits. Key articles published before the 2007 Expert Consensus Report on IA were identified using citation analysis.

RESULTS

More than 50% of preadolescents with ADHD combined subtype reportedly display clinically significant aggression, with impulsive aggression being the predominant subtype. Impulsive aggression is strongly predictive of a highly unfavorable developmental trajectory characterized by the potential for persistent ADHD, increasing psychosocial burden, accumulating comorbidities, serious lifelong functional deficits across a broad range of domains, delinquency/criminality, and adult antisocial behavior. Impulsive aggression, which triggers peer rejection and a vicious cycle of escalating dysfunction, may be a key factor in unfavorable psychosocial outcomes attributed to ADHD. Because severe aggressive behavior does not remit in many children when treated with primary ADHD therapy (i.e., stimulants and behavioral therapy), a common practice is to add medication of a different class to specifically target aggressive behavior.

CONCLUSIONS

Impulsive aggression in children and adolescents with ADHD is a serious clinical and public health problem. Although adjunctive therapy with an aggression-targeted agent is widely recommended when aggressive behaviors do not remit with primary ADHD therapy, empirical evidence does not currently support the use of any specific agent. Randomized controlled trials are needed to identify aggression-targeted agents with favorable benefit-risk profiles.

Changing Academic Support in the Home for Adolescents with Attention-Deficit/Hyperactivity Disorder: A Family-Based Clinical Protocol for Improving School Performance

Attention-Deficit/Hyperactivity Disorder (ADHD) is highly prevalent among adolescent clinical populations and associated with myriad deficits in school functioning. Yet, behavior therapists have few developmentally appropriate tools for addressing school problems in this group. This article introduces a behavioral protocol designed to fill the gap: Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA). CASH-AA is a family-based intervention that targets home environment, adolescent skills, and family-school partnership characteristics in order to improve school performance. Protocol components are derived from three evidence-based approaches for adolescent behavior problems: family psychoeducation, clinical family interventions to heighten adolescent and caregiver motivation to change, and training interventions for homework planning and organization skills. CASH-AA contains four treatment modules: (1) Psychoeducation: ADHD and Academic Functioning; (2) Motivation & Preparation: Home Academic Environment; (3) Behavior Change: School Attendance and Homework Plan; (4) Collaboration: Therapist-Family-School Partnership. The protocol can be implemented as a stand-alone intervention for ADHD or an adjunct to other behavioral interventions for co-occurring disorders. Two case examples with markedly different treatment profiles are presented to illustrate the utility and flexibility of the protocol.

Markers, Models, and Measurement Error: Exploring the Links Between Attention Deficits and Language Impairments

PURPOSE

The empirical record regarding the expected co-occurrence of attention-deficit/hyperactivity disorder (ADHD) and specific language impairment is confusing and contradictory. A research plan is presented that has the potential to untangle links between these 2 common neurodevelopmental disorders.

METHOD

Data from completed and ongoing research projects examining the relative value of different clinical markers for separating cases of specific language impairment from ADHD are presented.

RESULTS

The best option for measuring core language impairments in a manner that does not potentially penalize individuals with ADHD is to focus assessment on key grammatical and verbal memory skills. Likewise, assessment of ADHD symptoms through standardized informant rating scales is optimized when they are adjusted for overlapping language and academic symptoms.

CONCLUSION

As a collection, these clinical metrics set the stage for further examination of potential linkages between attention deficits and language impairments.

Diagnostic Issues and Controversies in DSM-5: Return of the False Positives Problem

The fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was the most controversial in the manual's history. This review selectively surveys some of the most important changes in DSM-5, including structural/organizational changes, modifications of diagnostic criteria, and newly introduced categories. It analyzes why these changes led to such heated controversies, which included objections to the revision's process, its goals, and the content of altered criteria and new categories. The central focus is on disputes concerning the false positives problem of setting a valid boundary between disorder and normal variation. Finally, this review highlights key problems and issues that currently remain unresolved and need to be addressed in the future, including systematically identifying false positive weaknesses in criteria, distinguishing risk from disorder, including context in diagnostic criteria, clarifying how to handle fuzzy boundaries, and improving the guidelines for "other specified" diagnosis.

Attention-Deficit Hyperactivity Disorder Across the Lifespan

Up to 10% of school-age children have attention-deficit hyperactivity disorder (ADHD), which often persists into adulthood. ADHD can be associated with significant comorbidity of disruptive, mood, and anxiety disorders. Although many children with ADHD have good long-term outcomes, a significant subset has substance abuse, antisocial behavior, and mood disorders as adults. Pharmacotherapy with stimulants, atomoxetine, and alpha-agonists is highly effective in the short term; behavior therapy is valuable as an adjunct to medication or to address comorbid conditions. Multiple genes each likely contribute small effects to the risk of ADHD. Neuroimaging studies suggest that individuals with ADHD have insufficient activation of cortical attention networks, reduced activity of ventral striatal reward systems, and dysregulated control of the default mode network. No neuroimaging technique is yet useful clinically. More long-term studies of both medication and psychosocial interventions are needed to improve outcomes.

Persistence of Parent-Reported ADHD Symptoms From Childhood Through Adolescence in a Community Sample

OBJECTIVE

To examine ADHD symptom persistence and factors associated with elevated symptom counts in a diverse, longitudinal community-based sample.

METHOD

Parents reported demographics and completed a diagnostic interview repeatedly over a 6-year period. At Time 1, 481 interviews were completed about children (5-13 years); all participants were invited to four annual follow-up interviews, and 379 (79%) completed at least one. Inattentive (IA) and hyperactive-impulsive (HI) symptom counts were modeled with logistic quantile regression, while accounting for study design complexities.

RESULTS

The prevalence of seven IA symptoms remained stable from early childhood through late adolescence. The prevalence of eight HI symptoms decreased by more than half over time. After demographic adjustment, the upper quartile of HI symptom counts decreased with age (p < .01). High HI symptom counts persisted more among those with high IA symptom counts (p = .05).

CONCLUSION

This study further characterizes and provides insights into ADHD symptom trajectory through adolescence.

