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

Pharmacokinetics of AR19, an Immediate-Release Amphetamine Sulfate Formulation Designed to Deter Manipulation for Administration Via Nonoral Routes: Bioequivalence to Reference Racemic Amphetamine Sulfate, Dose Proportionality, and Food Effect

Objectives: We evaluated the pharmacokinetics (PK) of an investigational immediate-release amphetamine (AMP) sulfate formulation (AR19) designed to deter nonoral administration versus reference racemic amphetamine sulfate (RA-AMPH). We investigated AMP bioavailability from AR19, the effect of taking AR19 with food or sprinkling the capsules on food, and dose proportionality. Methods: Participants received AR19 (20 mg) or reference RA-AMPH (20 mg) (bioequivalence study) or AR19 5 or 30 mg (dose comparison study). Food effect study participants received AR19 (20 mg) as intact capsule while fasted or after high-fat/-calorie meal, or as pellets sprinkled on applesauce or yogurt (≥6-day washout). Blood samples were analyzed for dextroamphetamine (d-AMP) and levoamphetamine (l-AMP) PK: C_max, AUC_last, AUC_inf, λ_z, T_½, and T_max. Safety was assessed. Results: Bioequivalence, dose comparison, and food effect studies included 36, 24, and 36 participants. The 90% confidence intervals (CIs) of C_max, AUC_last, and AUC_inf for AR19 20 mg versus reference RA-AMPH or AR19 with intact capsule and meal or sprinkled AR19 pellets on food versus fasted were between 80% and 125%. Dose-normalized C_max/D, AUC_last/D, and AUC_inf/D for AR19 5 versus 30 mg had CIs within 80%-125%. Mean ± standard deviation (SD) T_max was comparable for AMP (d-AMP; l-AMP) following AR19 20 mg (2.84 ± 1.05; 3.05 ± 1.22) versus reference RA-AMPH (2.52 ± 0.75; 2.75 ± 1.00), and AR19 5 mg (2.48 ± 0.57; 2.65 ± 0.65) versus AR19 30 mg (2.55 ± 0.56; 2.72 ± 0.65). Mean ± SD T_max for AMP (d-AMP; l-AMP) was higher with intact capsule and meal (5.59 ± 1.57; 5.59 ± 1.59) versus fasted (2.85 ± 0.76; 2.97 ± 0.79). No serious adverse events were reported. Conclusion: AR19 was bioequivalent to reference RA-AMPH. Bioavailability was similar at doses between 5 and 30 mg and was not impacted by meal consumption or sprinkling on food. AR19 at tested doses was well tolerated.

Attention deficit hyperactivity disorder and its association with heavy metals in children from northern Chile

INTRODUCTION

Exposure to lead and arsenic has been associated with child behavior problems. In Arica, a northern city of Chile, the natural presence of arsenic in water has been registered. Also, the city has a history of heavy metals contamination of anthropogenic origin. The purpose of this study was to explore the association between the concentration of blood lead and urinary inorganic arsenic with attention deficit hyperactivity disorder (ADHD) as reported by parents.

METHODS

Cross-sectional design with data analysis of 2656 children between the ages of 3 and 17 enrolled at the Environmental Health Center of Arica between 2009 and 2015. The diagnosis of ADHD was made based on the parents' response to questions about health history. Multiple logistic regression models were used to adjust for confounding variables.

RESULTS

The prevalence of ADHD was 6.4%. The means urinary inorganic arsenic and blood lead were 21 μg/L and 1.5 μg/dl, respectively. In the lead model adjusted for sex, age, housing material quality and exposure to secondhand tobacco smoke report; children with blood lead concentrations ≥5 μg/dl were more likely to develop ADHD [Odds Ratio (OR): 2.33 95% confidence intervals (CI) 1.32-4.12)]. Regarding arsenic, the adjusted model revealed a higher chance of developing ADHD in the fifth quintile of exposure (OR = 2.02 IC 95% 1.12-3.61).

CONCLUSION

The findings of this study suggest that exposure of children to lead and inorganic arsenic was associated with ADHD. This study provides additional evidence to existing literature regarding the potential role of toxic metals such as lead and arsenic in children's behavior. However, our findings should be interpreted with caution due to the limitations of the study.

Randomized Trial of Academic Training and Medication Decision-Making for Adolescents with ADHD in Usual Care

Objective: This study tested two family-based interventions designed for delivery in usual care: Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA), containing motivational interventions, homework management and schoolwork organization training, and family-school partnership building; and Medication Integration Protocol (MIP), containing ADHD psychoeducation, medication decision-making, and integrated medication management.Method: This study used a cluster randomized design to test CASH-AA + MIP versus CASH-AA Only for adolescents with ADHD in five sites. Therapists (N = 49) were site clinicians randomized to condition. Clients (N = 145) included 72% males; 42% White Non-Hispanic, 37% Hispanic American, 15% African American, and 6% more than one race; average age was 14.8 years. Fidelity data confirmed protocol adherence and between-condition differentiation.Results: One-year improvements were observed across conditions in several outcomes. Overall, CASH-AA + MIP produced greater declines in adolescent-report inattentive symptoms and delinquent acts. Similarly, among non-substance users, CASH-AA + MIP clients attended more treatment sessions. In contrast, among substance users, CASH-AA Only clients showed greater declines in caregiver-report hyperactive symptoms and externalizing.Conclusions: This study provides initial experimental support for family-based ADHD medication decision-making when coupled with academic training in usual care. The treatment protocols, CASH-AA and MIP, showed positive effects in addressing not only ADHD symptoms but also common co-occurring problems, and youth with substance use problems benefitted along with non-using peers.

A Novel Text Message Intervention to Improve Adherence to Stimulants in Adults With Attention Deficit/Hyperactivity Disorder

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) is a prevalent neurobiological disorder associated with a wide range of adverse outcomes. Although large data sets document that stimulants decrease the risks for many ADHD-associated adverse outcomes, compliance with stimulants remains very poor. The main aim of this study was to assess the effectiveness of a novel text messaging-based intervention aimed at improving the poor rate of adherence to stimulant medications in adults with ADHD.

METHODS

Subjects were adults with ages 18 to 55, prescribed a stimulant medication for ADHD treatment. For comparators, we identified at a 5-to-1 ratio (age and sex matched) adult patients from the Partners HealthCare electronic medical record who had been prescribed stimulant medications over a 1-year period. We determined whether patients had timely prescription refills, defined as refilled within 37 days, using prescriptions documented in their electronic medical record.

RESULTS

Our results showed that 68% of the SMS intervention group refilled their prescriptions in a timely manner. In contrast, only 34% of patients receiving treatment as usual refilled their prescriptions in a timely fashion (odds ratio, 4.04; 95% confidence interval, 2.49-6.56; P < 0.001).

CONCLUSIONS

These data indicate that an innovative ADHD-centric text messaging intervention significantly improved patient engagement to treatment with stimulants in adults with ADHD. Findings provide strong support for the use of a readily accessible, inexpensive, and widely available technology to improve the poor rate of adherence to stimulant treatment in adults with ADHD. To the best of our knowledge, this study is the first digital health intervention aimed at improving adherence to stimulant medication for adults with ADHD.

Attention-Deficit/Hyperactivity Disorder Mimics the Post-concussion Syndrome in Adolescents

The objective of this study was to evaluate concussion-like symptom reporting among uninjured adolescents with Attention-deficit/hyperactivity disorder (ADHD), stratified by several cooccurring conditions, and to examine the base rate and predictors of uninjured adolescents with ADHD meeting diagnostic criteria for the International Classification of Diseases, 10th Revision (ICD-10) post-concussional syndrome (PCS). Participants in this cross-sectional, observational study, were drawn from a cohort of 48,834 adolescent student athletes from Maine (ages 13-18) with no concussion in the past 6 months who completed a preseason, baseline testing program between 2009 and 2015. The final sample included 3,031 students with ADHD, 2,146 (70.8%) boys and 885 (29.2%) girls. They were 15.2 years old on average (SD = 1.3). Concussion-like symptom reporting was more common in girls than boys. Most students with ADHD reported one or more symptoms (69.3% of boys and 81.1% of girls). The presence of an additional, co-occurring condition or comorbidity was associated with increased symptom reporting. In the absence of a recent concussion, 28.8% percent of boys and 47.1% of girls with ADHD endorsed symptoms resembling an ICD-10 diagnosis of post-concussional syndrome (PCS). Adolescents with pre-existing conditions were even more likely to endorse symptoms that resembled PCS (28-47% of boys and 45-69% of girls). Prior treatment for a psychiatric condition was the strongest independent predictor for meeting PCS criteria in boys, followed by treatment for migraines and co-occurring learning disorder. For girls, the only independent predictor was prior treatment of a psychiatric condition. In uninjured adolescent student athletes, ADHD appears to mimic the post-concussion syndrome. Adolescents with ADHD commonly endorse concussion-like symptoms in the absence of a recent concussion. Demographic characteristics (sex) and the presence of co-occurring conditions are related to symptom reporting in adolescents with ADHD. Understanding factors associated with baseline symptom reporting, such as pre-existing ADHD, is important when evaluating youth who have persistent symptoms following concussion as well as making both return to school and return to athletics decisions.

