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

Systematic review of the epidemiology of attention deficit hyperactivity disorder in Arab countries

Objective:

To assess the epidemiology of attention deficit hyperactivity disorder (ADHD) in Arab countries, and identify gaps for future research.

Methods:

We searched PubMed from July 1978 to July 2014 and reviewed local journals with cross-referencing. The keywords we used were ADHD, diagnosis, prevalence, incidence, factor, diagnosis, rate, risk, and each of the names of the 22 Arab countries (Jordan, Egypt, Lebanon, Saudi Arabia, and so on). Studies were eligible for inclusion if they investigated the epidemiology of ADHD in any Arab country, and were published in English. The search was conducted from 2nd to 5th August 2014 in King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

Results:

A total of 22 articles were included in the review. Twenty studies were cross-sectional and found the prevalence of ADHD ranged between 1.3-16%, prevalence of hyperactive type ADHD between 1.4-7.8%, and the prevalence of inattention type between 2.1-2.7%. Only 2 case-control studies investigated potential risk factors. Evidence extracted from these studies shows a significant association between ADHD and male gender, previous psychiatric illness in the family, vitamin D deficiency, poor school performance, sleep problems, and nocturnal enuresis.

Conclusion:

The prevalence of ADHD in Arab countries is comparable to reports in North America, Africa, and other countries of the Middle East. Longitudinal studies are needed to investigate the prognosis and determinants of this condition in the Arab world.

Executive functioning profiles from the BRIEF across pediatric medical disorders: Age and diagnosis factors

The objective of the study was to compare executive functioning (EF) profiles across several pediatric medical conditions and explore the influence of age of diagnosis and evaluation. A retrospective, cross-sectional study of 734 children aged 5 to 18 years was conducted across five medical groups (brain tumor, leukemia [ALL], epilepsy [EPI], neurofibromatosis type 1 [NF1], and ornithine transcarbamylase deficiency [OTC-D]), attention deficit hyperactivity disorder (ADHD) controls, and matched healthy controls. We compared groups across the scales of a parent-completed Behavior Rating Inventory of Executive Functioning (BRIEF) using a repeated measures analysis of variance (ANOVA). Separate ANOVAs were conducted to look at age factors. The results showed that the ADHD group differed from all other groups and had the highest level of reported EF problems. The NF1 and OTC-D groups differed significantly from the healthy comparison group for overall EF problems, while the EPI and cancer groups did not. Working memory was the most elevated scale across medical groups, followed by plan/organize. Children with medical disorders were two to four times more likely than healthy controls to have clinically significant problems in several EF domains. There was a main effect for age at diagnosis and age at evaluation. A subset of children with medical disorders were found to have parent-reported EF difficulties, with particular vulnerability noted in working memory and organizational/planning skills. This has relevance for the development of interventions that may be helpful across disorders. Children with particular diagnoses and earlier age of diagnosis and evaluation had greater reported EF problems.

Childhood: a suitable case for treatment?

We examine the contemporary debate on attention deficit hyperactivity disorder, in which concerns about medicalisation and overuse of drug treatments are paramount. We show medicalisation in attention deficit hyperactivity disorder to be a complex issue that requires systematic research to be properly understood. In particular, we suggest that the debate on this disorder might be more productive and less divisive if longitudinal, evidence-based understanding of the harms and benefits of psychiatric diagnosis and misdiagnosis existed, as well as better access to effective, non-drug treatments. If articulation of the values that should guide clinical practice in child psychiatry is encouraged, this might create greater trust and less division.

Caregiver Preferences Regarding Personal Health Records in the Management of ADHD

OBJECTIVE

Personal health records (PHRs) may address the needs of children with attention deficit hyperactivity disorder. Among parents, we assessed acceptance, barriers, and intentions regarding use of PHR for their children with attention deficit hyperactivity disorder.

METHODS

Survey of parents from 3 practices in Rochester, NY. Stepwise logistic regression analysis explored factors predicting respondents' intentions for future use of PHR, accounting for care coordination needs, caregiver education, socioeconomic status, and satisfaction with providers.

RESULTS

Of 184 respondents, 23% had used the PHR for their child, 82% intended future use. No difference was observed between users and nonusers regarding gender, age, race, or education. Users were more likely than nonusers to reside in the suburbs (P = .03). Caregivers were more likely to plan future use of the PHR if they felt engaged as partners in their child's care (adjusted odds ratio = 2.3, 95% confidence interval = 1.2, 4.5).

CONCLUSIONS

Parents are enthusiastic about PHRs. Future work should focus on engaging them as members of the health care team.

Anxiety, Decision Conflict, and Health in Caregivers of Children with ADHD: A Survey

The purpose of this study was to test a theoretical model to determine the effect of caregiver anxiety and decision conflict on the health of caregivers of children with ADHD. Cross-sectional analyses were conducted on data derived from caregivers (aged 24-70). Participants completed the Decision Conflict Scale, the Zung Anxiety Scale, the Duke Health Profile, and a demographic form. A path model that fit well indicated that anxiety and decision conflict had direct and indirect effects on the caregivers' health. Future study is needed to clarify factors contributing to uncertainty and to decrease emotional symptoms for caregivers, thus promoting their mental health.

Peak ages of risk for starting nonmedical use of prescription stimulants

BACKGROUND

To produce population-level, year- and age-specific risk estimates of first time nonmedical use of prescription stimulants among young people in the United States.

METHODS

Data are from the National Surveys on Drug Use and Health 2004-2012; a nationally representative probability sample survey administered each year. Subpopulations included youths aged 12 to 21 years (n=240,160) who had not used prescription stimulants nonmedically prior to their year of survey assessment. A meta-analytic approach was used to produce population-level age-, year-, and cohort-specific risk estimates of first time nonmedical use of prescription stimulants.

RESULTS

Peak risk of starting nonmedical use of prescription stimulants was concentrated between ages 16 and 19 years, when an estimated 0.7% to 0.8% of young people reported nonmedical use of these medicines for the first time in the past twelve months. Smaller risk estimates ranging from 0.1% to 0.6% were observed at ages 12 to 15 years and 20 to 21 years. Compared with males, females were more likely to have started nonmedical use of prescription stimulants (odds ratio=1.35; 95% CI, 1.13-1.62), particularly between the ages of 14 and 19. Females showed a peak annual incidence rate of 1% at age 18, while males the same age showed an incidence rate of 0.5%.

CONCLUSIONS

Peak annual incidence rates for nonmedical use of prescription stimulants were observed between the ages of 16 and 19 years. There is reason to initiate interventions during the earlier adolescent years to prevent youths from starting nonmedical use of prescription stimulants.

The role of maternal obesity in the risk of neuropsychiatric disorders

Recent evidence indicates that perinatal exposure to maternal obesity, metabolic disease, including diabetes and hypertension, and unhealthy maternal diet has a long-term impact on offspring behavior and physiology. During the past three decades, the prevalence of both obesity and neuropsychiatric disorders has rapidly increased. Epidemiologic studies provide evidence that maternal obesity and metabolic complications increase the risk of attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, anxiety, depression, schizophrenia, eating disorders (food addiction, anorexia nervosa, and bulimia nervosa), and impairments in cognition in offspring. Animal models of maternal high-fat diet (HFD) induced obesity also document persistent changes in offspring behavior and impairments in critical neural circuitry. Animals exposed to maternal obesity and HFD consumption display hyperactivity, impairments in social behavior, increased anxiety-like and depressive-like behaviors, substance addiction, food addiction, and diminished cognition. During development, these offspring are exposed to elevated levels of nutrients (fatty acids, glucose), hormones (leptin, insulin), and inflammatory factors (C-reactive protein, interleukin, and tumor necrosis factor). Such factors appear to permanently change neuroendocrine regulation and brain development in offspring. In addition, inflammation of the offspring brain during gestation impairs the development of neural pathways critical in the regulation of behavior, such as serotoninergic, dopaminergic, and melanocortinergic systems. Dysregulation of these circuits increases the risk of mental health disorders. Given the high rates of obesity in most developed nations, it is critical that the mechanisms by which maternal obesity programs offspring behavior are thoroughly characterized. Such knowledge will be critical in the development of preventative strategies and therapeutic interventions.

