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

NPs' use of guidelines to diagnose and treat childhood ADHD

Current research on NPs' use of the American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents is limited. This cross-sectional survey examined 89 NPs in Upstate New York regarding self-reported practice behaviors based on the guideline. Most NPs followed at least 50% of the AAP guideline for diagnosis and treatment. However, use of all criteria was less than optimal.

Shared Decision Making and Treatment for Minority Children With ADHD

Shared decision making (SDM) involves the patient and family in medical decisions regarding treatment. The purpose of this article is to utilize the 2016 National Survey of Children’s Health to explore whether family engagement in SDM increases the odds of treatment for children with ADHD, and more specifically, if the presence of SDM is associated with the reduction of racial and ethnic disparities in treatment. Multivariate logistic regression was used to model the odds of treatment for each racial/ethnic group controlling for sociodemographic and health-related variables. Results indicated that White and Multiracial families engaged in SDM were twice as likely to report treatment for ADHD. Black and Latinx families, however, showed no difference in treatment for ADHD when SDM was present. Based on these findings, we conclude that SDM may be less important for Black and Latinx families when making treatment decisions for children with ADHD.

Attention-Deficit Hyperactivity Disorder in Pediatric Patients With Type 1 Diabetes Mellitus: Clinical Outcomes and Diabetes Control

OBJECTIVE

To assess the interactions between attention-deficit hyperactivity disorder (ADHD) and type 1 diabetes mellitus (T1DM), including diabetes outcomes and patients' general health status.

METHODS

Primary care and hospital records of patients aged 5 to 18 years with T1DM were analyzed using the Leumit Health Services database. The diabetic control and general health of patients with T1DM and ADHD diagnoses were compared with those of patients with T1DM alone in a cross-sectional study. The ADHD group included patients with ADHD diagnosis who purchased at least 3 prescriptions of psychostimulant agents and nootropics. Parameters including demographic, clinical, and laboratory data were collected and assessed.

RESULTS

The study included 230 patients with T1DM; of them, 24 had ADHD (10.4%). Twenty of 24 patients with ADHD (83.3%) had hemoglobin A1C of 9% and higher versus 87 of 206 patients with diabetes alone (43.3%) (p < 0.05). The ADHD group had significantly higher annual emergency department admissions [15/24 (62.5%) vs 77/201 (37.4%); p < 0.05], higher annual hospitalization rates [18/24 (75%) vs 78/206 (37.9%); p < 0.05], and longer hospitalization stays (mean, 2.21 vs 0.65 days; p < 0.05). The total medical annual costs per patient were twice as high in the ADHD group (p < 0.05). In multivariate analysis, these unfavorable outcomes of the ADHD group were preserved.

CONCLUSION

In this study, having ADHD and T1DM comorbidity was associated with a higher complications rate and poorer diabetes control in comparison to having T1DM alone. Although further research is needed, our data suggest that this group requires special care and attention of the medical staff.

Attention-Deficit Hyperactivity Disorder Risk: Interaction Between Parental Age and Maternal History of Attention-Deficit Hyperactivity Disorder

OBJECTIVE

To assess the interaction between maternal attention-deficit/hyperactivity disorder (ADHD) history and young parental age on child's ADHD risk.

METHODS

The study included 321,272 singleton children born between 1995 and 2012 from hospitals within a single integrated health care organization. The children were prospectively followed up through electronic medical record systems from birth until the first date of the following: date of clinical diagnosis of ADHD, last date of continuous health plan membership, death due to any cause, or December 31, 2017. Risks of ADHD associated with a maternal history of ADHD before pregnancy and young parental age were assessed by using Cox regression adjusting for potential confounders.

RESULTS

The children were followed up for a median (interquartile range) of 8.9 (6.2, 13.6) years from birth. Among them, 5.1% had ADHD diagnosis, 1.8% had a maternal history of ADHD before the pregnancy, and 4.4% had mothers <20 years and 2.3% had fathers <20 years at date of birth. The hazard ratio (HR) of ADHD in children associated with parental age <20 years varied by maternal history of ADHD (p < 0.005 for both multiplicative and additive interactions). For children without a maternal history of ADHD, the HR associated with at least 1 parent <20 years was 1.14 (95% confidence interval 1.04-1.24). However, for children with a maternal history of ADHD, the HR associated with at least 1 parent <20 years was 1.92 (95% confidence interval 1.31-2.82).

CONCLUSION

High ADHD risk in offspring associated with young parenthood was predominantly observed among children with a maternal history of ADHD.