ADHD Medication Use During Pregnancy and Risk for Selected Birth Defects: National Birth Defects Prevention Study, 1998-2011

Objective: The objective of this study was to examine the prevalence of, and maternal characteristics associated with, ADHD medication use before and during pregnancy, and associations between early pregnancy ADHD medication use and risk for 12 selected birth defects. Method: We used data from the National Birth Defects Prevention Study (1998-2011), a U.S. population-based case-control study examining risk factors for major structural birth defects. Results: There was an increase in ADHD medication use from 1998-1999 (0.2%) to 2010-2011 (0.5%; p < .001). Early pregnancy ADHD medication use was more commonly reported by mothers of infants/fetuses with gastroschisis (crude odds ratio [cOR]: 2.9, 95% confidence interval [CI] = [1.2, 6.9]), omphalocele (cOR: 4.0, 95% CI = [1.2, 13.6]), and transverse limb deficiency (cOR: 3.3, 95% CI = [1.1, 9.6]). Conclusion: ADHD medication use before and during pregnancy was rare, but the prevalence of use has increased over time. In this analysis, early pregnancy ADHD medication use was associated with three of 12 selected birth defects.

Non-pharmacologic management of attention-deficit/hyperactivity disorder in children and adolescents: a review

Attention-deficit/hyperactivity disorder (ADHD) is a very common neurobehavioral disorder that affects children and adolescents with impact that persists beyond adolescence into adulthood. Medication and non-pharmacological treatments are evidence-based interventions for ADHD in various age groups, and this article will elaborate on the psychosocial, physical and integrative medicine interventions that have been studied in ADHD.

What Differentiates Children with ADHD Symptoms Who Do and Do Not Receive a Formal Diagnosis? Results from a Prospective Longitudinal Cohort Study

ADHD diagnoses are increasing worldwide, in patterns involving both overdiagnosis of some groups and underdiagnosis of others. The current study uses data from a national longitudinal study of Irish children (N = 8568) to examine the sociodemographic, clinical and psychological variables that differentiate children with high hyperactivity/inattention symptoms, who had and had not received a diagnosis of ADHD. Analysis identified no significant differences in the demographic characteristics or socio-emotional wellbeing of 9-year-olds with hyperactivity/inattention who had and who had not received a diagnosis of ADHD. However, by age 13, those who had held a diagnosis at 9 years showed more emotional and peer relationship problems, worse prosocial behaviour, and poorer self-concept. Further research is required to clarify the developmental pathways responsible for these effects.

Pediatric Attention-Deficit/Hyperactivity Disorder in Louisiana: Trends, Challenges, and Opportunities for Enhanced Quality of Care

Background: Attention-deficit/hyperactivity disorder (ADHD) is a common pediatric condition with significant developmental, social, educational, and safety implications. The American Academy of Pediatrics has developed guidelines to support quality care of children with ADHD, but studies demonstrate that the guidelines are variably followed.

Methods: This review highlights patterns of diagnosis and treatment of children with ADHD nationally and in Louisiana and provides examples of system- and practice-level opportunities to improve adherence to quality standards.

Results: Possible contributors to the higher prevalence of ADHD and medication use in Louisiana compared to the nation are specialty workforce shortages, factors in the educational system, and factors associated with race and geography. Innovative system approaches have been developed to address workforce shortages and training limitations. Practice-level innovations include improving the use of validated measures, offering adequate scheduling, and identifying relevant resources and sharing the information with families.

Conclusion: Despite the availability of evidence-based recommendations and resources, significant opportunities exist to provide enhanced ADHD care at the primary care level, especially in Louisiana where the high prevalence of some risk factors for ADHD and the high rates of ADHD and medication prescriptions have been noted nationally and at the state level. Attention to these factors can potentially help address these disproportionalities. Additionally, innovative models of training and collaboration in pediatrics are imperative. Pediatric clinicians, mental health providers, and families can work together to increase awareness about the needs of children and families affected by ADHD in medical, educational, and policy arenas and move the system forward for children.

Sensory processing and organisational abilities in children with inattentive-hyperactive behaviours

Background/Aims

Sensory processing has been theorised to contribute to object and temporal organisation. Sensory processing and organisational abilities in children with inattention-hyperactivity was assessed, and investigated if there was a relationship between the two.

Methods

A community sample of children aged 9–12 years was categorised into inattentive-hyperactive (n=20) and non-inattentive-hyperactive groups (n=56) using the Vanderbilt Attention Deficit Hyperactivity Disorder Parent and Teacher Rating Scales. The Sensory Profile, Child Organisation Scale and Child Organisation Parent Perception Scale were used to collect additional data.

Results

Sensory processing and organisational abilities differed significantly between the groups. Object organisation correlated significantly with multisensory processing; temporal organisation failed to correlate with sensory processing.

Conclusions

Results suggest there is a need to screen children with informant-reported inattention-hyperactivity for sensory processing differences and organisational deficits. Sensory processing and object organisation may be associated; further research on potential factors underlying this association is needed.

Health Care Trajectories for Children With ADHD in France: Results From the QUEST Survey

Objective: The objective of this study is to retrospectively describe the pathway toward ADHD diagnosis and treatment, and identify potential areas for improvement. Method: Parent-reported questionnaires were collected by a national sample of ADHD specialists. Results: In total, 473 complete questionnaires were analyzed. Initial onset of ADHD symptoms was reported at a mean age of 4.45 years. Mean age at diagnosis was 8.07 years, and half of the families had seen at least three health care professionals previously. Psychiatrists were most commonly consulted. A "combined" (89% boys) and inattentive (49% boys) profile was identified. Diagnosis was made 1 year later for the latter group. Two thirds of patients received pharmacological treatment. The delay in diagnosis was identified as the main source of concern for caregivers. Conclusion: The 4-year delay in diagnosis may represent a loss of opportunity. Training health care professionals in the core symptoms of ADHD may help reduce disparities and improve patient trajectory.

Attention Deficit Hyperactivity Disorder (ADHD) Subtypes, Co-Occurring Psychiatric Symptoms and Sexual Risk Behaviors among Adolescents Receiving Substance Abuse Treatment

Background: Adolescents entering substance abuse treatment report clustered psychiatric symptoms and sexual risk behaviors representing differential levels of impairment and risk for maladaptive health outcomes. Objectives: To examine the prevalence of Attention Deficit Hyperactivity Disorder (ADHD) subtypes among adolescents receiving outpatient substance abuse treatment; To document group differences in (a) past-year psychiatric symptom scores and (b) sexual risk behaviors by ADHD subtype and gender. Methods: Self-report data were collected via structured interviews from 394 adolescents (280 males, M = 16.33 years, SD = 1.15 years), enrolled in an HIV/STI risk reduction intervention for adolescents receiving outpatient substance abuse treatment. ADHD diagnostic subtypes and other past-year psychiatric symptoms were assessed using the Brief Michigan Version of the Composite Internal Diagnostic Interview (UM-CIDI). Adolescents provided self-report data on sexual risk behaviors. Results: Multivariate analyses of variance (MANOVAs) documented that Inattentive and Hyperactive-Impulsive ADHD subtypes were significantly associated with higher scores for all past-year psychiatric symptoms. The combined ADHD subtype was significantly associated with higher scores for all psychiatric symptoms except affective disorder. Girls reported significantly higher mean symptoms than boys for alcohol abuse and dependence, anxiety, and affective disorder symptoms. Sexual risk behavior scores were not associated with ADHD status, but girls reported consistently higher scores for multiple risk behavior outcomes. Several psychiatric disorder symptoms were significant covariates of multiple sexual risk behaviors. Conclusion/Importance: Brief screenings for ADHD, other psychiatric disorders and sexual risk behaviors can provide data for tailoring substance abuse services to improve adolescent health outcomes for high-risk subgroups.