Sex differences in ADHD symptom severity

BACKGROUND

Males show higher rates of attention deficit hyperactivity disorder (ADHD) than do females. Potential explanations include genuine etiological differences or artifact.

METHODS

2,332 twin and sibling youth participated in behavioral and cognitive testing. Partially competing models of symptom severity distribution differences, the mean difference, and variance difference models, were tested within a randomly selected subsample. The Delta method was used to test for mediation of sex differences in ADHD symptom severity by processing speed, inhibition and working memory.

RESULTS

The combined mean difference and variance difference models fully explained the sex difference in ADHD symptom severity. Cognitive endophenotypes mediated 14% of the sex difference effect.

CONCLUSIONS

The sex difference in ADHD symptom severity is valid and may be due to differing genetic and cognitive liabilities between the sexes.

The Efficacy and Safety of Evekeo, Racemic Amphetamine Sulfate, for Treatment of Attention-Deficit/Hyperactivity Disorder Symptoms: A Multicenter, Dose-Optimized, Double-Blind, Randomized, Placebo-Controlled Crossover Laboratory Classroom Study

OBJECTIVE

The study goal was to determine the efficacy and safety of an optimal dose of Evekeo, racemic amphetamine sulfate, 1:1 d-amphetamine and l-amphetamine (R-AMPH), compared to placebo in treating children with attention-deficit/hyperactivity disorder (ADHD) in a laboratory classroom setting.

METHODS

A total of 107 children ages 6-12 years were enrolled in this multicenter, dose-optimized, randomized, double-blind, placebo-controlled crossover study. After 8 weeks of open-label dose optimization, 97 subjects were randomized to 2 weeks of double-blind treatment in the sequence of R-AMPH followed by placebo (n=47) or placebo followed by R-AMPH (n=50). Efficacy measures included the Swanson, Kotkin, Agler, M-Flynn, and Pelham (SKAMP) Rating Scale and Permanent Product Measure of Performance (PERMP) administered predose and at 0.75, 2, 4, 6, 8, and 10 hours postdose on 2 laboratory classroom days. Safety assessments included physical examination, chemistry, hematology, vital signs, and treatment-emergent adverse events (TEAEs).

RESULTS

Compared to placebo, a single daily dose of R-AMPH significantly improved SKAMP-Combined scores (p<0.0001) at each time point tested throughout the laboratory classroom days, with effect onset 45 minutes postdose and extending through 10 hours. R-AMPH significantly improved PERMP number of problems attempted and correct (p<0.0001) throughout the laboratory classroom days. During the twice-daily dose-optimization open-label phase, improvements were observed with R-AMPH in scores of the ADHD-Rating Scale IV and Clinical Global Impressions Severity and Improvement Scales. TEAEs and changes in vital signs associated with R-AMPH were generally mild and not unexpected. The most common TEAEs in the open-label phase were decreased appetite (27.6%), upper abdominal pain (14.3%), irritability (14.3%), and headache (13.3%).

CONCLUSIONS

Compared to placebo, R-AMPH was effective in treating children aged 6-12 years with ADHD, beginning at 45 minutes and continuing through 10 hours postdose, and was well tolerated.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01986062. https://clinicaltrials.gov/ct2/show/NCT01986062.

Recent international trends in psychotropic medication prescriptions for children and adolescents

Prescriptions of psychotropic medications have become an important intervention for many children and adolescents with mental disorders, and the rise of these prescriptions is debated intensively both among experts and the public. This review reports some recent international findings on point prevalence rates, cross-country comparisons, and time trends in psychotropic medication prescriptions for children and adolescents. Besides the total prescription rates, figures for antidepressants, antipsychotics, stimulants, and anxiolytics prescriptions are provided. The overall prescription rates of psychotropics in general and the major medication subgroups prescribed to children and adolescents vary substantially between countries with the US consumption being markedly higher than the use in European countries. However, even among the latter there are marked variations in findings. Studies reporting on time trends clearly indicate that there was a marked increase in the use of psychotropics for children and adolescents in the recent past. However, only a single study adjusted prevalence rates for the increasing number of children and adolescents assessed and treated in institutions providing mental health care. Considering the increasing numbers of children and adolescents seen in psychiatric services, the increase of psychotropic medications is less strong though still pronounced enough to stimulate further reflections on the use of these interventions.

Treatment of Attention Deficit/Hyperactivity Disorder among Children with Special Health Care Needs

OBJECTIVES

To describe the parent-reported prevalence of treatments for attention deficit/hyperactivity disorder (ADHD) among a national sample of children with special health care needs (CSHCN), and assess the alignment of ADHD treatment with current American Academy of Pediatrics guidelines.

STUDY DESIGN

Parent-reported data from the 2009-2010 National Survey of Children with Special Health Care Needs allowed for weighted national and state-based prevalence estimates of medication, behavioral therapy, and dietary supplement use for ADHD treatment among CSHCN aged 4-17 years with current ADHD. National estimates were compared across demographic groups, ADHD severity, and comorbidities. Medication treatment by drug class was described.

RESULTS

Of CSHCN with current ADHD, 74.0% had received medication treatment in the past week, 44.0% had received behavioral therapy in the past year, and 10.2% used dietary supplements for ADHD in the past year. Overall, 87.3% had received past week medication treatment or past year behavioral therapy (both, 30.7%; neither, 12.7%). Among preschool-aged CSHCN with ADHD, 25.4% received medication treatment alone, 31.9% received behavioral therapy alone, 21.2% received both treatments, and 21.4% received neither treatment. Central nervous system stimulants were the most common medication class (84.8%) among CSHCN with ADHD, followed by the selective norepinephrine reuptake inhibitor atomoxetine (8.4%).

CONCLUSION

These estimates provide a benchmark of clinical practice for the period directly preceding issuance of the American Academy of Pediatrics' 2011 ADHD guidelines. Most children with ADHD received medication treatment or behavioral therapy; just under one-third received both. Multimodal treatment was most common for CSHCN with severe ADHD and those with comorbidities. Approximately one-half of preschoolers received behavioral therapy, the recommended first-line treatment for this age group.

DSM-5, psychiatric epidemiology and the false positives problem

The revision effort leading to the publication of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was flawed in process, goals and outcome. The revision process suffered from lack of an adequate public record of the rationale for changes, thus shortchanging future scholarship. The goals, such as dimensionalising diagnosis, incorporating biomarkers and separating impairment from diagnosis, were ill-considered and mostly abandoned. However, DSM-5's greatest problem, and the target of the most vigorous and sustained criticism, was its failure to take seriously the false positives problem. By expanding diagnosis beyond plausible boundaries in ways inconsistent with DSM-5's own definition of disorder, DSM-5 threatened the validity of psychiatric research, including especially psychiatric epidemiology. I present four examples: increasing the symptom options while decreasing the diagnostic threshold for substance use disorder, elimination of the bereavement exclusion from major depression, allowing verbal arguments as evidence of intermittent explosive disorder and expanding attention-deficit/hyperactivity disorder to adults before addressing its manifest false positives problems.