Prescription Psychostimulant Use Among Young Adults: A Narrative Review of Qualitative Studies

BACKGROUND

Within the last decade, the nonmedical use of prescription drugs has raised concern, particularly among young adults. Psychostimulants, that is to say amphetamine and its derivatives, are pharmaceuticals, which contribute to what has come to be known in Canada and the United States as the "prescription drug crisis." Research in the fields of public health, addiction studies, and neuroethics has attempted to further understand this mounting issue; however, there is a paucity of data concerning the underlying social logics related to the use of these substances.

OBJECTIVES

The objective of this article is to provide an overview of the current literature related to the social context of prescription psychostimulant use among young adults, and to discuss theoretical considerations as well as implications for future research.

METHODS

A narrative review of the literature was performed.

RESULTS

We found that research efforts have chiefly targeted college students, yet there is a lack of knowledge concerning other social groups likely to use these pharmaceuticals nonmedically, such as persons with high strain employment. Three main emerging patterns related to prescription psychostimulant use were identified: (1) control of external stressors, (2) strategic use toward the making of the self, and (3) increasing one's performance.

CONCLUSIONS

Prescription psychostimulant use among young adults is anchored in contemporary normativity and cannot be separated from the developing performance ethic within North-American and other Western societies. We suggest that pharmaceuticalization and Actor-Network Theory are useful conceptual tools to frame future research efforts.

Drugs That Bind to α-Synuclein: Neuroprotective or Neurotoxic?

The misfolding of α-synuclein is a critical event in the death of dopaminergic neurons and the progression of Parkinson's disease. Drugs that bind to α-synuclein and form a loop structure between the N- and C-terminus tend to be neuroprotective, whereas others that cause a more compact structure tend to be neurotoxic. The binding of several natural products and other drugs that are involved in dopamine metabolism were investigated by nanopore analysis and isothermal titration calorimetry. The antinausea drugs, cinnarizine and metoclopramide, do not bind to α-synuclein, whereas amphetamine and the herbicides, paraquat and rotenone, bind tightly and cause α-synuclein to adopt a more compact conformation. The recreational drug, cocaine, binds to α-synuclein, whereas heroin and methadone do not. Metformin, which is prescribed for diabetes and is neuroprotective, binds well without causing α-synuclein to adopt a more compact conformation. Methylphenidate (ritalin) binds to sites in both the N- and C-terminus and causes α-synuclein to adopt a loop conformation. In contrast, amphetamine only binds to the N-terminus. Except for cinnarizine and metoclopramide, there is a good correlation between the mode of binding to α-synuclein and whether a drug is neuroprotective or neurotoxic.

Incorporating Informatics for Integrating Biology and the Bedside (i2b2) into Predoctoral Trainee Curriculum to Evaluate Student-Generated Hypotheses

As part of the Clinical and Translational Science Institute predoctoral TL1 training program at the Pennsylvania State University, a multidisciplinary team of predoctoral trainees representing the Chemistry, Neurosurgery, Nutritional Sciences, and Public Health Sciences departments were introduced to the NIH-sponsored Informatics for Integrating Biology and the Bedside (i2b2) database to test the following student-generated hypothesis: children with iron deficiency anemia (IDA) are at increased risk of attention deficit-hyperactivity disorder (ADHD). Children aged 4-12 and 4-17 years were categorized into IDA and control groups. De-identified medical records from the Penn State Milton S. Hershey Medical Center (HMC) and the Virginia Commonwealth University Medical Center (VCUMC) were used for the analysis. Overall, ADHD prevalence at each institution was lower than 2011 state estimates. There was a significant association between IDA and ADHD in the 4-17-year-old age group for all children (OR: 1.902 [95% CI: 1.363-2.656]), Caucasian children (OR: 1.802 [95% CI: 1.133-2.864]), and African American children (OR: 1.865 [95% CI: 1.152-3.021]). Clinical and Translational Science Award (CTSA) infrastructure is particularly useful for trainees to answer de novo scientific questions with minimal additional training and technical expertise. Moreover, projects can be expanded by collaborating within the CTSA network.

Dissociation of working memory impairments and attention-deficit/hyperactivity disorder in the brain

Prevailing neuropsychological models of attention-deficit/hyperactivity disorder (ADHD) propose that ADHD arises from deficits in executive functions such as working memory, but accumulating clinical evidence suggests a dissociation between ADHD and executive dysfunctions. This study examined whether ADHD and working memory capacity are behaviorally and neurobiologically separable using functional magnetic resonance imaging (fMRI). Participants diagnosed with ADHD in childhood who subsequently remitted or persisted in their diagnosis as adults were characterized at follow-up in adulthood as either impaired or unimpaired in spatial working memory relative to controls who never had ADHD. ADHD participants with impaired spatial working memory performed worse than controls and ADHD participants with unimpaired working memory during an n-back working memory task while being scanned. Both controls and ADHD participants with unimpaired working memory exhibited significant linearly increasing activation in the inferior frontal junction, precuneus, lingual gyrus, and cerebellum as a function of working-memory load, and these activations did not differ significantly between these groups. ADHD participants with impaired working memory exhibited significant hypoactivation in the same regions, which was significantly different than both control participants and ADHD participants with unimpaired working memory. These findings support both a behavioral and neurobiological dissociation between ADHD and working memory capacity.

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ADHD and working memory deficits were behaviorally and neurally dissociable.

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Working memory performance was unrelated to the current ADHD diagnosis.

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Impaired working memory was associated with reduced brain activations.

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Working memory status was stable, while ADHD diagnostic status was more variable.

Assent as an ethical imperative in the treatment of ADHD

The American Academy of Paediatrics endorses obtaining assent when prescribing medications for attention-deficit/hyperactivity disorder (ADHD) in older children whenever possible. Studies indicate the concept of assent may not be well understood by clinicians, possibly effecting effective and widespread implementation. We argue that though the concept of assent continues to evolve, it is critical in the context of patient-centred care, shared decision-making and in supporting minors' transition to adulthood. Based on the principle of respect for young persons, we argue that obtaining assent is an ethical imperative when prescribing medication for ADHD. We highlight the instrumental benefits of obtaining assent in the paediatric clinical encounter when prescribing medications for treatment of ADHD.