Behavioral Treatment for the Social-Emotional Difficulties of Preadolescent and Adolescent Girls with ADHD

Girls with attention-deficit/hyperactivity disorder (ADHD) are at high risk for peer difficulties that often persist into adolescence and adulthood and portend risk for additional difficulties, such as depression, anxiety, and borderline personality disorder. However, very little research has examined interventions that address the widespread peer difficulties of girls with ADHD. This paper describes two open trials of behavior therapy aimed at addressing their social-emotional difficulties. The first trial includes 33 preadolescent girls (ages 7-11) with ADHD enrolled in an eight-week treatment and the second trial includes 22 adolescent girls (ages 12-16) with ADHD enrolled in a 12-week treatment. Measures of treatment feasibility and acceptability and measures of social functioning and psychopathology were collected in both trials. High levels of treatment feasibility and acceptability were reported in both the preadolescent and adolescent trial. In addition, improvements were reported in areas of social functioning and reductions in psychopathology, although the magnitude and specific areas of improvement differed somewhat in the preadolescent versus adolescent group. These preliminary findings provide a first step towards addressing the widespread social-emotional difficulties of girls with ADHD and offer insight into continuing efforts to address their treatment needs.

Attention deficit hyperactivity disorder

Many authors have contributed to the description of attention deficit/hyperactivity disorder (ADHD) for the two last centuries. In this chapter, we review the current diagnostic criteria, epidemiology, and history of ADHD. The different phenotypes (predominantly inattentive, predominantly hyperactive/impulsive, or combined) and diagnostic process are detailed. The DSM-5 includes the three phenotypes that begin before age 12, are present in at least two settings, and cannot be explained by another condition. Theoretical underpinnings and biological and environmental etiologies reported in the latest literature are discussed. There are many comorbidities associated with ADHD, which are associated with an increase in the negative impact on everyday life. Treatment decisions involve a complex interaction between child's age, symptom severity levels, comorbidities, functional impairments, and parents' preferences. Medication (psychostimulant and nonstimulant) and psychosocial (mainly behavioral parent training) treatments as well as school-based interventions are described.

Associations Between Family and Community Protective Factors and Attention-Deficit/Hyperactivity Disorder Outcomes Among US Children

BACKGROUND

Evidence has established the association between risk factors and attention-deficit/hyperactivity disorder (ADHD) severity, but less is known about factors that may have protective effects on clinical, academic, and social outcomes among children with ADHD.

OBJECTIVE

To examine associations between family cohesion, caregiver social support, community support, and (1) ADHD severity, (2) school engagement, and (3) difficulty making or keeping friends.

METHODS

Cross-sectional study of school-aged and adolescent children with ADHD using data from the 2016 National Survey of Children's Health. Our outcomes were (1) parent-rated ADHD severity, (2) school engagement, and (3) difficulty making or keeping friends. Our independent variables were (1) family cohesion, (2) caregiver social support, and (3) community support. We used logistic regression models to examine associations between our independent variables and each of our outcome variables, adjusting for child and parent sociodemographic characteristics.

RESULTS

In our sample (N = 4,122, weighted N = 4,734,322), children exposed to family cohesion and community support had lower odds of moderate to severe ADHD [adjusted OR (aOR): 0.73 (0.55-0.97); aOR: 0.73 (0.56-0.95), respectively], higher odds of school engagement [aOR: 1.72, (1.25-2.37); aOR: 1.38, (1.04-1.84), respectively], and lower odds of difficulty making or keeping friends [aOR: 0.64, (0.48-0.85); aOR: 0.52, (0.40-0.67), respectively].

CONCLUSION

Among children with ADHD, family cohesion and community support show protective effects in clinical, academic, and social outcomes. Systematically identifying family- and community-level strengths may be important components of multimodal treatment strategies in children with ADHD.

Physician Perceptions of ADHD Stimulant Diversion and Misuse

Objective: The recent rise in ADHD has prompted concerns about adolescents with ADHD diverting and/or misusing stimulants. This is the first study to assess physician perceptions of the pervasiveness of these issues. Method: Questionnaires were mailed to a national sample of pediatric subspecialists. Responses were analyzed (n = 826; 18% response rate) using descriptive statistics and regression analyses. Results: In the past year, 59% of physicians suspected ≥1 patient(s) with ADHD diverted stimulants. Seventy-four percent believed ≥1 patient(s) feigned symptoms to obtain an initial ADHD diagnosis; 66% believed ≥1 patient(s) wanted stimulants to improve academic performance. Child and adolescent psychiatrists were most likely to suspect diversion and feigning symptoms. Thirty-nine percent of physicians believed diversion was at least "common." Conclusion: Although many physicians suspected stimulant diversion and misuse, a substantial number were unaware of these issues, and subspecialist perceptions varied. These findings support the potential pervasiveness of these issues and the need for increased physician awareness.

Drug Prescribing and Outcomes After Pharmacogenomic Testing in a Developmental and Behavioral Health Pediatric Clinic

OBJECTIVE

To describe drug prescribing and outcomes after pharmacogenomic (PGx) testing in children with developmental and/or behavioral disorders.

METHODS

This is a single-clinic retrospective analysis of patients aged 5 to 17 years with documented behavioral and/or development disorder(s) and having received PGx testing between May 2015 and May 2017. The primary endpoint was frequency of PGx-guided medication changes after testing. Secondary endpoints included frequency of medications in each category from the PGx report (use as directed, use with caution, and use with increased caution), changes in therapy within each category, frequency and type of actionable genes, symptomatic improvement, and frequency of medication changes up to 6 months after PGx-guided therapy.

RESULTS

Of 200 patients, 75% were male, 78% were white, 83% had attention-deficit/hyperactivity disorder, and 45% had anxiety, and their mean age was 10 years. Most common reasons for ordering PGx testing were lack of response (83%) and/or adverse events (42%). Approximately 84% had PGx-guided medication change(s) after testing. At baseline, 50% of medications were categorized in "use as directed," 40% in "use with caution," and 11% in "use with increased caution." After testing, 8%, 29%, and 30% of medications in "use as directed," "use with caution," and "use with increased caution" categories were discontinued; 85% were added or continued from "use as directed" category. The most common actionable genes were ADRA2A (47%), COMT (22%), and CYP2D6 (20%). Sixty percent were on the same medication(s) suggested by the PGx report 6 months later, and 64% had provider-documented symptomatic improvement.

CONCLUSION

Pharmacogenomic testing may affect drug prescribing and clinical outcomes in a pediatric behavioral health clinic.

Discriminating malingered attention Deficit Hyperactivity Disorder from genuine symptom reporting using novel Personality Assessment Inventory validity measures

It is now widely understood that ADHD can be feigned easily and convincingly. Despite this, almost no methods exist to assist clinicians in identifying when such behavior occurs. Recently, new validity indicators specific to feigned ADHD were reported for the Personality Assessment Inventory (PAI). Derived from a logistic regression, these algorithms are said to have excellent specificity and good sensitivity in identifying feigned ADHD. However, these authors compared those with genuine ADHD only to nonclinical undergraduate students (asked to respond honestly or asked to simulate ADHD); no criterion group of definite malingerers was included. We therefore investigated these new validity indicators with 331 postsecondary students who underwent assessment for possible ADHD and compared scores of those who were eventually diagnosed with ADHD (n = 111) to those who were not [Clinical controls (66), Definite malingerers (36); No diagnosis (117)]. The two proposed PAI algorithms were found to have poor positive predictive value (.19 and .17). Self-report validity measures from the Connors' Adult Attention Rating Scale, and the Negative Impression Management scale on the PAI returned more positive results. Overall, more research is needed to better identify noncredible ADHD presentation, as the PAI-based methods proposed by Aita et al. appear inadequate as symptom validity measures.