ADHD symptomatology is best conceptualized as a spectrum: a dimensional versus unitary approach to diagnosis

The aim of this paper is to build a case for the utility of conceptualizing ADHD, not as a unitary disorder that contains several subtypes, but rather as a marker of impairment in attention and/or impulsivity that can be used to identify one of several disorders belonging to a spectrum. The literature will be reviewed to provide an overview of what is known about ADHD in terms of heterogeneity in symptomatology, neuropsychology, neurobiology, as well as comorbidity with other diseases and treatment options. The data from these areas of research will be critically analyzed to support the construct of a spectrum of disorders that can capture the great variability that exists between individuals with ADHD and can discriminate between separate disorders that manifest similar symptoms. The symptoms associated with ADHD can be viewed as dimensional markers that point to a spectrum of related disorders that have as part of their characteristics impairments of attention and impulsivity. The spectrum can accommodate symmetrically and asymmetrically comorbid psychiatric disorders associated with ADHD as well as the wide heterogeneity known to be a part of the ADHD disorder. Individuals presenting with impairments associated with ADHD should be treated as having a positive marker for a spectrum disorder that has as part of its characteristics impairments of attention and/or impulsivity. The identification of impairment in attention and/or impulsivity should be a starting point for further testing rather than being an endpoint of diagnosis that results in pharmacological treatment that may or may not be the optimal therapy. Rather than continuing to attribute a large amount of heterogeneity in symptom presentation as well as a high degree of symmetric and asymmetric comorbidity to a single disorder, clinical evaluation should turn to the diagnosis of the type of attentional deficit and/or impulsivity an individual has in order to colocate the individual's disorder on a spectrum that captures the heterogeneity in symptomatology, the symmetrical and asymmetrical comorbidity, as well as subthreshold presentation and other variants often worked into the disorder of ADHD. The spectrum model can accommodate not only the psychophysiological profiles of patients, but is also consistent with what is known about the functional heterogeneity of the prefrontal cortex as well as the construct that cognitive processes are supported by overlapping and collaborative networks.

Stimulant therapy in children with attention-deficit/hyperactivity disorder and concomitant long QT syndrome: A safe combination?

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is prevalent in about 11% of children in the United States. As such, ADHD is expected to be present in patients with long QT syndrome (LQTS), a rare, potentially lethal but highly treatable cardiac channelopathy. ADHD-directed stimulant therapy is relatively contraindicated in patients with LQTS because of concern for LQTS-triggered events.

OBJECTIVE

The purpose of this study was to evaluate the ADHD-directed treatment, outcome, and frequency of LQTS-triggered events in patients with LQTS and concomitant ADHD.

METHODS

A retrospective electronic medical record review of 357 pediatric patients with LQTS evaluated between 1999 and 2014 was performed to determine the prevalence of concomitant ADHD and the incidence of LQTS-triggered events in patients with LQTS, with or without concomitant ADHD.

RESULTS

Overall, 28 patients (8%) were diagnosed with LQTS concomitant ADHD. There were no phenotypic differences between patients with LQTS and ADHD, and LQTS alone. ADHD-directed stimulant therapy was stopped or advised against in 19 patients (68%) at the time of first evaluation or after diagnosis. None of the 15 stimulant-treated patients experienced LQTS-triggered events in a combined 56 person-years of treatment. Perhaps paradoxically, there was a statistically lower LQTS-triggered event rate in the stimulant-treated ADHD group compared to the LQTS alone cohort.

CONCLUSION

Among patients with mild- to moderate-risk LQTS, we found a prevalence of ADHD similar to that in the general population, which can be treated effectively and safely with stimulant therapy. Physicians should find reassurance in the low adverse event rate and should weigh the potential effects of suboptimal treatment of ADHD with the theoretical proarrhythmic risk from stimulant medications.

Probabilistic Markov Model Estimating Cost Effectiveness of Methylphenidate Osmotic-Release Oral System Versus Immediate-Release Methylphenidate in Children and Adolescents: Which Information is Needed?

BACKGROUND

Incidence of attention deficit hyperactivity disorder (ADHD) in children and adolescents has been increasing. The disorder results in high societal costs. Policymakers increasingly use health economic evaluations to inform decisions on competing treatments of ADHD. Yet, health economic evaluations of first-choice medication of ADHD in children and adolescents are scarce and generally do not include broader societal effects.

OBJECTIVES

This study presents a probabilistic model and analysis of methylphenidate osmotic-release oral system (OROS) versus methylphenidate immediate-release (IR). We investigate and include relevant societal aspects in the analysis so as to provide cost-effectiveness estimates based on a broad societal perspective.

METHODS

We enhanced an existing Markov model and determined the cost effectiveness of OROS versus IR for children and adolescents responding suboptimally to treatment with IR. Enhancements included screening of a broad literature base, updated utility values, inclusion of costs and effects on caregivers and a change of the model type from deterministic to probabilistic.

RESULTS

The base case scenario resulted in lower incremental costs (€-5815) of OROS compared with IR and higher incremental quality-adjusted life-year (QALY) gains (0.22). Scenario analyses were performed to determine sensitivity to changes in transition rates, utility of caregivers, medical costs of caregivers and daily medication dose.

CONCLUSIONS

The results indicate that, for children responding suboptimally to treatment with IR, the beneficial effect of OROS on compliance may be worth the additional costs of medication. The presented model adds to the health economic information available for policymakers and to considerations on a broader perspective in cost-effectiveness analyses.

Treatment of toxicity from amphetamines, related derivatives, and analogues: a systematic clinical review

BACKGROUND

Overdose of amphetamine, related derivatives, and analogues (ARDA) continues to be a serious worldwide health problem. Patients frequently present to the hospital and require treatment for agitation, psychosis, and hyperadrenegic symptoms leading to pathologic sequelae and mortality.

OBJECTIVE

To review the pharmacologic treatment of agitation, psychosis, and the hyperadrenergic state resulting from ARDA toxicity.

METHODS

MEDLINE, PsycINFO, and the Cochrane Library were searched from inception to September 2014. Articles on pharmacologic treatment of ARDA-induced agitation, psychosis, and hyperadrenergic symptoms were selected. Evidence was graded using Oxford CEBM. Treatment recommendations were compared to current ACCF/AHA guidelines.

RESULTS

The search resulted in 6082 articles with 81 eligible treatment involving 835 human subjects. There were 6 high-quality studies supporting the use of antipsychotics and benzodiazepines for control of agitation and psychosis. There were several case reports detailing the successful use of dexmedetomidine for this indication. There were 9 high-quality studies reporting the overall safety and efficacy of β-blockers for control of hypertension and tachycardia associated with ARDA. There were 3 high-quality studies of calcium channel blockers. There were 2 level I studies of α-blockers and a small number of case reports for nitric oxide-mediated vasodilators.

CONCLUSIONS

High-quality evidence for pharmacologic treatment of overdose from ARDA is limited but can help guide management of acute agitation, psychosis, tachycardia, and hypertension. The use of butyrophenone and later-generation antipsychotics, benzodiazepines, and β-blockers is recommended based on existing evidence. Future randomized prospective trials are needed to evaluate new agents and further define treatment of these patients.