Digital Attention-Related Augmented-Reality Game: Significant Correlation between Student Game Performance and Validated Clinical Measures of Attention-Deficit/Hyperactivity Disorder (ADHD)

As many as half of school children with autism spectrum disorder (ASD) exhibit symptoms of attention-deficit/hyperactivity disorder (ADHD), resulting in marked negative academic, social, and behavioral outcomes. The focus of the US Food and Drug Administration (FDA) on real-world data from novel digital sources, and the emergence of Current Procedural Terminology (CPT) codes to reimburse for digital monitoring and neurobehavioral testing suggest an increasing acceptance of the role of technology in augmenting clinical care and research. Empowered Brain is an augmented reality and artificial intelligence-based social-emotional communication aid for students with ASD. In this study, student performance on Empowered Brain is correlated to validated clinical measures of ADHD. Seven high school students with a diagnosis of ASD were recruited from a public high school. All students were assessed for severity of ADHD-related symptoms via three clinical gold-standard assessments, namely the Aberrant Behavioral Checklist (ABC), Social Responsiveness Scale 2 (SRS-2), and Teacher Report Form (TRF). Students used Empowered Brain over a one-week period. We measured the correlation of student in-game performance (as measured by point- and star-based rewards) relative to the hyperactivity subscale of the ABC (ABC-H), and the ADHD-subscale of the TRF. All seven students completed the study and managed to successfully use Empowered Brain. Students received a culminative total of 32 sessions, an average of 4.6 sessions per student (range 2–8). Student in-game performance demonstrated highly significant correlation relative to ABC-H (points: p = 0.0013; stars: p = 0.0013), and significant correlation to TRF ADHD scores (points: p = 0.012; stars: p = 0.012). No adverse effects were noted among students who used Empowered Brain. New technologies may herald novel ways of identifying and characterizing symptoms of ADHD in student populations. This study provides evidence that Empowered Brain in-game performance correlates with ADHD symptom severity in students with ASD. Larger samples are required to validate these findings, with more diverse participants that can also widen the generalizability of these findings to a broader range of brain conditions that manifest with inattention, impulsivity, and hyperactivity. Through further research, we may find that such technologies can help us to identify and longitudinally monitor such symptoms, and potentially aid in severity stratification and digital phenotyping.

Does the education system serve as a persuasion agent for recommending ADHD diagnosis and medication uptake? A qualitative case study to identify and characterize the persuasion strategies of Israeli teachers and school counselors

BACKGROUND

There has been a steady rise in the use of medication by Israeli school children to treat ADHD, partly due to what seems like school teachers' and counselors' tendency to express positive attitudes towards its use. Therfore it is important to examine the involvement of the school teachers and counselors in the parents' decision-making about giving their children medication.

METHODS

This study used a qualitative constructivist research method of semi-structured interviews. It included individual interviews with 36 teachers and school counselors and 11 parents of students ages 9-14 from the Jewish and Arab populations.

RESULTS

Teachers and school counselors use different strategies to encourage parents to have their children diagnosed for ADHD and medicated. First they suggest diagnosis as a necessary step in the best interest of the child, distinguishing between diagnosis and medication to mitigate parents' concerns. In the second stage, teachers normalize the use of medication, as well as framing it as a drug that provides not only a medical treatment but also emotional wellbeing.

CONCLUSIONS

Teachers and counselors are involved in parents' decision-making process about medicating their children to treat ADHD, which contradicts the education system's guidelines. It is necessary to set clear and explicit limits and guidelines for education system employees so that they do not cross professional and ethical limits.

Current Pattern of Psychiatric Comorbidity and Psychotropic Drug Prescription in Child and Adolescent Patients

Background: In recent years, patterns of the use of psychotropic drugs vary with increasing rates of psychiatric presentation and diagnosis in children and adolescents. Purpose: In this study, we aimed to investigate distributions of current psychiatric symptoms and diagnosis, patterns of the use of psychotropic drugs, and differences according to age and gender in patients presented to a child and adolescent outpatient clinic. Methods: All patients aged between 0 and 18 years presenting to a child and adolescent psychiatry outpatient clinic between November 1, 2017 and November 1, 2018 were included in the study. Files of all patients were examined in detail, and patients' demographic characteristics, symptoms, psychiatric diagnoses established according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), psychotropic drugs initiated, and side effect profiles were recorded. Psychiatric symptoms and diagnostic features of the patients were determined, and the differences were investigated according to gender. Clinical characteristics were compared between diagnosed and undiagnosed patients, and between patients with and without drug initiation. Results: Of the 2066 patients, 1298 (62.8%) were male and the mean age was 10.14 ± 4.42 years. The most common symptoms were hyperactivity (23.8%) and inattention (21.6%) in males, inattention (15.1%) and irritability (14.2%) in females, and 79% of the patients received one or more psychiatric diagnoses. The most common psychiatric diagnoses in both genders were attention-deficit hyperactivity disorder (ADHD), specific learning disorder (SLD), and conduct disorder, respectively. Of the patients who received a psychiatric diagnosis, 61.8% were using psychotropic drugs, with the majority of them (71.3%) receiving monotherapy. The most frequently initiated drugs included psychostimulants, antipsychotics, and antidepressants, with 28.7% of the drug user patients receiving multiple drug therapy. Conclusion: Our study indicates that rate of presentation to child and adolescent psychiatry outpatient clinics is increasing, and rates of diagnosis and initiation of psychiatry drugs are high among the presented children. The prevalence of ADHD shows an increase in males and females in our country, and psychiatric polypharmacy has reached significant rates.