Slow Processing Speed and Sluggish Cognitive Tempo in Pediatric Attention-Deficit/Hyperactivity Disorder: Evidence for Differentiation of Functional Correlates

The association between slow processing speed and sluggish cognitive tempo (SCT), a phenotype described within attention-deficit/hyperactivity disorder (ADHD) samples over the past decade, remains unclear. We examined whether SCT and processing speed predict different functional correlates within children and adolescents with ADHD. Participants were 193 clinically-referred youth meeting DSM ADHD criteria without comorbid conditions (mean age = 9.9 years, SD = 2.5; age range 6-16). The incremental utility of SCT and processing speed to predict (1) adaptive functioning and (2) academic achievement, after controlling for age, sex, medication status, and ADHD symptom burden, was assessed using hierarchical multiple regressions. SCT symptoms significantly predicted adaptive functioning, accounting for 6% of the variance, but did not predict academic achievement. Processing speed did not add incrementally to the prediction of adaptive functioning, but did predict academic achievement, accounting for 4% of the variance. Results suggest that SCT and processing speed differentially predict functional abilities not accounted for by ADHD symptom burden.

Addressing Discrepancies Between ADHD Prevalence and Case Identification Estimates Among U.S. Children Utilizing NSCH 2007-2012

Objective: Among U.S. children, ADHD epidemiological estimates (3%-5%) vary significantly from case identification rates (over 11%), leading to confusion about true incidence and prevalence. We investigated the extent to which this discrepancy could be resolved by definitional issues through reexamining the most cited U.S. survey of case identification, the National Survey of Children's Health (NSCH). Method: Using NSCH 2007/2008 and 2011/2012, we stratified identification of ADHD by current status, severity, psychiatric comorbidity, and ADHD medication usage. Using those criteria, definitional strength was coded into "Definite," "Probable," "Doubtful," and "No." Results: "Definite" ADHD in caseness in 2007/2008 was 4.04%, increasing to 5.49% in 2011/2012, roughly corresponding to epidemiological estimates. "Definite" ADHD was the primary contributor to an overall increase in caseness over that period. Conclusion: This analysis strengthens understanding of discrepancies in estimated ADHD rates. When low confidence identification is considered false positives, ADHD case identification rates match epidemiological estimates more closely.

A Commercial Insurance Claims Analysis of Correlates of Behavioral Therapy Use Among Children With ADHD

OBJECTIVE

The study examined factors associated with uptake of behavioral therapy among children with attention-deficit hyperactivity disorder (ADHD).

METHODS

Insurance claims data from 2008-2014 (MarketScan) were reviewed to examine associations between behavioral therapy use and demographic, patient, family, and provider factors. The association between ADHD medication use and future uptake of behavioral therapy was examined with logistic regression adjusted for covariates found to affect behavioral therapy use.

RESULTS

Among 827,396 youths with ADHD, under 50% received any billable behavioral therapy services over the 7 years. ADHD severity, gender, region of residence, assessment year, comorbid behavioral disorders, and behavioral therapy use by siblings were significantly associated with behavioral therapy use (p<0.001). Parent psychopathology and sibling medication use was not. Children prescribed ADHD medication were 2.5 times less likely than those not prescribed medication to use behavioral therapy, even after adjustment for severity of behavioral health symptoms and other covariates (odds ratio [OR]= 0.41, 95% confidence interval [CI]=.40-.41, p<0.001). Effects of medication use were stronger for future uptake of behavioral therapy (OR=0.25, 95% CI =0.24-0.25, p<.001). The impact of medication use on behavioral therapy use was equally strong for children under age 6 and for older children and did not weaken after release of 2011 guidelines recommending behavioral therapy as the initial ADHD treatment for young children.

CONCLUSIONS

Multiple systems, family, patient and provider factors affected behavioral therapy uptake. ADHD medication was a robust and potentially modifiable factor. It may be advisable to engage families in behavioral therapy prior to initiation of ADHD medication.

EEG power spectral slope differs by ADHD status and stimulant medication exposure in early childhood

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by hyperactivity/impulsivity and inattentiveness. Efforts toward the development of a biologically based diagnostic test have identified differences in the EEG power spectrum; most consistently reported is an increased ratio of theta to beta power during resting state in those with the disorder, compared with controls. Current approaches calculate theta/beta ratio using fixed frequency bands, but the observed differences may be confounded by other relevant features of the power spectrum, including shifts in peak oscillation frequency and altered slope or offset of the aperiodic 1/f-like component of the power spectrum. In the present study, we quantify the spectral slope and offset, peak alpha frequency, and band-limited and band-ratio oscillatory power in the resting-state EEG of 3- to 7-yr-old children with and without ADHD. We found that medication-naive children with ADHD had higher alpha power, greater offsets, and steeper slopes compared with typically developing children. Children with ADHD who were treated with stimulants had comparable slopes and offsets to the typically developing group despite a 24-h medication-washout period. We further show that spectral slope correlates with traditional measures of theta/beta ratio, suggesting the utility of slope as a neural marker over and above traditional approaches. Taken with past research demonstrating that spectral slope is associated with executive functioning and excitatory/inhibitory balance, these results suggest that altered slope of the power spectrum may reflect pathology in ADHD.NEW & NOTEWORTHY This article highlights the clinical utility of comprehensively quantifying features of the EEG power spectrum. Using this approach, we identify, for the first time, differences in the aperiodic components of the EEG power spectrum in children with attention-deficit/hyperactivity disorder (ADHD) and provide evidence that spectral slope is a robust indictor of an increase in low- relative to high-frequency power in ADHD.

Mental health is biological health: Why tackling "diseases of the mind" is an imperative for biological anthropology in the 21st century

The germ theory of disease and the attendant public health initiatives, including sanitation, vaccination, and antibiotic treatment, led to dramatic increases in global life expectancy. As the prevalence of infectious disease declines, mental disorders are emerging as major contributors to the global burden of disease. Scientists understand little about the etiology of mental disorders, however, and many of the most popular psychopharmacological treatments, such as antidepressants and antipsychotics, have only moderate-to-weak efficacy in treating symptoms and fail to target biological systems that correspond to discrete psychiatric syndromes. Consequently, despite dramatic increases in the treatment of some mental disorders, there has been no decrease in the prevalence of most mental disorders since accurate record keeping began. Many researchers and theorists are therefore endeavoring to rethink psychiatry from the ground-up. Anthropology, especially biological anthropology, can offer critical theoretical and empirical insights to combat mental illness globally. Biological anthropologists are unique in that we take a panhuman approach to human health and behavior and are trained to address each of Tinbergen's four levels of analysis as well as culture. The field is thus exceptionally well-situated to help resolve the mysteries of mental illness by integrating biological, evolutionary, and sociocultural perspectives.

Evidence of potential overdiagnosis and overtreatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents: protocol for a scoping review

INTRODUCTION

Worldwide, attention deficit hyperactivity disorder (ADHD) diagnosis rates in children and adolescents have been increasing consistently over the past decades, fuelling a debate about the underlying reasons for this trend. While many hypothesise that a substantial number of these additional cases are overdiagnosed, to date there has been no comprehensive evaluation of evidence for or against this hypothesis. Thus, with this scoping review we aim to synthesise published evidence on the topic in order to investigate whether existing literature is consistent with the occurrence of overdiagnosis and/or overtreatment of ADHD in children and adolescents.

METHODS AND ANALYSIS

The proposed scoping review will be conducted in the context of a framework of five questions, developed specifically to identify areas in medicine with the potential for overdiagnosis and overtreatment. The review will adhere to the Joanna Briggs Methodology for Scoping Reviews. We will search Medline, Embase, PsycINFO and the Cochrane Library electronic databases for primary studies published in English from 1979 onwards. We will also conduct forward and backward citation searches of included articles. Data from studies that meet our predefined exclusion and inclusion criteria will be charted into a standardised extraction template with results mapped to our predetermined five-question framework in the form of a table and summarised in narrative form.

ETHICS AND DISSEMINATION

The proposed study is a scoping review of the existing literature and as such does not require ethics approval. We intend to disseminate the results from the scoping review through publication in a peer-reviewed journal and through conference presentations. Further, we will use the findings from our scoping review to inform future research to fill key evidence gaps identified by this review.