[Has the prevalence of parent-reported diagnosis of attention deficit hyperactivity disorder (ADHD) in Germany increased between 2003-2006 and 2009-2012? Results of the KiGGS-study: first follow-up (KiGGS Wave 1)]

Recent international studies have reported a considerable increase in the diagnosis of attention deficit hyperactivity disorder (ADHD). Data from German statutory health insurance companies suggest a comparable trend for Germany. Based on data from the nationally representative study KiGGS Wave 1 (2009-2012) it was the aim of this study to report on the prevalence rates of parent-reported ADHD diagnoses in children and adolescents aged 3-17 years as well as to report on time trends in comparison with the KiGGS baseline study (2003-2006). ADHD caseness was met if a parent reported that a physician or a psychologist diagnosed their child with ADHD. Participants without a reported ADHD diagnosis but who scored ≥ 7 (clinical range) on the parent-rated hyperactivity subscale of the Strengths and Difficulties Questionnaire (SDQ) were considered as potential ADHD cases. The prevalence of diagnosed ADHD was 5.0% (prevalence of potential ADHD cases 6.0%). An ADHD diagnosis was more than four and a half times more likely to be reported among boys than girls. Children from families with low socioeconomic status (SES) were more than two and a half times more likely to be diagnosed with ADHD than children from families with high SES. Among potential cases, boys were twice as common as girls, and children from families with low SES were approximately three times more common compared with those from high SES families. The proportion of lifetime ADHD diagnoses increased with age and was highest in 11- to 17-year-olds. In every fifth child with ADHD the initial diagnosis was made by the age of 6 years and in 1 out of 11 children with ADHD the initial diagnosis was made by the age of 5 years. In total, we observed no significant changes regarding the frequency of ADHD diagnosis compared to the KiGGS baseline study. Increases reported using data from German statuary health insurance companies were not reflected in the KiGGS data.

Integration of an EEG biomarker with a clinician's ADHD evaluation

BACKGROUND

This study is the first to evaluate an assessment aid for attention-deficit/hyperactivity disorder (ADHD) according to both Class-I evidence standards of American Academy of Neurology and De Novo requirements of US Food and Drug Administration. The assessment aid involves a method to integrate an electroencephalographic (EEG) biomarker, theta/beta ratio (TBR), with a clinician's ADHD evaluation. The integration method is intended as a step to help improve certainty with criterion E (i.e., whether symptoms are better explained by another condition).

METHODS

To evaluate the assessment aid, investigators conducted a prospective, triple-blinded, 13-site, clinical cohort study. Comprehensive clinical evaluation data were obtained from 275 children and adolescents presenting with attentional and behavioral concerns. A qualified clinician at each site performed differential diagnosis. EEG was collected by separate teams. The reference standard was consensus diagnosis by an independent, multidisciplinary team (psychiatrist, psychologist, and neurodevelopmental pediatrician), which is well-suited to evaluate criterion E in a complex clinical population.

RESULTS

Of 209 patients meeting ADHD criteria per a site clinician's judgment, 93 were separately found by the multidisciplinary team to be less likely to meet criterion E, implying possible overdiagnosis by clinicians in 34% of the total clinical sample (93/275). Of those 93, 91% were also identified by EEG, showing a relatively lower TBR (85/93). Further, the integration method was in 97% agreement with the multidisciplinary team in the resolution of a clinician's uncertain cases (35/36). TBR showed statistical power specific to supporting certainty of criterion E per the multidisciplinary team (Cohen's d, 1.53). Patients with relatively lower TBR were more likely to have other conditions that could affect criterion E certainty (10 significant results; P ≤ 0.05). Integration of this information with a clinician's ADHD evaluation could help improve diagnostic accuracy from 61% to 88%.

CONCLUSIONS

The EEG-based assessment aid may help improve accuracy of ADHD diagnosis by supporting greater criterion E certainty.

Attention skills and executive functioning in children with Noonan syndrome and their unaffected siblings

AIM

Emerging research indicates that gene mutations within the RAS-MAPK signaling cascade, which cause Noonan syndrome and related disorders, affect neurophysiologic activity in brain regions underlying attention and executive functions. The present study examined whether children with Noonan syndrome are at heightened risk for symptoms of attention-deficit-hyperactivity disorder (ADHD) and executive dysfunction relative to an unaffected sibling comparison group, and investigated three key aspects of behavioral attention: auditory attention, sustained attention, and response inhibition.

METHOD

Children and adolescents with Noonan syndrome (n=32, 17 males, 15 females, mean age 11y 3mo, SD 3y) and their unaffected siblings (n=16, eight males, eight females, mean age 11y, SD 3y 6mo) were administered standardized tests of intellectual functioning and clinic-based measures of behavioral attention. Parent ratings of ADHD symptoms, executive functioning, and behavior were also obtained.

RESULTS

Children with Noonan syndrome demonstrated higher rates of past ADHD diagnosis, as well as reduced performance compared with unaffected siblings on behavioral attention measures. Parent-rated functional impairments in attention, social skills, working memory, and self-monitoring were more prevalent in the Noonan syndrome group. The relationship between attention regulation skills (sustained attention and inhibitory control) and intellectual test performance was significantly stronger in the Noonan syndrome group than the comparison group.

INTERPRETATION

Clinical screening/evaluation for ADHD and executive dysfunction in Noonan syndrome is recommended to facilitate appropriate intervention and to address functional impact on daily life activities.

Psychostimulant prescription for ADHD in new South Wales: a longitudinal perspective

OBJECTIVE

There is a need for Australian studies of ADHD that utilize the individual child as the unit of analysis because they provide a more accurate picture of national patterns (in new prescriptions, start age, and duration). The aim of this study was to build toward a national picture of patterns in psychostimulant use for ADHD by undertaking a retrospective analysis of archival data on prescriptions within New South Wales (NSW), Australia's most populated state.

METHOD

A person-based data set was used to assess (a) rate of new prescriptions by age group, (b) demographic characteristics (age of start, male:female ratio), (c) duration of use, and (d) comparisons across the two decades.

RESULTS

Five findings were observed: (a) The prevalence of psychostimulant use was 1.24% in 2010, (b) there was significant variability in the rate of new prescriptions by age group after 2003, (c) start age declined over the 1990 to 2000 period, but began to increase from 2000 to 2010, (d) the male:female ratio declined, and (e) the duration of psychostimulant use declined consistently.

CONCLUSION

Results suggest disconnect between persistence across the life span and actual treatment patterns. A decline in medication treatment for more than 1 year and the growing proportion of discontinuous treatment suggests a need for strategies to assist families with the transition onto and off medications.

Sensation-to-cognition cortical streams in attention-deficit/hyperactivity disorder

We sought to determine whether functional connectivity streams that link sensory, attentional, and higher-order cognitive circuits are atypical in attention-deficit/hyperactivity disorder (ADHD). We applied a graph-theory method to the resting-state functional magnetic resonance imaging data of 120 children with ADHD and 120 age-matched typically developing children (TDC). Starting in unimodal primary cortex-visual, auditory, and somatosensory-we used stepwise functional connectivity to calculate functional connectivity paths at discrete numbers of relay stations (or link-step distances). First, we characterized the functional connectivity streams that link sensory, attentional, and higher-order cognitive circuits in TDC and found that systems do not reach the level of integration achieved by adults. Second, we searched for stepwise functional connectivity differences between children with ADHD and TDC. We found that, at the initial steps of sensory functional connectivity streams, patients display significant enhancements of connectivity degree within neighboring areas of primary cortex, while connectivity to attention-regulatory areas is reduced. Third, at subsequent link-step distances from primary sensory cortex, children with ADHD show decreased connectivity to executive processing areas and increased degree of connections to default mode regions. Fourth, in examining medication histories in children with ADHD, we found that children medicated with psychostimulants present functional connectivity streams with higher degree of connectivity to regions subserving attentional and executive processes compared to medication-naïve children. We conclude that predominance of local sensory processing and lesser influx of information to attentional and executive regions may reduce the ability to organize and control the balance between external and internal sources of information in ADHD.

Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents

BACKGROUND

The literature on the prevalence of mental disorders affecting children and adolescents has expanded significantly over the last three decades around the world. Despite the field having matured significantly, there has been no meta-analysis to calculate a worldwide-pooled prevalence and to empirically assess the sources of heterogeneity of estimates.