Prevalence of severe ADHD: an epidemiological study in the Italian regions of Tuscany and Latium

BACKGROUND

The rate with which attention deficit/hyperactivity disorder (ADHD) is diagnosed varies widely across countries, suggesting that cultural factors influence the clinical interpretation of child behaviour. This study estimated the point prevalence of severe ADHD among elementary and middle-school Italian children.

METHOD

An epidemiological sample of 2016 children attending 2nd-8th grade in the Italian regions of Tuscany and Latium was selected based on census distribution of the school-age population. Teachers completed the Italian version of the ADHD Rating Scale for Teachers (SDAI). For children with at least six inattention symptoms and/or at least six hyperactivity/impulsivity symptoms rated 'very often' by the teachers, the parents completed the Italian ADHD Rating Scale for Parents (SDAG). Children with documented ADHD symptoms at both school and home received a complete psychiatric interview with the Kiddie Schedule for Affective Disorders and Schizophrenia-present and lifetime version (K-SADS-PL).

RESULTS

Of the 1887 assessed children, 4.45% (95% CI 3.58-5.51) met the ADHD cut-off on teacher ratings, 1.43% (0.96-2.12) had ADHD symptoms endorsed by both teacher and parent, and 1.32% (0.87-1.97) were further confirmed by the psychiatric evaluation. The male:female ratio was 7:1. The inattentive type accounted for about half of the ADHD cases.

CONCLUSIONS

When applying stringent criteria for both severity and pervasiveness of symptoms, it is estimated that about 1.3% of the Italian elementary and middle-school children suffer from severe ADHD.

Stimulant Medications and Sleep for Youth With ADHD: A Meta-analysis

CONTEXT

Mixed findings exist on whether stimulant medications alter youth sleep.

OBJECTIVE

To determine the effect of stimulant medications on sleep.

DATA STUDIES

Studies published through March 2015 were collected via CINAHL, PsycINFO, and PubMed. References of retrieved articles were reviewed.

STUDY SELECTION

Eligibility criteria included studies with children/adolescents who had attention-deficit/hyperactivity disorder (ADHD), random assignment to stimulants, and objective sleep measurement. Studies that did not include information about key variables were excluded.

DATA EXTRACTION

Study-level, child-level, and sleep data were extracted by 2 independent coders. Effect sizes were calculated by using random effects models. Potential moderators were examined by using mixed effect models.

RESULTS

A total of 9 articles (N = 246) were included. For sleep latency, the adjusted effect size (0.54) was significant, indicating that stimulants produce longer sleep latencies. Frequency of dose per day was a significant moderator. For sleep efficiency, the adjusted effect size (-0.32) was significant. Significant moderators included length of time on medication, number of nights of sleep assessed, polysomnography/actigraphy, and gender. Specifically, the effect of medication was less evident when youth were taking medication longer. For total sleep time, the effect size (-0.59) was significant, such that stimulants led to shorter sleep duration.

LIMITATIONS

Limitations include few studies, limited methodologic variability, and lack of unpublished studies.

CONCLUSIONS

Stimulant medication led to longer sleep latency, worse sleep efficiency, and shorter sleep duration. Overall, youth had worse sleep on stimulant medications. It is recommended that pediatricians carefully monitor sleep problems and adjust treatment to promote optimal sleep.

Differentiating patterns of prescription stimulant medical and nonmedical use among youth 10-18 years of age

OBJECTIVE

To assess the past 30-day prevalence of prescription stimulant use, report different forms of nonmedical use, and investigate different characteristics associated with Medical Users Only, Nonmedical Users Only, and youth who reported both medical and nonmedical use (MU+NMU youth).

METHODS

The National Monitoring of Adolescent Prescription Stimulants Study recruited 11,048 youth aged 10-18 years from entertainment venues in 10 US cities.

RESULTS

In this study, 6.8% youth used prescription stimulants in the past 30 days, with 3.0% reporting Medical Use Only (MU Only), 1.1% reporting Both Medical and Nonmedical Use (MU+NMU), and 2.5% reporting Nonmedical Use Only (NMU Only). Use of other's stimulants was the most frequently reported form of nonmedical use (88.4%), followed by using more than prescribed (38.9%), and using outside of the prescribed route (32.2%). Medical Users Only and MU+NMU youth did not differ from Non-Users in cigarette, alcohol, and illicit drug use. MU+NMU youth tended to have more conduct problem behaviors compared to Medical Users Only (p=0.0011) and Nonmedical Users Only (p=0.0132). Compared to MU+NMU youth, Nonmedical Users Only were more likely to have close friends who tried Adderall (p=0.0123), endorse binge drinking (p=0.0118) and illicit drug use (p<0.0015).

CONCLUSIONS

Future research should investigate the sources of the nonmedically used prescription stimulants and how they were diverted. Intervention programs need to acknowledge the differences between MU+NMU youth and Nonmedical Users Only, and employ different strategies to prevent nonmedical use in these subgroups.

Prescription Stimulant Use and Hospitalization for Psychosis or Mania: A Population-Based Study

Small studies suggest that prescription stimulants can precipitate psychosis and mania. We conducted a population-based case-crossover study to examine whether hospitalization for psychosis or mania was associated with initiation of stimulant therapy. Between October 1, 1999 and March 31, 2013, we studied 12,856 young people who received a stimulant prescription and were subsequently hospitalized for psychosis or mania. Of these, 183 commenced treatment during 1 of 2 prespecified 60-day intervals (defined as the "risk interval" and "control interval," respectively) prior to admission. We found that stimulant initiation was associated with an increased risk of hospitalization for psychosis or mania in the subsequent 60 days (odds ratio, 1.86; 95% confidence interval, 1.39-2.56). The risk was marginally higher in patients treated with antipsychotic drugs (odds ratio, 2.06; 95% confidence interval, 1.38-3.28), but remained in patients with no such history (odds ratio, 1.66; 95% confidence interval, 1.09-2.66). One third of subjects received another stimulant prescription after hospital discharge. Of these, 45% were readmitted with psychosis or mania shortly thereafter. We conclude that initiation of prescription stimulants is associated with an increased risk of hospitalization for psychosis or mania. Resumption of therapy is common, which may reflect a lack of awareness of the potential causative role of these drugs.