Inter-hemispheric Asymmetry Patterns in the ADHD Brain: A Neuroimaging Replication Study

Attention-deficit/ hyperactivity disorder (ADHD) is the most common neurodevelopment disorder in children, and many genetic markers have been linked to the behavioral phenotypes of this highly heritable disease. The neuroimaging correlates are similarly complex, with multiple combinations of structural and functional alterations associated with the disease presentations of hyperactivity and inattentiveness. Thus far, neuroimaging studies have provided mixed results in ADHD patients, particularly with respect to the laterality of findings. It is possible that hemispheric asymmetry differences may help reconcile the variability of these findings. We recently reported that inter-hemispheric asymmetry differences were more sensitive descriptors for identifying differences between ADHD and typically developing (TD) brains (n=849) across volumetric, morphometric, and white matter neuroimaging metrics. Here, we examined the replicability of these findings across a new data set (n=202) of TD and ADHD subjects at the time of diagnosis (medication naive) and after a six week course of either stimulant drugs, non-stimulant medications, or combination therapy. Our findings replicated our earlier work across a number of volumetric and white matter measures confirming that asymmetry is more robust at detecting differences between TD and ADHD brains. However, the effects of medication failed to produce significant alterations across either lateralized or symmetry measures. We suggest that the delay in brain volume maturation observed in ADHD youths may be hemisphere dependent. Future work may investigate the extent to which these inter-hemispheric asymmetry differences are causal or compensatory in nature.

Combined association of BTEX and material hardship on ADHD-suggestive behaviours among a nationally representative sample of US children

BACKGROUND

Previous research shows that environmental and social factors contribute to the development of attention-deficit/hyperactivity disorder (ADHD).

OBJECTIVE

To determine the relationship between early-life exposure to common ambient air pollutants (benzene, toluene, ethylbenzene, and xylene, also known as BTEX), household material hardship (a measure of socio-economic status), and ADHD-suggestive behaviours in kindergarten-age children.

METHODS

Pollutant exposure estimated from the 2002 National Air Toxics Assessment at each child's residential ZIP code at enrolment was linked to the Early Childhood Longitudinal Study Birth Cohort (n = 4650). Material hardship was assigned as a composite score of access to food, health care, and housing. Kindergarten teachers rated children's behaviours and activity in the classroom using a five-point Likert scale. Children with summary scores in the bottom decile were classified as displaying ADHD-suggestive behaviours. Logistic regression models were constructed to estimate the association between both BTEX exposure and material hardship on ADHD-suggestive behaviours.

RESULTS

The odds of displaying ADHD-suggestive behaviours were greater in children with combined high-level exposure to BTEX and in those experiencing material hardship (odds ratio 1.54, 95% confidence interval [CI] 1.12, 2.11, and OR 2.12, 95% CI 1.25, 3.59, respectively), adjusting for covariates. These associations were stronger when restricting the study population to urban areas. There was no evidence of interaction between early life BTEX exposure and material hardship, although the effects of BTEX exposure were slightly greater in magnitude among those with higher material hardship scores.

CONCLUSIONS

Children exposed to air toxics, material hardship, or both early in life are more likely to display signs of ADHD-suggestive behaviours as assessed by their kindergarten teachers. The associations between exposures to air pollution and to socio-economic hardship were observed in all children but were particularly strong in those living in urban areas.

Childhood methylphenidate adherence as a predictor of antidepressants use during adolescence

Methylphenidate (MPH) is a common and effective treatment for attention deficit hyperactivity disorder (ADHD), but little is known about the relationship between early childhood intake of MPH and onset of antidepressant treatment during adolescence. The study aimed to examine whether adherence to MPH during early childhood predicts the initiation of antidepressants during adolescence. This is a 12-year historical prospective nationwide cohort study of children enrolled in an integrated care system who were first prescribed MPH between the ages of 6 and 8 years (N = 6830). We tested for an association between their adherence to MPH during early childhood (as indicated by medication possession ratio from MPH onset through the age of twelve) and the likelihood of being prescribed any antidepressant during adolescence (age 13-18). As all country citizens are covered by mandatory health insurance, and full services are provided by one of the four integrated care systems, data regarding patients' diagnoses, prescriptions, and medical purchases are well documented. Logistic regression analysis indicated that those with higher adherence to MPH had a 50% higher risk (95% CI 1.16-1.93) of receiving antidepressants during adolescence when controlling for other comorbid psychiatric conditions and parental use of antidepressants. In this large-scale longitudinal study, MPH adherence during early childhood emerged as a predictor for antidepressant treatment during adolescence, which may reflect increased emotional and behavioral dysregulation in this group. The highly adherent patients are at higher risk and should be clinically monitored more closely, particularly into adolescence.

Prevalence and Trends of Developmental Disabilities among Children in the United States: 2009-2017

OBJECTIVES

To study the national prevalence of 10 developmental disabilities in US children aged 3 to 17 years and explore changes over time by associated demographic and socioeconomic characteristics, using the National Health Interview Survey.

METHODS

Data come from the 2009 to 2017 National Health Interview Survey, a nationally representative survey of the civilian noninstitutionalized population. Parents reported physician or other health care professional diagnoses of attention-deficit/hyperactivity disorder; autism spectrum disorder; blindness; cerebral palsy; moderate to profound hearing loss; learning disability; intellectual disability; seizures; stuttering or stammering; and other developmental delays. Weighted percentages for each of the selected developmental disabilities and any developmental disability were calculated and stratified by demographic and socioeconomic characteristics.

RESULTS

From 2009 to 2011 and 2015 to 2017, there were overall significant increases in the prevalence of any developmental disability (16.2%-17.8%, P < .001), attention-deficit/hyperactivity disorder (8.5%-9.5%, P < .01), autism spectrum disorder (1.1%-2.5%, P < .001), and intellectual disability (0.9%-1.2%, P < .05), but a significant decrease for any other developmental delay (4.7%-4.1%, P < .05). The prevalence of any developmental disability increased among boys, older children, non-Hispanic white and Hispanic children, children with private insurance only, children with birth weight ≥2500 g, and children living in urban areas and with less-educated mothers.

CONCLUSIONS

The prevalence of developmental disability among US children aged 3 to 17 years increased between 2009 and 2017. Changes by demographic and socioeconomic subgroups may be related to improvements in awareness and access to health care.

Factors Associated with Attention Deficit Hyperactivity Disorder Medication Use in Community Care Settings

OBJECTIVES

To examine patient- and provider-level factors associated with receiving attention-deficit/hyperactivity disorder (ADHD) medication treatment in a community care setting. We hypothesized that the likelihood of ADHD medication receipt would be lower in groups with specific patient sociodemographic (eg, female sex, race other than white) and clinical (eg, comorbid conditions) characteristics as well as physician characteristics (eg, older age, more years since completing training).

STUDY DESIGN

A retrospective cohort study was conducted with 577 children (mean age, 7.8 years; 70% male) presenting for ADHD to 50 community-based practices. The bivariate relationship between each patient- and physician-level predictor and whether the child was prescribed ADHD medication was assessed. A multivariable model predicting ADHD medication prescription was conducted using predictors with significant (P < .05) bivariate associations.

RESULTS

Sixty-nine percent of children were prescribed ADHD medication in the year after initial presentation for ADHD-related concerns. Eleven of 31 predictors demonstrated a significant (P < .05) bivariate relationship with medication prescription. In the multivariable model, being male (OR, 1.34; 95% CI, 1.01-1.78; P = .02), living in a neighborhood with higher medical expenditures (OR, 1.11 for every $100 increase; 95% CI, 1.03-1.21; P = .005), and higher scores on parent inattention ratings (OR, 1.06; 95% CI, 1.03-1.10; P < .0001) increased the likelihood of ADHD medication prescription.

CONCLUSIONS

We found that some children, based on sociodemographic and clinical characteristics, are less likely to receive an ADHD medication prescription. An important next step will be to examine the source and reasons for these disparities in an effort to develop strategies for minimizing treatment barriers.

Evidence of Low Adherence to Stimulant Medication Among Children and Youths With ADHD: An Electronic Health Records Study

OBJECTIVE

The objective of this study was to evaluate rates and correlates of stimulant medication adherence in a sample of pediatric patients using data derived from electronic medical records (EMRs) from a large health care organization in a large metropolitan area. The study relied on a novel definition of medication adherence as a timely renewal of an index prescription determined using the electronically recorded issuance of a stimulant prescription in the EMR ("refill").

METHODS

Prescription and sociodemographic data were extracted from the Partners HealthCare Research Patient Data Registry to calculate adherence to stimulant medication treatment.

RESULTS

In the EMR, 2,206 patients with prescriptions for central nervous system stimulant medication were identified. Results showed that 46% of the index prescriptions were refilled within the timeframe necessary for the patient to be considered consistently medicated. A multivariable logistic regression model predicting medication adherence from patient demographic and treatment characteristics yielded an area-under-the-curve statistic of 0.57, indicating that these characteristics predicted adherence only modestly better than chance.