Physical Activity, Screen Time, and Sleep in Children With ADHD

Background: Children with attention deficit hyperactivity disorder (ADHD) are at increased risk for poor health and obesity. The authors describe obesity-related movement behaviors in children with ADHD, determine higher risk groups, and compare with children with other disorders. Methods: Physical activity (PA), sleep, and screen time of children with ADHD (aged 6-18 y) were compared with recommendations and with behaviors of children with autism, asthma, and a normative group using 2011 National Survey of Child Health data. Results: Approximately one-third of children with ADHD participated in daily PA and half in sports in the past year. Older children with ADHD were less likely to get daily PA, get enough sleep, and limit screen time to <2 hours per day. Obese children had lower odds of daily PA. Children who had lower socioeconomic status, or severe ADHD, had lower odds of sports participation. Children with ADHD had 50% lower odds of sports participation than children with asthma. Conclusions: Children with ADHD did not engage in recommended amounts of PA, sleep, and screen time. Children with ADHD who are older, poor, obese, and/or with more severe symptoms are at higher risk for suboptimal movement behaviors. These domains represent novel treatment targets in ADHD youth.

The Association Between Attention-Deficit Hyperactivity Disorder, Injuries, and Methylphenidate

Objective. To evaluate the relationship between attention-deficit hyperactivity disorder (ADHD) and injuries and to verify whether methylphenidate (MPH), is associated with decreasing the risk of injuries. Methods. A retrospective cohort study using the computerized database of Maccabi Healthcare Services. The ADHD cohort included all children between 12 and 20 years of age, newly diagnosed with ADHD between 2003 and 2013. The comparison cohort was composed of children who were not diagnosed with ADHD. The primary outcome was traumatic injuries. A Cox proportional hazard regression analysis was conducted to estimate ADHD effects on the risk of injuries. We also conducted a nested case-control study to examine how MPH influences this relationship. Results. A total of 59 798 children were included in the cohort study; 28 921 were classified as exposed (ADHD cohort) and 30 877 were unexposed. The traumatic injuries incidence in the exposed group was significantly higher (adjusted hazard ratio = 1.63 [95% confidence interval = 1.60-1.66]). Similar increased risk was documented also for severe injuries (adjusted hazard ratio = 1.72 [1.59-1.86]). MPH use was significantly associated with 28% lower injury events. Therapy groups were significantly associated with 29% to 40% lower injuries rate for medium- or long-acting MPH. The intensity of therapy was significantly associated with 29% to 33% lower injury rate when the intensity was lower than 0.69 mg/kg/day. Conclusion. Children with ADHD have a 60% increased odds of experiencing an injury. Treatment with MPH reduced the risk by up to 28%. The individual and financial cost secondary to injuries, underscores the public health significance of this problem. Injury prevention should be considered in clinical evaluation of MPH risks and benefits, beyond the conventional consideration of enhancing academic achievements.

Cigarette and e-cigarette use and social perceptions over the transition to college: The role of ADHD symptoms

Cigarette and electronic cigarette (e-cigarette) use prevalence increases during adolescence and peaks in young adulthood, with substantial increases during the transition from high school to college especially more recently for e-cigarette use. It is important to identify the underlying factors that serve as risk factors for tobacco use and social perceptions about cigarette and e-cigarette use. It is unknown whether attention-deficit/hyperactivity disorder (ADHD) symptoms are associated with social perceptions about tobacco or increased tobacco use during the high school to college transition. This three timepoint prospective longitudinal study evaluates the reciprocal relationship between ADHD symptoms and social perceptions about tobacco as well as the frequency of cigarette and e-cigarette use in a sample of 150 high school seniors (Mage = 18.25, 66.0% female, 65.3% White) across the transition to college. ADHD symptoms in high school predicted increases in e-cigarette use during the first semester of college, and this association maintained through the end of the first year. ADHD symptoms predicted changes in social perceptions about cigarette and e-cigarette use after the transition to college. ADHD symptoms were predicted by social perceptions about e-cigarettes at the beginning of college. Understanding the psychosocial mechanisms underlying the pathways from ADHD symptoms to e-cigarette use may advance tobacco use etiology and prevention efforts, which is important considering the rapid growth in e-cigarette use among emerging adults. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Power-Law Distribution of Natural Visibility Graphs from Reaction Times Series

In this study, we analyze the response times of students to yes/no decision tasks from the perspective of network science. We analyze the properties of the natural visibility graphs (NVG) associated with their reaction time series. We observe that the degree distribution of these graphs usually fits a power-law distribution px = x-α. We study the range in which parameter α occurs and the changes of this exponent with respect to the age and gender of the students. In addition to this, we also study the links between the parameter α and the parameters of the ex-Gaussian distribution that best fit the response times for each subject.