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children with ADHD find it difficult to pay attention, they are hyperactive and impulsive.Methylphenidate is the drug most often prescribed to treat children and adolescents with ADHD but, despite its widespread use, this is the first comprehensive systematic review of its benefits and harms.

OBJECTIVES

To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD.

SEARCH METHODS

In February 2015 we searched six databases (CENTRAL, Ovid MEDLINE, EMBASE, CINAHL, PsycINFO, Conference Proceedings Citations Index), and two trials registers. We checked for additional trials in the reference lists of relevant reviews and included trials. We contacted the pharmaceutical companies that manufacture methylphenidate to request published and unpublished data.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. At least 75% of participants needed to have an intellectual quotient of at least 70 (i.e. normal intellectual functioning). Outcomes assessed included ADHD symptoms, serious adverse events, non-serious adverse events, general behaviour and quality of life.

DATA COLLECTION AND ANALYSIS

Seventeen review authors participated in data extraction and risk of bias assessment, and two review authors independently performed all tasks. We used standard methodological procedures expected within Cochrane. Data from parallel-group trials and first period data from cross-over trials formed the basis of our primary analyses; separate analyses were undertaken using post-cross-over data from cross-over trials. We used Trial Sequential Analyses to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach for high risk of bias, imprecision, indirectness, heterogeneity and publication bias.

MAIN RESULTS

The studies.We included 38 parallel-group trials (5111 participants randomised) and 147 cross-over trials (7134 participants randomised). Participants included individuals of both sexes, at a boys-to-girls ratio of 5:1, and participants' ages ranged from 3 to 18 years across most studies (in two studies ages ranged from 3 to 21 years). The average age across all studies was 9.7 years. Most participants were from high-income countries.The duration of methylphenidate treatment ranged from 1 to 425 days, with an average duration of 75 days. Methylphenidate was compared to placebo (175 trials) or no intervention (10 trials). Risk of Bias.All 185 trials were assessed to be at high risk of bias. Primary outcomes. Methylphenidate may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.77, 95% confidence interval (CI) -0.90 to -0.64; 19 trials, 1698 participants; very low-quality evidence). This corresponds to a mean difference (MD) of -9.6 points (95% CI -13.75 to -6.38) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points; DuPaul 1991a). A change of 6.6 points on the ADHD-RS is considered clinically to represent the minimal relevant difference. There was no evidence that methylphenidate was associated with an increase in serious (e.g. life threatening) adverse events (risk ratio (RR) 0.98, 95% CI 0.44 to 2.22; 9 trials, 1532 participants; very low-quality evidence). The Trial Sequential Analysis-adjusted intervention effect was RR 0.91 (CI 0.02 to 33.2).

SECONDARY OUTCOMES

Among those prescribed methylphenidate, 526 per 1000 (range 448 to 615) experienced non-serious adverse events, compared with 408 per 1000 in the control group. This equates to a 29% increase in the overall risk of any non-serious adverse events (RR 1.29, 95% CI 1.10 to 1.51; 21 trials, 3132 participants; very low-quality evidence). The Trial Sequential Analysis-adjusted intervention effect was RR 1.29 (CI 1.06 to 1.56). The most common non-serious adverse events were sleep problems and decreased appetite. Children in the methylphenidate group were at 60% greater risk for trouble sleeping/sleep problems (RR 1.60, 95% CI 1.15 to 2.23; 13 trials, 2416 participants), and 266% greater risk for decreased appetite (RR 3.66, 95% CI 2.56 to 5.23; 16 trials, 2962 participants) than children in the control group.Teacher-rated general behaviour seemed to improve with methylphenidate (SMD -0.87, 95% CI -1.04 to -0.71; 5 trials, 668 participants; very low-quality evidence).A change of seven points on the Child Health Questionnaire (CHQ; range 0 to 100 points; Landgraf 1998) has been deemed a minimal clinically relevant difference. The change reported in a meta-analysis of three trials corresponds to a MD of 8.0 points (95% CI 5.49 to 10.46) on the CHQ, which suggests that methylphenidate may improve parent-reported quality of life (SMD 0.61, 95% CI 0.42 to 0.80; 3 trials, 514 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

The results of meta-analyses suggest that methylphenidate may improve teacher-reported ADHD symptoms, teacher-reported general behaviour, and parent-reported quality of life among children and adolescents diagnosed with ADHD. However, the low quality of the underpinning evidence means that we cannot be certain of the magnitude of the effects. Within the short follow-up periods typical of the included trials, there is some evidence that methylphenidate is associated with increased risk of non-serious adverse events, such as sleep problems and decreased appetite, but no evidence that it increases risk of serious adverse events.Better designed trials are needed to assess the benefits of methylphenidate. Given the frequency of non-serious adverse events associated with methylphenidate, the particular difficulties for blinding of participants and outcome assessors point to the advantage of large, 'nocebo tablet' controlled trials. These use a placebo-like substance that causes adverse events in the control arm that are comparable to those associated with methylphenidate. However, for ethical reasons, such trials should first be conducted with adults, who can give their informed consent.Future trials should publish depersonalised individual participant data and report all outcomes, including adverse events. This will enable researchers conducting systematic reviews to assess differences between intervention effects according to age, sex, comorbidity, type of ADHD and dose. Finally, the findings highlight the urgent need for large RCTs of non-pharmacological treatments.

Diversion of ADHD Stimulants and Victimization Among Adolescents

OBJECTIVE

To examine whether a recent prescription for stimulant medication is associated with peer victimization among youth with attention deficit/hyperactivity disorder (ADHD).

METHODS

Data from 4,965 adolescents attending five public schools who completed an annual web survey over 4 years were used to examine recent stimulant medication prescription and self-reported frequent victimization.