CONCLUSIONS

EMR data from a large health care organization showed that 46% of pediatric patients were adherent to treatment with stimulants. Rates of medication adherence were worse among patients receiving care from a primary care provider than among those receiving care from a psychiatrist, in older patients, and in female patients and did not appear to be influenced by racial-ethnic group, economic class, stimulant type, or medication formulation (short or long acting). These findings, which show low rates of medication adherence among children and adolescents with ADHD, suggest the need for efforts to improve these rates.

Childhood ADHD Symptoms and Future Illicit Drug Use: The Role of Adolescent Cigarette Use

Objectives

The aim of this study is to understand how early cigarette use might predict subsequent illicit drug use, especially among individuals with attention-deficit hyperactivity disorder (ADHD) symptoms during childhood.

Methods

Data were drawn from the National Longitudinal Study of Adolescent Health (Waves I-IV). The analysis sample involves participants who had not used illicit drugs at Wave I, with no missing responses for studied predictors (N = 7,332).

Results

Smoking status at Wave I (ever regular vs. never regular) and childhood ADHD symptoms predicted subsequent illicit drug use at Waves II to IV. No interaction effect of smoking status at Wave I and childhood ADHD symptoms was found. However, an indirect effect from childhood ADHD symptoms on illicit drug use was identified, through smoking status at Wave I. Similar results were observed for predicting illicit drug dependence.

Conclusions

The findings support the notion that smoking status during early adolescence may mediate the association between childhood ADHD symptoms and risk of later adult drug use. Interventions to prevent smoking among adolescents may be particularly effective at decreasing subsequent drug use, especially among children with ADHD symptoms.

Glutaminergic signaling in the caudate nucleus is required for behavioral sensitization to methylphenidate

Methylphenidate (MPD) is a widely prescribed psychostimulant for the treatment of attention deficit hyperactivity disorder, and is growing in use as a recreational drug and academic enhancer. MPD acts on the reward/motive and motor circuits of the CNS to produce its effects on behavior. The caudate nucleus (CN) is known to be a part of these circuits, so a lesion study was designed to elucidate the role of the CN in response to acute and chronic MPD exposure. Five groups of n = 8 rats were used: control, sham CN lesions, non-specific electrolytic CN lesions, dopaminergic-specific (6-OHDA toxin) CN lesion, and glutaminergic-specific (ibotenic acid toxin) CN lesions. On experimental day (ED) 1, all groups received saline injections. On ED 2, surgeries took place, followed by a 5-day recovery period (ED 3-7). Groups then received six daily MPD 2.5 mg/kg injections (ED 9-14), then three days of washout with no injection (ED 15-17), followed by a re-challenge with the previous 2.5 mg/kg MPD dose (ED 18). Locomotive activity was recorded for 60 min after each injection by a computerized animal activity monitor. The electrolytic CN lesion group responded to the MPD acute and chronic exposures similarly to the control and sham groups, showing an increase in locomotive activity, i.e. sensitization. The dopaminergic-specific CN lesion group failed to respond to MPD exposure both acute and chronically. The glutaminergic-specific CN lesion group responded to MPD exposure acutely but failed to manifest chronic effects. This confirms the CN's dopaminergic system is necessary for MPD to manifest its acute and chronic effects on behavior, and demonstrates that the CN's glutaminergic system is necessary for the chronic effects of MPD such as sensitization. Thus, the dopaminergic and glutaminergic components of the CN play a significant role in differentially modulating the acute and chronic effects of MPD respectively.

The association between attention deficit hyperactivity disorder severity and risk of mild traumatic brain injury in children with attention deficit hyperactivity disorder in the United States of America: A cross-sectional study of data from the National Survey of Children with Special Health Care Needs

BACKGROUND

As children with attention deficit hyperactivity disorder (ADHD) have shown to be at higher risk of accidents and injury, one may assume that they may also bear a higher likelihood of mild traumatic brain injuries (mTBI). However, the current scientific evidence whether ADHD severity is associated with traumatic brain injuries is controversial. The objective of this study was too assess the association between the severity of ADHD and prevalence of mTBI in 0- to 18-year-old children with ADHD in the United States.

METHODS

Cross-sectional study using secondary data gathered in 2009/10 from the National Survey of Children with Special Healthcare Needs. After excluding comorbidity and those with nonspecific attention deficits, the final study population consisted of 10,739 children with ADHD from 40,052 households. The main exposure variable was self-reported ADHD severity (mild, moderate, or severe). The main outcome was mTBI, defined as head injury, traumatic brain injury, and/or concussion). Covariates included age, gender and race, medication status. Unadjusted and adjusted logistic regression analysis were used.

RESULTS

Children with more severe ADHD had consistently increased incidences of mTBI. Adjusted logistic regression analysis revealed a statistically significant association between severity of ADHD and occurrence of mTBI. The corresponding odds ratios were 1.57 (95% confidence interval (CI) [1.13, 2.18] for moderate, and 1.79 (95% CI [1.18, 2.72]) for severe ADHD, respectively, compared with mild ADHD. In males, children with moderate and severe ADHD had increased odds of mTBI. The corresponding odds ratio for mTBI in those with moderate ADHD was 1.60 (95% CI [1.07, 2.39]) and 1.86 (95% CI [1.15, 3.00]) for severe ADHD, respectively. No associations between severity and mTBI were found in girls.

CONCLUSIONS

As ADHD severity was associated with incidence of mTBI, it is important to identify those who need increased attention and counselling to prevent injury.

Early developmental pathways to childhood symptoms of attention-deficit hyperactivity disorder, anxiety and autism spectrum disorder

BACKGROUND

Children with autism spectrum disorder (ASD) often have co-occurring symptoms of attention-deficit/hyperactivity disorder (ADHD) and/or anxiety. It is unclear whether these disorders arise from shared or distinct developmental pathways. We explored this question by testing the specificity of early-life (infant and toddler) predictors of mid-childhood ADHD and anxiety symptoms compared to ASD symptoms.

METHODS

Infants (n = 104) at high and low familial risk for ASD took part in research assessments at 7, 14, 24 and 38 months, and 7 years of age. Symptoms of ASD, ADHD and anxiety were measured by parent report at age 7. Activity levels and inhibitory control, also measured by parent report, in infancy and toddlerhood were used as early-life predictors of ADHD symptoms. Fearfulness and shyness measured in infancy and toddlerhood were used as early-life predictors of anxiety symptoms. Correlations and path analysis models tested associations between early-life predictors and mid-childhood ADHD and anxiety symptoms compared to mid-childhood ASD symptoms, and the influence of controlling for ASD symptoms on those associations.

RESULTS

Increased activity levels and poor inhibitory control were correlated with ADHD symptoms and not ASD or anxiety; these associations were unchanged in path models controlling for risk-group and ASD symptoms. Increased fearfulness and shyness were correlated with anxiety symptoms, but also ASD symptoms. When controlling for risk-group in path analysis, the association between shyness and anxiety became nonsignificant, and when further controlling for ASD symptoms the association between fearfulness and anxiety became marginal.

CONCLUSIONS

The specificity of early-life predictors to ADHD symptoms suggests early developmental pathways to ADHD might be distinct from ASD. The overlap in early-life predictors of anxiety and ASD suggests that these disorders are difficult to differentiate early in life, which could reflect the presence of common developmental pathways or convergence in early behavioural manifestations of these disorders.

Maternal psychosocial stress and children's ADHD diagnosis: a prospective birth cohort study

Objective: Examine the association of mothers' psychosocial stressors before and during pregnancy with their children's diagnosis of attention deficit hyperactivity disorder (ADHD). Methods: This study included 2140 mother-child pairs who had at least one postnatal pediatric visit at the Boston Medical Center between 2003 and 2015. Child ADHD was determined via International Classification of Diseases, Ninth Revision (ICD-9) codes documented in electronic medical records. Latent factors of maternal stress and social support and measures of the physical home environment and psychosocial adversities were constructed using exploratory factor analysis. The association between the latent factors and child ADHD diagnosis was examined using multiple logistic regression, controlling for known risk factors for ADHD. Results: Children were 1.45 (95% CI: 1.06, 1.99) and 3.03 (95% CI: 2.19, 4.20) times more likely to receive an ADHD diagnosis if their mother experienced a major stressful event during pregnancy or reported a high level of perceived stress, respectively. The number of family adversities increases the risk of ADHD diagnosis [second quartile: OR = 1.90; CI (1.31, 2.77); third quartile: OR = 1.96 CI (1.34, 2.88); fourth quartile: OR = 2.89 CI (2.01, 4.16)] compared to first quartile. Conclusions: In this prospective, predominantly urban, low-income, minority birth cohort, mothers' psychosocial stress before and during pregnancy appears to be an independent risk factor for the development of ADHD in their children.