METHODS

We conducted a systematic review of the literature searching in PubMed, PsycINFO, and EMBASE for prevalence studies of mental disorders investigating probabilistic community samples of children and adolescents with standardized assessments methods that derive diagnoses according to the DSM or ICD. Meta-analytical techniques were used to estimate the prevalence rates of any mental disorder and individual diagnostic groups. A meta-regression analysis was performed to estimate the effect of population and sample characteristics, study methods, assessment procedures, and case definition in determining the heterogeneity of estimates.

RESULTS

We included 41 studies conducted in 27 countries from every world region. The worldwide-pooled prevalence of mental disorders was 13.4% (CI 95% 11.3-15.9). The worldwide prevalence of any anxiety disorder was 6.5% (CI 95% 4.7-9.1), any depressive disorder was 2.6% (CI 95% 1.7-3.9), attention-deficit hyperactivity disorder was 3.4% (CI 95% 2.6-4.5), and any disruptive disorder was 5.7% (CI 95% 4.0-8.1). Significant heterogeneity was detected for all pooled estimates. The multivariate metaregression analyses indicated that sample representativeness, sample frame, and diagnostic interview were significant moderators of prevalence estimates. Estimates did not vary as a function of geographic location of studies and year of data collection. The multivariate model explained 88.89% of prevalence heterogeneity, but residual heterogeneity was still significant. Additional meta-analysis detected significant pooled difference in prevalence rates according to requirement of funcional impairment for the diagnosis of mental disorders.

CONCLUSIONS

Our findings suggest that mental disorders affect a significant number of children and adolescents worldwide. The pooled prevalence estimates and the identification of sources of heterogeneity have important implications to service, training, and research planning around the world.

Psychotic disorders comorbid with attention-deficit hyperactivity disorder: an important knowledge gap

Psychotic disorders (PDs) and attention-deficit hyperactivity disorder (ADHD) are frequently comorbid. Clinicians are often reticent to treat ADHD in patients with psychosis, fearing that psychostimulants will worsen psychotic symptoms. Advances in neurobiology have challenged the simplistic dichotomy where PD is considered a disorder of high dopamine (DA), treated by DA antagonists, and ADHD a disorder of low DA, treated by DA agonists. In our paper, we review the literature on comorbid ADHD and psychosis. Treating ADHD with psychostimulants may be considered in patients with PD who have been stabilized with antipsychotics (APs). Not treating ADHD may have consequences because ADHD may predispose patients to drug abuse, which further increases the risk of PD. Nevertheless, more systematic studies are needed as there remains some uncertainty on the combined use of APs and psychostimulants in comorbid PD and ADHD.

Exposure to fluoridated water and attention deficit hyperactivity disorder prevalence among children and adolescents in the United States: an ecological association

BACKGROUND

Epidemiological and animal-based studies have suggested that prenatal and postnatal fluoride exposure has adverse effects on neurodevelopment. The aim of this study was to examine the relationship between exposure to fluoridated water and Attention-Deficit Hyperactivity Disorder (ADHD) prevalence among children and adolescents in the United States.

METHODS

Data on ADHD prevalence among 4-17 year olds collected in 2003, 2007 and 2011 as part of the National Survey of Children's Health, and state water fluoridation prevalence from the Centers for Disease Control and Prevention (CDC) collected between 1992 and 2008 were utilized.

RESULTS

State prevalence of artificial water fluoridation in 1992 significantly positively predicted state prevalence of ADHD in 2003, 2007 and 2011, even after controlling for socioeconomic status. A multivariate regression analysis showed that after socioeconomic status was controlled each 1% increase in artificial fluoridation prevalence in 1992 was associated with approximately 67,000 to 131,000 additional ADHD diagnoses from 2003 to 2011. Overall state water fluoridation prevalence (not distinguishing between fluoridation types) was also significantly positively correlated with state prevalence of ADHD for all but one year examined.

CONCLUSIONS

Parents reported higher rates of medically-diagnosed ADHD in their children in states in which a greater proportion of people receive fluoridated water from public water supplies. The relationship between fluoride exposure and ADHD warrants future study.

Cross-fostering differentially affects ADHD-related behaviors in spontaneously hypertensive rats

Although both genetic and non-genetic factors are known to contribute to the occurrence of Attention-Deficit Hyperactivity/Disorder (ADHD), little is known about how they impact specific symptoms. We used a cross-fostering approach with an established animal model of ADHD, the Spontaneously Hypertensive Rat strain (SHR), to test the influence of genotype and maternal behavior on ADHD-related behaviors. SHRs and their normo-active genetic relative, Wistar Kyoto rats (WKY), were cross-fostered to an unfamiliar dam of either the same or different strain. Behavioral testing took place when the rats reached adulthood. Locomotor hyperactivity was completely dependent on the strain of the offspring. In contrast, social behavior was primarily determined by the strain of the mother, while attentional orienting behavior was influenced by both the strain of the offspring and the strain of the dam. Anxiety-related behavior was influenced by an interaction between offspring and dam strain.

Attention-Deficit/Hyperactivity Disorder in a VA Polytrauma Clinic

A large-scale study suggests that veterans with attention-deficit/hyperactivity disorder may benefit from structured treatment interventions focused on developing compensatory skills for their attention and impulsivity issues.

A best-worst scaling experiment to prioritize caregiver concerns about ADHD medication for children

OBJECTIVE

The objective of this feasibility study was to develop and pilot an instrument to elicit caregivers' priorities when initiating attention-deficit hyperactivity disorder (ADHD) medication for their child.

METHODS

A best-worst scaling experiment was used to rank competing priorities when initiating ADHD medicine. Forty-six participants were recruited for a two-phase study involving survey development (phase 1, N=21) and the survey pilot (phase 2, N=25). Best-worst scores and 95% confidence intervals indicating the relative importance of 16 concerns were determined, and t tests were used to determine the scores' significance.

RESULTS

The significance of best-worst scores for most concerns indicated that the choices were purposeful. Concerns about helping the child become a successful adult, having a doctor who addresses caregivers' concerns, and improving school behavior were ranked highest.

CONCLUSIONS

The best-worst scaling method can elicit priorities for children's mental health treatment. Future work using this method will guide family-centered care.

Natural environments, ancestral diets, and microbial ecology: is there a modern "paleo-deficit disorder"? Part I

Famed microbiologist René J. Dubos (1901-1982) was an early pioneer in the developmental origins of health and disease (DOHaD) construct. In the 1960s, he conducted groundbreaking experimental research concerning the ways in which early-life experience with nutrition, microbiota, stress, and other environmental variables could influence later-life health outcomes. He also wrote extensively on potential health consequences of a progressive loss of contact with natural environments (now referred to as green or blue space), arguing that Paleolithic experiences have created needs, particularly in the mental realm, that might not be met in the context of rapid global urbanization. He posited that humans would certainly adapt to modern urban landscapes and high technology, but there might be a toll to be paid in the form of higher psychological distress (symptoms of anxiety and depression) and diminished quality of life. In particular, there might be an erosion of humanness, exemplified by declines in altruism/empathy. Here in the first of a two-part review, we examine contemporary research related to natural environments and question to what extent Dubos might have been correct in some of his 50-year-old assertions.

Does 5HTTLPR Genotype Moderate the Association of Family Environment With Child Attention-Deficit Hyperactivity Disorder Symptomatology?