RESULTS

Adolescents with ADHD and recent stimulant prescription reported more victimization than those without ADHD, but similar to adolescents with ADHD and no recent prescription. Adolescents with ADHD and past 12-month diversion of their prescribed stimulants were at greatest risk of 12-month frequent victimization compared with adolescents without ADHD and adolescents with ADHD but no recent prescription. Youth approached to divert reported more victimization than youth not approached. Youth who diverted reported more victimization than those who did not divert.

CONCLUSIONS

Close parent-prescriber collaboration is needed to ensure effective medical treatment for ADHD without greater risk for victimization and treatment failure.

A Randomized, Placebo-Controlled Trial of Guanfacine Extended Release in Adolescents With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Despite the continuity of attention-deficit/hyperactivity disorder (ADHD) into adolescence, little is known regarding use of nonstimulants to treat ADHD in adolescents. This phase 3 trial evaluated the safety and efficacy of guanfacine extended release (GXR) in adolescents with ADHD.

METHOD

This 13-week, multicenter, randomized, double-blind, placebo-controlled trial evaluated once-daily GXR (1-7 mg per day) in adolescents with ADHD aged 13 to 17 years. The primary endpoint was the change from baseline in the ADHD Rating Scale-IV (ADHD-RS-IV) total score; key secondary endpoints included scores from the Clinical Global Impressions-Severity of Illness (CGI-S), and Learning and School domain and Family domain scores from the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) at week 13.

RESULTS

A total of 314 participants were randomized (GXR, n = 157; placebo, n = 157). The majority of participants received optimal doses of 3, 4, 5, or 6 mg (30 [22.9%], 26 [19.8%], 27 [20.6%], or 24 [18.3%] participants, respectively), with 46.5% of participants receiving an optimal dose above the currently approved maximum dose limit of 4 mg. Participants receiving GXR showed improvement in ADHD-RS-IV total score compared with placebo (least-squares mean score change, -24.55 [GXR] versus -18.53 [placebo]; effect size, 0.52; p <.001). More participants on GXR also showed significant improvement in CGI-S scores compared with placebo (50.6% versus 36.1%; p = .010). There was no statistically significant difference between treatments at week 13 in the 2 WFIRS-P domains. Most treatment-emergent adverse events were mild to moderate, with sedation-related events reported most commonly.

CONCLUSION

GXR was associated with statistically significant improvements in ADHD symptoms in adolescents. GXR was well tolerated, with no new safety signals reported.

CLINICAL TRIAL REGISTRATION INFORMATION

Dose-Optimization in Adolescents Aged 13-17 Diagnosed With Attention-Deficit/Hyperactivity Disorder (ADHD) Using Extended-Release Guanfacine HCl; http://ClinicalTrials.gov/; NCT01081132.

Antipsychotic prescribing for behavioral disorders in US youth: physician specialty, insurance coverage, and complex regimens

PURPOSE

To assess antipsychotic prescribing patterns according to insurance coverage type and physician specialty in the outpatient treatment of behavioral disorders (BD) in US youth.

METHODS

We used 2003-2010 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data to compare antipsychotic prescribing in the outpatient treatment of BD in youth (6-19 years) according to insurance coverage (public vs. private) and physician specialty (psychiatrist vs. non-psychiatrist) using population-weighted Chi-square and multivariable analyses. Also, we examined co-prescribing of antipsychotics with other psychotropic medication classes. Subgroup analyses were conducted in BD visits with no other clinician-reported psychiatric diagnosis (non-comorbid BD visits).

RESULTS

A large majority (71.0%) of BD visits were provided by non-psychiatrists. However, psychiatrists prescribed antipsychotics far more frequently than non-psychiatrists (24.2% vs. 4.6%; adjusted odds ratio (AOR) = 5.1 [95% confidence interval (CI), 2.8-9.2]) in total BD visits as well as in non-comorbid BD visits (18.6% vs. 3.6%; AOR = 5.8 [95% CI, 3.2-10.5]). Antipsychotic prescribing was nearly two-fold greater in visits by publicly insured 6-12 year olds (11.3% vs. 5.8%; AOR = 1.9 [95% CI, 1.1-3.5]) and 13-19 year olds (16.2% vs. 8.9%; AOR = 2.0 [95% CI, 1.1-3.6]) compared with their privately insured counterparts. In more than one-third of antipsychotic-prescribed BD visits, antipsychotics were prescribed concomitantly with ≥2 psychotropic medication classes regardless of age group, insurance coverage, or even in the absence of psychiatric comorbidities.

CONCLUSION

In outpatient visits by youth for BD, antipsychotics were primarily prescribed by psychiatrists, concomitantly, and for the publicly insured. These treatment patterns merit further investigation.

Are the Recent Secular Increases in Waist Circumference among Children and Adolescents Independent of Changes in BMI?

Background

Several studies have shown that the waist circumference of children and adolescents has increased over the last 25 years. However, given the strong correlation between waist circumference and BMI, it is uncertain if the secular trends in waist circumference are independent of those in BMI.

Methods

We analyzed data from 6- to 19-year-olds who participated in the 1988–1994 through 2011–2012 cycles of the National Health and Nutrition Examination Survey to assess whether the trends in waist circumference were independent of changes in BMI, race-ethnicity and age.

Results

Mean, unadjusted levels of waist circumference increased by 3.7 cm (boys) and 6.0 cm (girls) from 1988–94 through 2011–12, while mean BMI levels increased by 1.1 kg/m² (boys) and 1.6 kg/m² (girls). Overall, the proportional changes in mean levels of both waist circumference and BMI were fairly similar among boys (5.3%, waist vs. 5.6%, BMI) and girls (8.7%, waist vs. 7.7%, BMI). As assessed by the area under the curve, adjustment for BMI reduced the secular increases in waist circumference by about 75% (boys) and 50% (girls) beyond that attributable to age and race-ethnicity. There was also a race-ethnicity interaction (p < 0.001). Adjustment for BMI reduced the secular trend in waist circumference among non-Hispanic (NH) black children (boys and girls) to a greater extent (about 90%) than among other children.