Patterns and Predictors of Service Utilization Among Youth With ADHD-Predominantly Inattentive Presentation

Objective: This study examined rates and predictors of educational and mental health service utilization among youth with ADHD-predominantly inattentive presentation (ADHD-I). Method: Participants were 199 children with ADHD-I in Grades 2 to 5. Parents reported past-year child service utilization. Parents and teachers rated child ADHD and oppositional defiant disorder (ODD) symptom severity and functional impairment. Children completed an academic achievement test. Results: All children had impairment at school and home. Most received some sort of school service (79%), but only 23% received community-based services. ADHD symptom severity was unrelated to service utilization. However, higher parent-rated functional impairment predicted community service utilization. Academic underachievement and higher teacher-rated functional impairment predicted school service utilization. Conclusion: Many youth with ADHD-I experience impairment across domains without receiving adequate services for these problems. Functional impairment appears to be a stronger predictor of service utilization than ADHD symptom severity, demonstrating the importance of impairment in understanding service needs for ADHD-I.

Opposing effects of impulsivity and mindset on sources of science self-efficacy and STEM interest in adolescents

Impulsivity has been linked to academic performance in the context of Attention Deficit Hyperactivity Disorder, though its influence on a wider spectrum of students remains largely unexplored, particularly in the context of STEM learning (i.e. science, technology, engineering, and math). STEM learning was hypothesized to be more challenging for impulsive students, since it requires the practice and repetition of tasks as well as concerted attention to task performance. Impulsivity was assessed in a cross-sectional sample of 2,476 students in grades 6-12. Results show impulsivity affects a larger population of students, not limited to students with learning disabilities. Impulsivity was associated with lower sources of self-efficacy for science (SSSE), interest in most STEM domains (particularly math), and self-reported STEM skills. The large negative effect size observed for impulsivity was opposed by higher mindset, which describes a student's belief in the importance of effort when learning is difficult. Mindset had a large positive effect size associated with greater SSSE, STEM interest, and STEM skills. When modeled together, results offer that mindset interventions may benefit impulsive students who struggle with STEM. Together, these data suggest important interconnected roles for impulsivity and mindset that can influence secondary students' STEM trajectories.

Brain iron levels in attention-deficit/hyperactivity disorder normalize as a function of psychostimulant treatment duration

Brain iron homeostasis is a dopamine-related mechanism that may be modified with long-term psychostimulant treatment in attention-deficit/hyperactivity disorder (ADHD). We previously reported that while medication-naïve youth with ADHD have reduced brain iron compared to controls and psychostimulant-medicated patients, no differences were detected between the latter groups. In this follow-up study, we examined whether the duration of psychostimulant treatment correlates with the degree of iron normalization. Brain iron was indexed with MRI using an advanced method called magnetic field correlation (MFC) imaging and the conventional R2* proton transverse relaxation rate method. MFC was acquired in 30 psychostimulant-medicated youth with comorbid-free ADHD and 29 age-matched controls (all males). R2* was acquired in a subset of these individuals. Region-of-interest analyses for MFC and R2* group differences and within-group correlations with age and years of psychostimulant treatment were conducted in the globus pallidus (GP), putamen (PUT), caudate nucleus (CN), thalamus (THL) and red nucleus. No significant MFC and R2* group differences were detected. However, while all regional MFC and R2* significantly increased with age in the control group, MFC and R2* increased in the GP, PUT, CN and THL with psychostimulant treatment duration in the ADHD group to a greater degree than with age. Our findings suggest that while youth with ADHD may have less prominent age-related brain iron increases than that seen in typical development, long-term use of psychostimulant medications may compensate through a normalizing effect on basal ganglia iron. Longitudinal studies following ADHD patients before and after long-term psychostimulant treatment are needed to confirm these findings.

ADHD remission, inclusive special education, and socioeconomic disparities

To understand how institutional environments and socioeconomic backgrounds may influence health outcomes, we examined the relationship among special education environments, socioeconomic status (SES), and likelihood of ADHD remission in children. While the majority of children experience remission by adulthood, the likelihood of remission varies across different SES levels and education environments. We find that for low SES children the likelihood of remission is higher in states that have more inclusive special education regimes. In contrast, for more advantaged children, the odds of remission do not depend on the level of special education inclusivity. Our findings suggest that providing more inclusive education can reduce disparities in behavioral disorders and are particularly important for less advantaged children. In doing so, this study contributes to the fundamental cause and health inequality literature by adding to a growing body of work showing how institutional environments can affect socioeconomic gradients in health treatment and outcomes.

The Many Channels of Screen Media Technology in ADHD: a Paradigm for Quantifying Distinct Risks and Potential Benefits

PURPOSE OF REVIEW

Individuals with attention-deficit hyperactivity disorder (ADHD) may be unusually sensitive to screen media technology (SMT), from television to mobile devices. Although an association between ADHD and SMT use has been confirmed, its importance is uncertain partly due to variability in the way SMT has been conceptualized and measured. Here, we identify distinct, quantifiable dimensions of SMT use and review possible links to ADHD to facilitate more precise, reproducible investigation.

RECENT FINDINGS

Display characteristics, media multitasking, device notifications, SMT addiction, and media content all may uniquely impact the ADHD phenotype. Each can be investigated with a digital health approach and counteracted with device-based interventions. Novel digital therapeutics for ADHD demonstrate that specific forms of SMT can also have positive effects. Further study should quantify how distinct dimensions of SMT use relate to ADHD. SMT devices themselves can serve as a self-monitoring study platform and deliver digital interventions.

Invalid Baseline Testing with ImPACT: Does Sandbagging Occur with High School Athletes?

The aim of this large-scale research was to determine the frequency of valid, invalid, and sandbagging results in ImPACT baseline testing of high school athletes. This retrospective study identified valid, invalid (identified by five embedded Invalidity Indicators), and sandbagging (identified by three "red flags") results in the ImPACT baseline test scores of 6,346 high school athletes. In addition, the ImPACT postconcussion scores of 266 athletes who sustained a concussion during the school year were evaluated to compare the baseline-to-postconcussion changes of valid versus a combined group of invalid and sandbagging scorers. There were 3,299 (51.99%) athletes who had valid baseline scores, 269 (4.24%) had invalid scores, and 3,009 (47.42%) had sandbagging scores. (There were 231 who obtained both invalidity and sandbagging scores.) The overall difference in baseline-to-postconcussion changes between the valid scorers and the combined group of invalid and sandbagging scorers was statistically significant. The high rate of athletes who had invalid and sandbagging scores raised concern that the underperformance of baseline testing occurs more commonly than is probably realized by those who utilize computerized neuropsychological testing with high school athletes. Accordingly, efforts are needed to improve test administration procedures so that maximal attention and effort can be maintained among the test takers. In the meantime, increased caution is called for in employing the baseline-to-postconcussion paradigm when return-to-play decisions are made.

Influence of Psychopharmacotherapy on the Quality of Life of Children with Attention-Deficit/Hyperactivity Disorder

Objective: Attention-deficit/hyperactivity disorder (ADHD) may have a lasting effect on the quality of life (QoL) of children and their parents. Children with ADHD as well as their parents report a lower QoL compared with healthy children and children with chronic diseases such as bronchial asthma. The primary objective of this study was to investigate the changes of QoL of children with ADHD and their parents' subjective well-being before and after starting pharmacotherapy. We used the appropriate KINDL questionnaire for assessing the children's QoL and the World Health Organization (WHO) Big Five Questionnaire for assessing parental well-being. Methods: We assessed the QoL and the parental well-being in 60 children and adolescents with ADHD between the ages of 6 and 12 years [mean age 8.7 years, (standard deviation = 1.8)], treated at the Department of Child and Adolescent Psychiatry of the Medical University of Vienna. QoL was rated using the KINDL questionnaires, and parental well-being was assessed using the WHO Big Five Questionnaire (WHO-5) before and after starting pharmacotherapy. We used t-tests and three-way GLM-ANOVA (SPSS, version 22; IBM Corp.) for evaluating the statistical significance of pre-post differences. Results: The QoL of the children with ADHD and the subjective well-being of the parents improved significantly after introducing pharmacotherapy. Conclusions: Pharmacotherapy is recommended in children with clinically significant ADHD not only because it helps to improve the symptoms of ADHD, but also their QoL and the well-being of their parents.