Problematic family dynamics are common among youth with attention-deficit hyperactivity disorder (ADHD). Multiple mechanisms, including diathesis-stress (vulnerability) and differential susceptibility Gene × Environment interaction effects (G × E), have been proposed to account for this association. G × E effects for ADHD were examined via interactions between a genetic marker hypothesized to influence sensitivity to the environment (the promoter polymorphism of the serotonin transporter gene -5HTTLPR) and family conflict and cohesion in predicting ADHD symptoms. There were 498 youth ages 6-17 years (251 ADHD, 213 non-ADHD) and their parents who completed a multistage, multi-informant assessment (including parent and youth reports on the Family Environment Scale), and saliva sample collection for genotyping. Linear regression analyses examined interactions between 5HTTLPR genotype and the Family Environment Scale scales of conflict and cohesion reported by parent and child. Criteria laid out by Roisman et al. ( 2012 ) were applied to evaluate diathesis stress versus differential susceptibility G × E mechanisms. Results demonstrated interactions between 5HTTLPR genotype and both conflict and cohesion in predicting inattention but not hyperactivity-impulsivity. Both interactions were highly consistent with differential susceptibility models of G × E effects. 5HTTLPR genotype appeared to moderate the relationship between family conflict/cohesion and inattentive symptoms. Interactions highlight the role of 5HTTLPR genotype as a potential marker of environmental sensitivity and provide support for differential susceptibility models of G × E effects for ADHD.

Anesthesia-related neurotoxicity and the developing animal brain is not a significant problem in children

A multitude of animal studies have shown that virtually all general anesthetics used in clinical practice possibly during a vulnerable period of brain development (i.e., brain growth spurt, peak of synaptogenesis) may lead to neurodegeneration (particularly apoptosis) and abnormal synaptic development with functional deficits in learning and behavior later in life. Initial studies were mainly performed in immature rodent pups, but more recent studies have included nonhumans primates (rhesus monkeys). Given the number of neonates, infants, and young children anesthetized annually worldwide, these findings could have significant public health implications. So far, relatively few human (cohort) studies focusing on this topic have been published with inconsistent results. While some studies have indicated an association between exposure to anesthesia and surgery, other studies have indicated no such association. Prospective studies are underway, but the result will not be available for several years. This paper reviews some of the preclinical background behind anesthesia-related neurotoxicity but focuses mainly on the human studies so far. It is concluded that although disturbing, the animal data lack verification in humans. Fortunately, the humans studies performed so far have been unable to confirm these animal data. A single brief anesthetic seems safe in infants. Multiple anesthetic and surgical exposures on the other hand are different. But there may be other reasons for this than merely the anesthetics. Currently, there is no need to change current anesthetic clinical practice or to postpone or cancel truly urgent surgeries in young children.

Neurobehavioral Concerns Among Males with Dystrophinopathy Using Population-Based Surveillance Data from the Muscular Dystrophy Surveillance, Tracking, and Research Network

OBJECTIVE

To describe the occurrence of selected neurobehavioral concerns among males with a dystrophinopathy and to explore the associations with corticosteroid or supportive device use.

METHODS

Medical record abstraction of neurobehavioral concerns was conducted for 857 affected males from 765 families, born since 1982 and followed through 2011, and enrolled in the population-based Muscular Dystrophy Surveillance, Tracking, and Research Network. Cumulative probabilities for attention-deficit hyperactivity disorder (ADHD), behavior problems, and depressed mood were calculated from Kaplan-Meier estimates for the subsample of oldest affected males (n = 765). Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for corticosteroid and supportive device use were estimated from Cox regression models with time-dependent covariates.

RESULTS

Of the 857 affected males, 375 (44%) had at least 1 of the 3 selected neurobehavioral concerns; a similar percentage (45%) was found among the 765 oldest affected males. The estimated cumulative probabilities among these oldest affected males were 23% for ADHD, 43% for behavior problems, and 51% for depressed mood. Corticosteroid (HR = 2.35, 95% CI = 1.75-3.16) and mobility device (HR = 1.53, 95% CI = 1.06-2.21) use were associated with behavior problems. Use of a mobility device (HR = 3.53, 95% CI = 2.13-5.85), but not corticosteroids, was associated with depressed mood. ADHD was not significantly associated with corticosteroid or mobility device use. Respiratory assist device use was not examined due to low numbers of users before onset of neurobehavioral concerns.

CONCLUSION

Selected neurobehavioral concerns were common among males with a dystrophinopathy. Reported associations highlight the importance of increased monitoring of neurobehavioral concerns as interventions are implemented and disease progresses.

The Subject of Enhancement: Augmented Capacities, Extended Cognition, and Delicate Ecologies of the Mind

This paper argues for an inflationary and capacity-relative understanding of human enhancement technology. In doing so it echoes the approach followed by Buchanan (2011a, 2011b). Particular emphasis is placed on the point that capacities themselves are relative to demands placed on the organism by its environment. In the case of human beings, this environment is to a very large extent institutionally structured. On the basis of the inflationary and capacity-relative concept of enhancement, I argue that the subject of enhancement must be understood in terms of a bundle of capacities that is both extended (Clark 1998) and ecological. This consequence of the inflationary enhancement concept has some surprising upshots, namely that the subject itself must be considered as a technological enhancement and not a ‘platform’ or subjectum upon which the enhancement enterprise builds. This conclusion clashes, I argue, with some of the presuppositions of liberal philosophy, which starts by assuming a reflective subject. The paper ends with some reflection on the desirability of reflective subjectivity for human flourishing and addressing the ecological crisis.

The impact of case definition on attention-deficit/hyperactivity disorder prevalence estimates in community-based samples of school-aged children

OBJECTIVE

To determine the impact of varying attention-deficit/hyperactivity disorder (ADHD) diagnostic criteria, including new DSM-5 criteria, on prevalence estimates.

METHOD

Parent and teacher reports identified high- and low-screen children with ADHD from elementary schools in 2 states that produced a diverse overall sample. The parent interview stage included the Diagnostic Interview Schedule for Children-IV (DISC-IV), and up to 4 additional follow-up interviews. Weighted prevalence estimates, accounting for complex sampling, quantified the impact of varying ADHD criteria using baseline and the final follow-up interview data.

RESULTS

At baseline 1,060 caregivers were interviewed; 656 had at least 1 follow-up interview. Teachers and parents reported 6 or more ADHD symptoms for 20.5% (95% CI = 18.1%-23.2%) and 29.8% (CI = 24.5%-35.6%) of children respectively, with criteria for impairment and onset by age 7 years (DSM-IV) reducing these proportions to 16.3% (CI = 14.7%-18.0%) and 17.5% (CI = 13.3%-22.8%); requiring at least 4 teacher-reported symptoms reduced the parent-reported prevalence to 8.9% (CI = 7.4%-10.6%). Revising age of onset to 12 years per DSM-5 increased the 8.9% estimate to 11.3% (CI = 9.5%-13.3%), with a similar increase seen at follow-up: 8.2% with age 7 onset (CI = 5.9%-11.2%) versus 13.0% (CI = 7.6%-21.4%) with onset by age 12. Reducing the number of symptoms required for those aged 17 and older increased the overall estimate to 13.1% (CI = 7.7%-21.5%).

CONCLUSION

These findings quantify the impact on prevalence estimates of varying case definition criteria for ADHD. Further research of impairment ratings and data from multiple informants is required to better inform clinicians conducting diagnostic assessments. DSM-5 changes in age of onset and number of symptoms required for older adolescents appear to increase prevalence estimates, although the full impact is uncertain due to the age of our sample.

Does Guanfacine Extended Release Impact Functional Impairment in Children with Attention-Deficit/Hyperactivity Disorder? Results from a Randomized Controlled Trial

BACKGROUND

In clinical trials of medications to treat attention-deficit/hyperactivity disorder (ADHD) in children, effects on functional impairment have been less well-studied than changes in ADHD symptoms.

OBJECTIVE

Data regarding functional impairment were analyzed from a multicenter, double-blind, placebo-controlled study of guanfacine extended release (GXR) in children with ADHD, using the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P). The correspondence of changes in WFIRS-P scores with symptomatic and global response to GXR treatment was also examined, with treatment response defined by scores on both the ADHD Rating Scale IV (ADHD-RS-IV) and the Clinical Global Impressions-Improvement Scale (CGI-I).