Conclusions

Our results indicate that among children in the U.S., about 75% (boys) and 50% (girls) of the secular increases in waist circumference since 1988–94 can be accounted for by changes in BMI. The reasons for the larger independent effects among girls and among NH blacks are uncertain.

Evaluating the content of Individualized Education Programs and 504 Plans of young adolescents with attention deficit/hyperactivity disorder

The purpose of this study was to evaluate the degree with which Individualized Education Programs (IEPs) and 504 Plans prepared for middle school students with attention deficit/hyperactivity disorder (ADHD) conformed to best practices and included evidence-based services. Specifically, we examined the problem areas identified in the statement of students' present level of academic achievement and functional performance (PLAAFP) and targeted in the students' measurable annual goals and objectives (MAGOs). In addition, we compared services with lists of recommended services provided by the U.S. Department of Education (ED) and reviews of evidence-based practices. Participants were 97 middle school students with ADHD, 61.9% with an IEP, and 38.1% with a 504 Plan. Most (85%) IEP PLAAFP statements described nonacademic/behavior problems, but fewer than half had MAGOs targeting these areas of need. Services listed on IEPs and Section 504 Plans were frequently consistent with ED recommendations, but had little to no research supporting their effectiveness. In addition, services with evidence supporting benefit to students with ADHD were rarely included on IEPs or 504 Plans. Implications for special education policy and future directions are discussed.

Adolescent D-amphetamine treatment in a rodent model of ADHD: Pro-cognitive effects in adolescence without an impact on cocaine cue reactivity in adulthood

Attention-deficit/hyperactivity disorder (ADHD) is comorbid with cocaine abuse. Whereas initiating ADHD medication in childhood does not alter later cocaine abuse risk, initiating medication during adolescence may increase risk. Preclinical work in the Spontaneously Hypertensive Rat (SHR) model of ADHD found that adolescent methylphenidate increased cocaine self-administration in adulthood, suggesting a need to identify alternatively efficacious medications for teens with ADHD. We examined effects of adolescent d-amphetamine treatment on strategy set shifting performance during adolescence and on cocaine self-administration and reinstatement of cocaine-seeking behavior (cue reactivity) during adulthood in male SHR, Wistar-Kyoto (inbred control), and Wistar (outbred control) rats. During the set shift phase, adolescent SHR needed more trials and had a longer latency to reach criterion, made more regressive errors and trial omissions, and exhibited slower and more variable lever press reaction times. d-Amphetamine improved performance only in SHR by increasing choice accuracy and decreasing errors and latency to criterion. In adulthood, SHR self-administered more cocaine, made more cocaine-seeking responses, and took longer to extinguish lever responding than control strains. Adolescent d-amphetamine did not alter cocaine self-administration in adult rats of any strain, but reduced cocaine seeking during the first of seven reinstatement test sessions in adult SHR. These findings highlight utility of SHR in modeling cognitive dysfunction and comorbid cocaine abuse in ADHD. Unlike methylphenidate, d-amphetamine improved several aspects of flexible learning in adolescent SHR and did not increase cocaine intake or cue reactivity in adult SHR. Thus, adolescent d-amphetamine was superior to methylphenidate in this ADHD model.

Timing of the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder

BACKGROUND AND OBJECTIVE

Symptoms of inattention, hyperactivity, and impulsivity are core features of attention-deficit/hyperactivity disorder (ADHD). However, children with autism spectrum disorder (ASD) often present with similar symptoms and may receive a diagnosis of ADHD first. We investigated the relationship between the timing of ADHD diagnosis in children with ASD and the age at ASD diagnosis.

METHODS

Data were drawn from the 2011-2012 National Survey of Children's Health, which asked parents to provide the age(s) at which their child received a diagnosis of ADHD and/or ASD. Using weighted prevalence estimates, we examined the association between a previous diagnosis of ADHD and the age at ASD diagnosis, while controlling for factors known to influence the timing of ASD diagnosis.

RESULTS

Our study consisted of 1496 children with a current diagnosis of ASD as reported by parents of children ages 2 to 17 years. Approximately 20% of these children had initially been diagnosed with ADHD. Children diagnosed with ADHD before ASD were diagnosed with ASD ∼3 years (95% confidence interval 2.3-3.5) after children in whom ADHD was diagnosed at the same time or after ASD. The children with ADHD diagnosed first were nearly 30 times more likely to receive their ASD diagnosis after age 6 (95% confidence interval 11.2-77.8). The delay in ASD diagnosis was consistent across childhood and independent of ASD severity.

CONCLUSION

To avoid potential delays in ASD diagnosis, clinicians should consider ASD in young children presenting with ADHD symptoms.

Exposure to bisphenol A during pregnancy and child neuropsychological development in the INMA-Sabadell cohort

BACKGROUND

Bisphenol A (BPA) may be a neurodevelopmental toxicant, but evidence is not consistent in terms of the sex-specific patterns of the associations and the specific behavioral or cognitive domains most affected.

OBJECTIVE

To examine the effects of prenatal BPA exposure on cognitive, psychomotor, and behavioral development in 438 children at 1, 4 and 7 years of age.

METHODS

BPA was measured in spot urine samples collected in trimester 1 and 3 of pregnancy from women participating in the INMA-Sabadell birth cohort study. Cognitive and psychomotor development was assessed at 1 and 4 years using psychologist-based scales. Attention deficit hyperactivity disorder (ADHD) symptoms and other behavioral problems were assessed at 4 years by teachers and at 7 years by parents using questionnaire-based rating scales.

RESULTS

Geometric mean creatinine-adjusted BPA concentration of the averaged samples was 2.6 μg/g creatinine. BPA exposure was not associated with the cognitive scores or their subscales at 1 and 4 years of age. At 1 year of age, exposure in the highest tertile of BPA concentrations was associated with a reduction of psychomotor scores (T3 vs T1 β=-4.28 points, 95% CI: -8.15, -0.41), but there was no association with psychomotor outcomes at 4 years. At 4 years, BPA exposure was associated with an increased risk of ADHD-hyperactivity symptoms (Incidence Rate Ratio (IRR) per log10 μg BPA/g creatinine increase=1.72; 1.08, 2.73) and this association was stronger in boys than in girls. Further, boys had an increased risk of ADHD-inattention symptoms whereas girls showed a reduced risk (p for interaction <0.1). At 7 years, these associations were not statistically significant nor were any other behavioral problems.