Associations of acetylcholinesterase activity with depression and anxiety symptoms among adolescents growing up near pesticide spray sites

BACKGROUND

The cholinergic system has an important role in mood regulation. Cholinesterase inhibitor pesticides (e.g. organophosphates) appear to increase depression and anxiety symptoms in the few existing animal and human studies. Human studies have not described such associations using biomarkers of exposure and studies among children are needed.

METHODS

We studied 529 adolescents (ages 11-17y) in agricultural communities in the Ecuadorian Andes (ESPINA study). Acetylcholinesterase (AChE) activity was measured in a finger-stick sample. Anxiety and depression symptoms were assessed using the CDI-2 and MASC-2 (greater scores reflect greater internalizing symptoms). Models adjusted for age, gender, hemoglobin, income among others.

RESULTS

The median age was 14.38y and 51% were female. The mean (SD) of the following parameters were: AChE 3.7 U/mL (0.55), depression T-score 53.0 (9.4) and anxiety T-score: 57.6 (9.8). Lower AChE activity (reflecting greater cholinesterase inhibitor exposure) was associated with higher depression symptoms (difference per SD decrease of AChE [β [95% CI:]]: 1.09 [0.02, 2.16]), was stronger among girls (β = 1.61) than boys (β = 0.69), and among younger (<14.38y, β = 1.61) vs. older children (β = 0.57). The associations were strongest among girls <14.38y (β = 3.30 [0.54, 6.05], OR for elevated symptoms per SD decrease in AChE = 2.58 [1.26, 5.27]). No associations were observed with anxiety scores. Analyses of AChE change between 2008 and 2016 concurred with these findings.

DISCUSSION

We observed associations between a biomarker of pesticide exposure and children's depression symptoms. Lower AChE activity may create risk for depression in teenagers, particularly among girls during early adolescence.

Screening Amazon's Mechanical Turk for Adults With ADHD

Objective: Researchers are increasingly using Amazon's Mechanical Turk (MTurk; www.mturk.com ) to recruit study participants. However, the utility of MTurk for investigations of ADHD in adulthood is unknown. Method: A total of 6,526 MTurk workers (median age range = 26-35 years) completed an online screening survey assessing their diagnostic histories and symptoms of ADHD, as well as relevant demographic correlates and diagnostic comorbidity. Results: The prevalence of MTurk workers who reported being diagnosed as children and as adults, and the percentage of workers whose ADHD appeared to persist from childhood into adulthood, are consistent with those observed in "offline" samples. Relative to MTurk workers diagnosed with ADHD as adults, workers diagnosed with ADHD as children were more likely to be male and without college degrees, as well as less likely to have comorbid depression or anxiety disorders. Conclusion: Amazon's MTurk holds promise as a recruitment tool for studying adults with ADHD.

Five-Year Outcomes of Behavioral Health Integration in Pediatric Primary Care

BACKGROUND AND OBJECTIVES

In the context of protracted shortages of pediatric behavioral health (BH) specialists, BH integration in pediatric primary care can increase access to BH services. The objectives of this study were to assess the structure and process of pediatric BH integration and outcomes in patient experience (access and quality), cost, and provider satisfaction.

METHODS

In 2013, we launched a multicomponent, transdiagnostic integrated BH model (Behavioral Health Integration Program [BHIP]) in a large pediatric primary care network in Massachusetts. Study participants comprised the first 13 practices to enroll in BHIP (Phase-1). Phase-1 practices are distributed across Greater Boston, with ∼105 primary care practitioners serving ∼114 000 patients. Intervention components comprised in-depth BH education, on-demand psychiatric consultation, operational support for integrated practice transformation, and on-site clinical BH service.

RESULTS

Over 5 years, BHIP was associated with increased practice-level BH integration (P < .001), psychotherapy (P < .001), and medical (P = .04) BH visits and guideline-congruent medication prescriptions for anxiety and depression (P = .05) and attention-deficit/hyperactivity disorder (P = .05). Total ambulatory BH spending increased by 8% in constant dollars over 5 years, mainly attributable to task-shifting from specialty to primary care. Although an initial decline in emergency BH visits from BHIP practices was not sustained, total emergency BH spending decreased by 19%. BHIP providers reported high BH self-efficacy and professional satisfaction from BHIP participation.

CONCLUSIONS

Findings from this study suggest that integrating BH in the pediatric setting can increase access to quality BH services while engendering provider confidence and satisfaction and averting substantial increases in cost.

Altered hypothalamus-pituitary-adrenal axis function: A relevant factor in the comorbidity of atopic eczema and attention deficit/hyperactivity disorder?

Epidemiological data show a significant association between childhood atopic eczema (AE) and an increased risk to develop attention deficit/hyperactivity disorder (ADHD). However, the underlying mechanisms of the comorbidity of AE and ADHD are mostly unknown. We investigated whether alterations of hypothalamus-pituitary-adrenal (HPA) axis function represent a shared feature of AE and ADHD potentiating AE-ADHD comorbidity. Children aged 6-12 years with AE, ADHD, or comorbid AE + ADHD and healthy control (HC) children were examined cross-sectionally (N = 145). To evaluate HPA axis function, salivary cortisol in response to psychosocial stress (Trier Social Stress Test for Children, TSST-C), after awakening (cortisol awakening response, CAR), and throughout the day (short diurnal profile) and hair cortisol capturing long-term HPA axis activity were assessed. Quantile regression analyses showed an attenuated cortisol response (% maximum change) to the TSST-C in children with ADHD compared to HC. A diminished cortisol response to acute stress was also observed in the comorbid AE + ADHD group, in which the reduction was numerically even more pronounced. Contrary to our previous findings, no alteration of the cortisol response to the TSST-C was observed in children with AE. However, in children with AE, increased ADHD-like behavior (i.e., inattention, impulsivity, and overall ADHD symptom severity) was associated with a reduced HPA axis response to acute stress. No such associations were observed in children without AE. Groups did not differ in CAR, short diurnal profile, and hair cortisol. These findings underscore the potential relevance of HPA axis function in the pathophysiology of AE and ADHD with emphasis on stress reactivity. Additional studies are required to further explore the separate and joint role of the HPA axis in the pathophysiology of AE and ADHD.

Latent resting-state network dynamics in boys and girls with attention-deficit/hyperactivity disorder

Neuroimaging studies of subjects with ADHD typically show altered functional connectivity in prefrontal, striatal, and several temporal brain regions. While the majority of studies have focused on connectivity that is averaged over time, we investigated the temporal dynamics of brain network changes in resting-state fMRI. Using the ADHD-200 consortium, we characterized the time course of latent state changes using Hidden Markov Modeling, and compared state changes between boys and girls with ADHD along with typically developing controls. Sex differences were found in latent state switching, with boys dwelling longer in a given state than girls, and concurrently having fewer overall state transitions. These sex differences were found in children with ADHD and in typically developing controls. Children with ADHD were also found to be more variable in terms of state transitions than controls. These findings add to the growing literature on neural sex differences and may be related to the sex difference in focal versus diffuse attention.

Mini Review: Socio-Cultural Influences on the Link Between ADHD and SUD

Attention-deficit/hyperactivity disorder (ADHD) is a risk factor for the development and persistence of substance use disorders (SUD). The prevalence of ADHD in patients with SUD varies across countries and cultures. So far, cross-cultural variance in ADHD prevalence rates among SUD patients was mainly ascribed to methodological differences between studies, leaving the role of societal and cultural practices in the ADHD-SUD link hardly acknowledged. The aim of the present mini review is to address this gap in the literature by providing evidence for the effect of socio-cultural practices on the ADHD-SUD link and suggesting directions for future research. To achieve this goal, we map the influence of socio-cultural factors on the ADHD-SUD link along three lines of research. The first line is concerned with the role of socio-cultural factors in the recognition, diagnosis and treatment of childhood ADHD. The second line of research is concerned with socio-cultural influences on substance use (e.g., religion, ethnic identity, acculturation, and socio-economic status). Finally, we describe potential socio-cultural factors which may operate as mechanisms for reducing or increasing access to substance abuse treatment (e.g., ethnic disparities in health care utilization). Identifying socio-cultural influences on the ADHD-SUD link may provide further insight into the bidirectional association between ADHD and SUD in different contexts and encourage future research in the field.