METHODS

In this 8-week, double-blind, placebo-controlled, dose optimization study at 47 sites across the USA and Canada, children aged 6-12 years with a diagnosis of ADHD [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria, and an ADHD-RS-IV score ≥28 and CGI-Severity of Illness Scale score ≥4 at baseline], were randomized 1:1:1 into three groups: GXR AM [GXR (1-4 mg/day) in the morning, placebo in the evening], GXR PM [placebo in the morning, GXR (1-4 mg/day) in the evening], or twice-daily placebo. Parents rated their children on the WFIRS-P at screening, baseline, the end of dose optimization, and at the final on-treatment assessment.

RESULTS

The efficacy population was composed of 333 subjects (GXR AM: n = 107; GXR PM: n = 114; placebo: n = 112). At the final on-treatment assessment, there were significant improvements from baseline in the placebo-adjusted difference in least-squares (LS) mean (95 % confidence interval) WFIRS-P Total scores for both GXR treatment groups combined [GXR all-active: -0.16 (-0.25, -0.07), effect size (ES) = 0.448, P <0.001] and separately [GXR AM: -0.15 (-0.26, -0.05), ES = 0.417, P = 0.004; GXR PM: -0.18 (-0.28, -0.07), ES = 0.478, P = 0.001]. Significant improvements in WFIRS-P domain scores for Family, Learning and School (including Academic Performance and Behavior in School), Social, and Risky Behavior were found for both GXR cohorts compared with placebo. However, the Life Skills and Self-Concept domain scores of the WFIRS-P did not improve with GXR treatment. Post hoc stratification by responder status revealed that significant (P <0.001) improvements in WFIRS-P Total and all domain scores were associated with symptomatic treatment response in the GXR all-active group.

CONCLUSIONS

GXR treatment in children with ADHD was associated with reductions in WFIRS-P functional impairment scores compared with placebo, regardless of time of GXR administration. Changes in WFIRS-P scores were congruent with clinical response, as determined by both ADHD symptom reduction and CGI-I scores. CLINICALTRIALS.

GOV IDENTIFIER

NCT00997984.

ADHD, Multimodal Treatment, and Longitudinal Outcome: Evidence, Paradox, and Challenge

Given major increases in the diagnosis of attention-deficit hyperactivity disorder (ADHD) and in rates of medication for this condition, we carefully examine evidence for effects of single versus multimodal (i.e., combined medication and psychosocial/behavioral) interventions for ADHD. Our primary data source is the Multimodal Treatment Study of Children with ADHD (MTA), a 14-month, randomized clinical trial in which intensive behavioral, medication, and multimodal treatment arms were contrasted with one another and with community intervention (treatment-as-usual), regarding outcome domains of ADHD symptoms, comorbidities, and core functional impairments. Although initial reports emphasized the superiority of well-monitored medication for symptomatic improvement, reanalyses and reappraisals have highlighted (a) the superiority of combination treatment for composite outcomes and for domains of functional impairment (e.g., academic achievement, social skills, parenting practices); (b) the importance of considering moderator and mediator processes underlying differential patterns of outcome, including comorbid subgroups and improvements in family discipline style during the intervention period; (c) the emergence of side effects (e.g., mild growth suppression) in youth treated with long-term medication; and (d) the diminution of medication's initial superiority once the randomly assigned treatment phase turned into naturalistic follow-up. The key paradox is that whereas ADHD clearly responds to medication and behavioral treatment in the short term, evidence for long-term effectiveness remains elusive. We close with discussion of future directions and a call for greater understanding of relevant developmental processes in the attempt to promote optimal, generalized, and lasting treatments for this important and impairing neurodevelopmental disorder.

Working with "Out-of-Control" Children--A Two-Systems Approach

The authors apply a two-systems approach to demonstrate improved treatment possibilities and outcomes in this group of children and suggest that psychoanalysis can be defined as a multimodal strengths-based learning experience. Using clinical material from the analysis of an aggressive, "out-of-control" child, they discuss how these behaviors and symptoms are better understood as an actively constructed effort at self-regulation than as a deficiency in capacity or primitive, lagging development. They illustrate how a two-systems framework can allow for an expanded repertoire of techniques and reclaim psychoanalytic concepts that have fallen into disuse.

Developmental trajectories of attentional control in preschool males with fragile X syndrome

Attention problems are among the most impairing features associated with fragile X syndrome (FXS). However, few studies have examined behavioral development of inhibitory control in very young children with FXS. We examined attentional control in 3-6 year boys with FXS using both an experimental inhibitory control paradigm and parent-report of attention problems. Study 1 examined attentional control in FXS compared to comparison groups matched on chronological and mental age. To determine the stability of impairments over time in FXS, Study 2 examined patterns of developmental change in an expanded longitudinal sample. Across studies, males with FXS demonstrated persistent impairments in inhibitory control and parent-reported attention problems. Inhibitory control was related to, but not solely driven by, lower mental age. Although parent-rated attention problems remained stable across ages, inhibitory control improved with time. Children with more severe attention problems often displayed initially poorer inhibitory control. However, these trajectories also improved more rapidly with age. Our findings indicate that despite persistent deficits in attentional control in young children with FXS, multi-method assessment can be used to capture developmental growth that should be further supported through early, targeted intervention.

Neurological Effects of Bisphenol A and its Analogues

The endocrine disrupting chemical bisphenol A (BPA) is widely used in the production of polycarbonate plastics and epoxy resins. The use of BPA-containing products in daily life makes exposure ubiquitous, and the potential human health risks of this chemical are a major public health concern. Although numerous in vitro and in vivo studies have been published on the effects of BPA on biological systems, there is controversy as to whether ordinary levels of exposure can have adverse effects in humans. However, the increasing incidence of developmental disorders is of concern, and accumulating evidence indicates that BPA has detrimental effects on neurological development. Other bisphenol analogues, used as substitutes for BPA, are also suspected of having a broad range of biological actions. The objective of this review is to summarize our current understanding of the neurobiological effects of BPA and its analogues, and to discuss preventive strategies from a public health perspective.

Why the Diagnosis of Attention Deficit Hyperactivity Disorder Matters

BACKGROUND

Attention Deficit Hyperactivity disorder (ADHD) is one of the most common and challenging childhood neurobehavioral disorders. ADHD is known to negatively impact children, their families, and their community. About one-third to one-half of patients with ADHD will have persistent symptoms into adulthood. The prevalence in the United States is estimated at 5-11%, representing 6.4 million children nationwide. The variability in the prevalence of ADHD worldwide and within the US may be due to the wide range of factors that affect accurate assessment of children and youth. Because of these obstacles to assessment, ADHD is under-diagnosed, misdiagnosed, and undertreated.

OBJECTIVES

We examined factors associated with making and receiving the diagnosis of ADHD. We sought to review the consequences of a lack of diagnosis and treatment for ADHD on children's and adolescent's lives and how their families and the community may be involved in these consequences.

METHODS

We reviewed scientific articles looking for factors that impact the identification and diagnosis of ADHD and articles that demonstrate naturalistic outcomes of diagnosis and treatment. The data bases PubMed and Google scholar were searched from the year 1995 to 2015 using the search terms "ADHD, diagnosis, outcomes." We then reviewed abstracts and reference lists within those articles to rule out or rule in these or other articles.

RESULTS

Multiple factors have significant impact in the identification and diagnosis of ADHD including parents, healthcare providers, teachers, and aspects of the environment. Only a few studies detailed the impact of not diagnosing ADHD, with unclear consequences independent of treatment. A more significant number of studies have examined the impact of untreated ADHD. The experience around receiving a diagnosis described by individuals with ADHD provides some additional insights.