CONCLUSIONS

These results suggest that prenatal BPA exposure does not affect cognitive development up to age 4 years. Associations are observed with psychomotor development and ADHD-related symptoms at early ages, but these do not appear to persist until later ages.

Age and Cohort Patterns of Medical and Nonmedical Use of Controlled Medication Among Adolescents

OBJECTIVES

We identified peak annual incidence rates for medical and nonmedical use of prescription opioid analgesics, stimulants, sedatives, and anxiolytics (controlled medication), and explored cohort effects on age of initiation.

METHODS

Data were gathered retrospectively between 2009 and 2012 from Detroit area students (n = 5185). Modal age at the last assessment was 17 years. A meta-analytic approach produced age-, year-, and cohort-specific risk estimates of first-time use of controlled medication. Cox regression models examined cohort patterns in age of initiation for medical and nonmedical use with any of 4 classes of controlled medication (opioid analgesics, stimulants, sedatives, or anxiolytics).

RESULTS

Peak annual incidence rates were observed at age 16 years, when 11.3% started medical use, and 3.4% started using another person's prescription for a controlled medication (ie, engaged in nonmedical use). In the more recent birth cohort group (1996-2000), 82% of medical users and 76% of nonmedical users reported initiating such use by age 12 years. In contrast, in the less recent birth cohort group (1991-1995), 42% of medical users and 35% of nonmedical users initiated such use by age 12 years. Time to initiation was 2.6 times less in the more recent birth cohort group (medical use: adjusted hazard ratio [aHR] = 2.57 [95% confidence interval {CI} = 2.32-2.85]; nonmedical use: aHR = 2.57 [95% CI = 2.17-3.03]).

CONCLUSIONS

Peak annual incidence rates were observed at age 16 years for medical and nonmedical use. More recent cohorts reported initiating both types of use at younger ages. Earlier interventions may be needed to prevent adolescent nonmedical use of controlled medication.

Use of Mental Health Services by Children Ages Six to 11 With Emotional or Behavioral Difficulties

OBJECTIVE

The authors reported use of mental health services among children in the United States between ages six and 11 who were described by their parents as having emotional or behavioral difficulties (EBDs).

METHODS

Using data from the 2010-2012 National Health Interview Survey, the authors estimated the national percentage of children ages six to 11 with serious or minor EBDs (N=2,500) who received treatment for their difficulties, including only mental health services other than medication (psychosocial services), only medication, both psychosocial services and medication, and neither type of service. They calculated the percentage of children who received school-based and non-school-based psychosocial services in 2011-2012 and who had unmet need for psychosocial services in 2010-2012.

RESULTS

In 2010-2012, 5.8% of U.S. children ages six to 11 had serious EBDs and 17.3% had minor EBDs. Among children with EBDs, 17.8% were receiving both medication and psychosocial services, 28.8% psychosocial services only, 6.8% medication only, and 46.6% neither medication nor psychosocial services. Among children with EBDs in 2011-2012, 18.6% received school-based psychosocial services only, 11.4% non-school-based psychosocial services only, and 17.3% both school- and non-school-based psychosocial services. In 2010-2012, 8.2% of children with EBDs had unmet need for psychosocial services.

CONCLUSIONS

School-age children with EBDs received a range of mental health services, but nearly half received neither medication nor psychosocial services. School-based providers played a role in delivering psychosocial services, but parents reported an unmet need for psychosocial services among some children.

Multimodal neuroimaging computing: a review of the applications in neuropsychiatric disorders

Multimodal neuroimaging is increasingly used in neuroscience research, as it overcomes the limitations of individual modalities. One of the most important applications of multimodal neuroimaging is the provision of vital diagnostic data for neuropsychiatric disorders. Multimodal neuroimaging computing enables the visualization and quantitative analysis of the alterations in brain structure and function, and has reshaped how neuroscience research is carried out. Research in this area is growing exponentially, and so it is an appropriate time to review the current and future development of this emerging area. Hence, in this paper, we review the recent advances in multimodal neuroimaging (MRI, PET) and electrophysiological (EEG, MEG) technologies, and their applications to the neuropsychiatric disorders. We also outline some future directions for multimodal neuroimaging where researchers will design more advanced methods and models for neuropsychiatric research.

The Effect of Medical Treatment of Attention Deficit Hyperactivity Disorder (ADHD) on Foster Care Caseloads: Evidence from Danish Registry Data

Since the early 2000s, foster care caseloads have decreased in many wealthy democracies, yet the causes of these declines remain, for the most part, a mystery. This article uses administrative data on all Danish municipalities (N = 277) and a 10% randomly drawn sample of all Danish children (N = 157,938) in the period from 1998 to 2010 to show that increasing medical treatment of attention deficit hyperactivity disorder (ADHD) accounts for a substantial share of the decrease in foster care caseloads. According to our estimates, the decline in foster care caseloads during this period would have been 45% smaller absent increases in medical treatment of ADHD. These findings are especially provocative in light of recent research showing ambiguous effects of medical treatment of ADHD. Future research should be attentive to how medical treatment aimed at addressing children's acute behavioral problems could also have a powerful effect on foster care caseloads.

The association between youth violence exposure and attention-deficit/hyperactivity disorder (ADHD) symptoms in a sample of fifth-graders

The purpose of the current study was to examine the association between violence exposures (no exposure, witness or victim only, and both witness and victim) and attention-deficit/hyperactivity disorder (ADHD) symptoms, as well as the potential moderating role of gender. Data from 4,745 5th graders and their primary caregivers were drawn from the Healthy Passages study of adolescent health. Parent respondents completed the DISC Predictive Scales for ADHD, and youth provided information about exposure to violence. Results indicated that youth who reported both witnessing and victimization had more parent-reported ADHD symptoms and were more likely to meet predictive criteria for ADHD. Among those with both exposures, girls exhibited a steeper increase in ADHD symptoms and higher probability of meeting predictive criteria than did boys. Findings indicate that being both victim-of and witness-to violence is significantly associated with ADHD symptoms particularly among girls.