CONCLUSION

ADHD diagnosis is influenced by perceptions of many different members of a child's community. A lack of clear understanding of ADHD and the importance of its diagnosis and treatment still exists among many members of the community including parents, teachers, and healthcare providers. More basic and clinical research will improve methods of diagnosis and information dissemination. Even before further advancements in science, strong partnerships between clinicians and patients with ADHD may be the best way to reduce the negative impacts of this disorder.

Time trends in symptoms of mental illness in children and adolescents in Canada

BACKGROUND

Existing research and media reports convey conflicting impressions of trends in the prevalence of mental illness. We sought to investigate trends in the prevalence of symptoms of mental illness in a large population-based cohort of Canadian children and adolescents.

METHODS

We obtained population-based data from the National Longitudinal Survey of Children and Youth. Every 2 years, participants completed self-reported measures of mental illness indicators, including conduct disorder, hyperactivity, indirect aggression, suicidal behaviour, and depression and anxiety. We analyzed trends in mean scores over time using linear regression.

RESULTS

We evaluated 11 725 participants aged 10-11 years from cycles 1 (1994/95) through 6 (2004/05), 10 574 aged 12-13 years from cycles 2 (1996/97) through 7 (2006/07), and 9835 aged 14-15 years from cycles 3 (1998/99) through 8 (2008/09). The distribution of scores on depression and anxiety, conduct and indirect aggression scales remained stable or showed small decreases over time for participants of all ages. The mean hyperactivity score increased over time in participants aged 10-11 years (change per 2-year cycle: 0.16, 95% CI 0.02 to 0.12) and those aged 12-13 years (0.13, 95% CI 0.09 to 0.18). Over time, fewer participants aged 12-13 years (0.40% per cycle, 95% CI -0.78 to -0.07) and aged 14-15 years (0.56% per cycle, 95% CI -0.91 to -0.23) reported attempting suicide in the previous 12 months.

INTERPRETATION

With the exception of hyperactivity, the prevalence of symptoms of mental illness in Canadian children and adolescents has remained relatively stable from 1994/95 to 2008/09. Conflicting reports of escalating rates of mental illness in Canada may be explained by differing methodologies between studies, an increase in treatment-seeking behaviour, or changes in diagnostic criteria or practices.

Management of newer medications for attention-deficit/hyperactivity disorder in commercial health plans

PURPOSE

In the United States, many individuals with attention-deficit/hyperactivity disorder (ADHD) pay for their medications using private health insurance coverage. As in other drug classes, private insurers are actively seeking to influence use and costs, particularly for newer and costlier medications. The approaches that insurers use may have important effects on patients' access to medications. This article examines approaches (eg, copayments, prior authorization, and step therapy) that commercial health plans are using to manage newer medications used to treat ADHD and changes in approaches since 2003.

METHODS

Data are from a nationally representative survey of commercial health plans in 60 market areas regarding alcohol, drug abuse, and mental health services in 2010. Responses were obtained from 389 plans (89% response rate), reporting on 925 insurance products. For each of 6 branded ADHD medications, respondents were asked whether the plan covered the medication and, if so, on what copayment tier each medication was placed and whether it was subject to prior authorization or step therapy. Measures of management approach were constructed for each medication and for the group of medications. Bivariate and multivariate analyses were used to test for association of the management approach with various health plan characteristics.

FINDINGS

There was considerable variation across these 6 medications in how tightly they were managed by health plans, with newer medications being subject to more stringent management. The proportion of insurance products relying solely on copayment tiering to manage new ADHD medications appears to have decreased since 2003. Less than half of insurance products (43%) managed these 6 medications solely by use of tier 3 or 4 placement, and most of the remainder (48%) used other restrictions (with or without tier 3 or 4 placement). The average insurance product restricted access to at least 3 of the 6 brand-only medications examined, whether through copayment tier placement or other approaches. More ADHD medications were left unrestricted in health maintenance organization products than in preferred provider organization ones, products with internal or hybrid-internal contracts for behavioral health, those not contracting with pharmacy benefits managers, and those with for-profit ownership.

IMPLICATIONS

Many plans have supplemented copayment tiering with other approaches, such as prior authorization and step therapy, to influence use and decrease costs. It may be that plans have found copayments to be less effective in redirecting use in this medication class. The effect on clinical outcomes was not examined in this study but should be prioritized using other data sources.

Prenatal bisphenol A exposure and maternally reported behavior in boys and girls

Prenatal exposure to gonadal hormones plays a major role in the normal development of the male and female brain and sexually dimorphic behaviors. Hormone-dependent differences in brain structure and function suggest that exposure to exogenous endocrine disrupting chemicals may be associated with sex-specific alterations in behavior. Bisphenol A (BPA) is an environmental chemical that has been shown to alter estrogen, androgen, and thyroid hormone signaling pathways. Epidemiological and experimental studies suggest associations between prenatal exposure to BPA and child behavior, however data are inconsistent, and few studies have examined school age children. We examined BPA concentration in spot urine samples from women at mean 27 weeks of pregnancy in relation to child behavior assessed at age 6-10 years using the parent-completed Child Behavior Checklist (CBCL). We report associations between maternal BPA urinary concentrations and several CBCL scores in 153 children (77 boys and 76 girls). We observed a significant interaction between maternal urinary BPA and sex for several behaviors (externalizing, aggression, Anxiety Disorder, Oppositional/Defiant Disorder and Conduct Disorder traits), but no significant associations between BPA and scores on any CBCL scales. However in analyses restricted to children of mothers with detectable prenatal urinary BPA (n=125), BPA was associated with moderately increased internalizing and externalizing behaviors, withdrawn/depressed behavior, somatic problems, and Oppositional/Defiant Disorder traits in boys. In addition we observed a significant interaction between BPA and sex for several behaviors (externalizing, withdrawn/depressed, rule-breaking, Oppositional/Defiant Disorder traits, and Conduct Disorder traits). These results suggest that prenatal exposure to BPA may be related to increased behavior problems in school age boys, but not girls.

ADHD as a risk factor for early onset and heightened adult problem severity of illicit substance use: an accelerated gateway model

The primary aims of the present study were to assess ADHD history as a risk factor for earlier initiation and current use of licit and illicit substances among a sample of drug using adults. It was hypothesized that ADHD history would accelerate the Gateway Theory of drug use. Participants included 941 drug-using African American and Caucasian individuals in Baltimore, Maryland. The sample consisted of 124 (13.2%) participants who reported a history of ADHD and 817 (86.8%) who reported no history of ADHD. The accelerated gateway hypothesis was supported, as a history of self-reported ADHD was significantly associated with younger ages of initiation for alcohol, cigarettes, marijuana, and cocaine use. Participants with a history of ADHD were also more likely to engage in recent HIV-risk behavior, such as injection drug use and needle sharing. This study provides compelling data in support of an accelerated gateway model for substance use related to ADHD history and increased problem severity in adulthood. Targeted substance use prevention and intervention may be beneficial for those with ADHD.

How do clinicians actually use the Diagnostic and Statistical Manual of Mental Disorders in clinical practice and why we need to know more

The clinical use of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is explicitly stated as a goal for both the DSM Fourth Edition and DSM Fifth Edition (DSM-5) revisions. Many uses assume a relatively faithful application of the DSM diagnostic definitions. However, studies demonstrate significant discrepancies between clinical psychiatric diagnoses with those made using structured interviews suggesting that clinicians do not systematically apply the diagnostic criteria. The limited information regarding how clinicians actually use the DSM raises important questions: a) How can the clinical use be improved without first having a baseline assessment? b) How can potentially significant shifts in practice patterns based on wording changes be assessed without knowing the extent to which the criteria are used as written? Given the American Psychiatric Association's plans for interim revisions to the DSM-5, the value of a detailed exploration of its actual use in clinical practice remains a significant ongoing concern and deserves further study including a number of survey and in vivo studies.