Mental Health Implications of Traumatic Brain Injury (TBI) in Children and Youth

OBJECTIVE

Traumatic brain injury (TBI) is the most common cause of death and disability in children and adolescents. Psychopathology is an established risk factor for, and a frequent consequence of, TBI. This paper reviews the literature relating psychopathology and TBI.

METHOD

Selective literature review.

RESULTS

The risk of sustaining a TBI is increased by pre-existing psychopathology (particularly ADHD and aggression) and psychosocial adversity. Even among individuals with no psychopathology prior to the injury, TBI is frequently followed by mental illness especially ADHD, personality change, conduct disorder and, less frequently, by post-traumatic stress and anxiety disorders. The outcome of TBI can be partially predicted by pre-injury adjustment and injury severity, but less well by age at injury. Few individuals receive treatment for mental illness following TBI.

CONCLUSION

TBI has substantial relevance to mental health professionals and their clinical practice. Available evidence, while limited, indicates that the risk for TBI in children and adolescents is increased in the presence of several, potentially treatable mental health conditions and that the outcome of TBI involves a range of mental health problems, many of which are treatable. Prevention and management efforts targeting psychiatric risks and outcomes are an urgent priority. Child and adolescent mental health professionals can play a critical role in the prevention and treatment of TBI through advocacy, education, policy development and clinical practice.

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a persistent neurodevelopmental disorder that affects 5% of children and adolescents and 2.5% of adults worldwide. Throughout an individual's lifetime, ADHD can increase the risk of other psychiatric disorders, educational and occupational failure, accidents, criminality, social disability and addictions. No single risk factor is necessary or sufficient to cause ADHD. In most cases ADHD arises from several genetic and environmental risk factors that each have a small individual effect and act together to increase susceptibility. The multifactorial causation of ADHD is consistent with the heterogeneity of the disorder, which is shown by its extensive psychiatric co-morbidity, its multiple domains of neurocognitive impairment and the wide range of structural and functional brain anomalies associated with it. The diagnosis of ADHD is reliable and valid when evaluated with standard criteria for psychiatric disorders. Rating scales and clinical interviews facilitate diagnosis and aid screening. The expression of symptoms varies as a function of patient developmental stage and social and academic contexts. Although there are no curative treatments for ADHD, evidenced-based treatments can markedly reduce its symptoms and associated impairments. For example, medications are efficacious and normally well tolerated, and various non-pharmacological approaches are also valuable. Ongoing clinical and neurobiological research holds the promise of advancing diagnostic and therapeutic approaches to ADHD. For an illustrated summary of this Primer, visit: http://go.nature.com/J6jiwl.

Attention Deficit Hyperactivity Disorder Medication Use Among Teens and Young Adults

PURPOSE

The purpose of this study was to determine rates of stimulant/atomoxetine use among teens (aged 12-17 years) and young adults (aged 18-23 years) and to investigate associations in medication use before and after the transition from teen to young adult.

METHODS

Repeated cross-sectional analyses using the nationally representative Medical Expenditure Panel Survey. The sample included all teens and young adults between 2003 and 2012. Within this group, a staggered sample of individuals between 2006 and 2012 born during a 5-year range was used to minimize false positive findings due to temporal trends. The primary outcome was attention deficit hyperactivity disorder (ADHD) medication use (two or more prescriptions and ≥60 tablets). A multivariable logistic regression was utilized to determine associations between ADHD medication use and race/ethnicity and other sociodemographic factors.

RESULTS

A total of 62,699 individuals were included between 2003 and 2012. Rates of ADHD medication use increased for both teens (4.2%-6.0%) and young adults (1.2%-2.6%) between 2003-2004 and 2011-2012. In adjusted analysis, blacks, Hispanics, and Asians had lower rates of use compared with whites. The decrease in use among young adults was more pronounced among blacks compared with whites. A usual source of care and health insurance were less common among young adults, and both were associated with ADHD medication use.

CONCLUSIONS

Although there has been an increase in the use of ADHD medications in both teens and young adults, we found a drop-off in levels of ADHD treatment among young adults when compared with teens. A portion of this decrease appears to be related to race/ethnicity, usual source of care, and health insurance status.

A comprehensive scoping review of ability and disability in ADHD using the International Classification of Functioning, Disability and Health-Children and Youth Version (ICF-CY)

This is the first in a series of four empirical investigations to develop International Classification of Functioning, Disability and Health (ICF) Core Sets for Attention Deficit Hyperactivity Disorder (ADHD). The objective here was to use a comprehensive scoping review approach to identify the concepts of functional ability and disability used in the scientific ADHD literature and link these to the nomenclature of the ICF-CY. Systematic searches were conducted using Medline/PubMed, PsycINFO, ERIC and Cinahl, to extract the relevant concepts of functional ability and disability from the identified outcome studies of ADHD. These concepts were then linked to ICF-CY by two independent researchers using a standardized linking procedure. Data from identified studies were analysed until saturation of ICF-CY categories was reached. Eighty studies were included in the final analysis. Concepts contained in these studies were linked to 128 ICF-CY categories. Of these categories, 68 were considered to be particularly relevant to ADHD (i.e., identified in at least 5 % of the studies). Of these, 32 were related to Activities and participation, 31 were related to Body functions, and five were related to environmental factors. The five most frequently identified categories were school education (53 %), energy and drive functions (50 %), psychomotor functions (50 %), attention functions (49 %), and emotional functions (45 %). The broad variety of ICF-CY categories identified in this study underlines the necessity to consider ability and disability in ADHD across all dimensions of life, for which the ICF-CY provides a valuable and universally applicable framework. These results, in combination with three additional preparatory studies (expert survey, focus groups, clinical study), will provide a scientific basis to define the ICF Core Sets for ADHD for multi-purpose use in basic and applied research, and every day clinical practice.