Attention Deficit Hyperactivity Disorder (ADHD) among Children Aged 6 to 17 Years Old Living in Girja District, Rural Ethiopia

Objective

Attention deficit hyperactivity disorder (ADHD) is one of the most common behavioral disorders in childhood with long-term outcomes. Although ADHD is the most studied behavioral disorders of childhood in developed countries, few studies have been conducted in Ethiopia. The aim of this study was to determine the prevalence of ADHD in rural parts of Ethiopia.

Method

A cross-sectional study was conducted from May to June 2015 among children aged 6 to 17 years living in rural areas. A multistage cluster sampling technique was used to select 1302 participants. The Disruptive Behavior Disorder Rating Scale was used to collect the data. Logistic regression analysis was used to see statistically significant variables.

Result

The prevalence rate of attention deficit hyperactivity disorder (ADHD) among children was 7.3%. Being male (Adjusted Odds Ratio (AOR) = 1.81, 95% CI: (1.13, 2.91)); living with a single parent (AOR = 5.0, 95% CI: (2.35, 10.65)); child birth order/rank (AOR = 2.35, 95% CI: (1.30, 4.25)); and low family socioeconomic status (AOR = 2.43, 95% CI: (1.29, 4.59)) were significantly associated with ADHD.

Conclusion

The ADHD prevalence rate was found to be similar with global reports. Prevention and early management of maternal complications is important to reduce the prevalence of ADHD among children.

Transcranial direct current stimulation in attention-deficit hyperactivity disorder: A meta-analysis of neuropsychological deficits

Transcranial direct current stimulation (tDCS) is a promising method for altering cortical excitability with clinical implications in neuropsychiatric diseases. Its application in neurodevelopmental disorders especially attention-deficit hyperactivity disorder (ADHD), is in early stage and promising but its effectiveness has not been systematically examined yet. We conducted a meta-analysis on the effectiveness of tDCS on the most studied neuropsychological symptoms of ADHD, which is the first reported meta-analysis of tDCS studies on ADHD. Data from 10 randomized controlled studies (including 11 separate experiments) targeting inhibitory control, and/or working memory (WM) in ADHD were included. Results show that overall tDCS significantly improved inhibitory control. Sub-analyses further show that dorsolateral prefrontal cortex (dlPFC) (but not right inferior frontal gyrus) tDCS and anodal (but not cathodal) tDCS significantly improved inhibitory control with a small effect size. Anodal dlPFC-tDCS had the largest significant effect on inhibitory control with a small-to-medium effect size. Additionally, a significant improving effect of tDCS on inhibitory control accuracy (but not response time) and WM speed (but not accuracy) were found. Overall, this meta-analysis supports a beneficial effect of tDCS on inhibitory control and WM in ADHD with a small-to-medium effect size. TDCS seems to be a promising method for improving neuropsychological and cognitive deficits in ADHD. However, there might be a dissociation between neuropsychological deficits and clinical symptoms of ADHD and therefore, the significance of this meta-analysis for clinical purposes is limited. Future studies should systematically evaluate the role of inter-individual factors (i.e., ADHD subtype, types of the deficit) and stimulation parameters (i.e., site, polarity, intensity, duration, repetition rate) on tDCS efficacy in ADHD population and examine whether benefits are long-term.

Prevalence of behavioral disorders and attention deficit/hyperactive disorder among school going children in Southwestern Uganda

BACKGROUND

Disruptive Behavioral Disorders (DBDs) and Attention Deficit/Hyperactivity Disorder (ADHD) are chronic, impairing, and costly child and adolescent mental health challenges which, when untreated, can result in disruptions in school performance, friendships and family relations. Yet, there is dearth of prevalence data on child and adolescent behavioral challenges within sub-Saharan Africa, including Uganda. This study aims to estimate the prevalence rate of behavioral challenges and ADHD among young school going children and early adolescents (ages 8-13 at study enrollment), utilizing a school-based sample in southwest Uganda.

METHODS

We present screening results from a 5-year scale-up study titled SMART Africa-Uganda (2016-2021), set across 30 public primary schools located in the greater Masaka region in Uganda, a region heavily impacted by poverty and HIV/AIDS. Specifically, we draw on screening data from caregivers of 2434 children that used well-established standardized measures that had been pre-tested in the region. These were: 1) oppositional defiant disorder (ODD) and conduct disorder (CD) subscales of the Disruptive Behavior Disorders (DBD) scale; and 2) the Iowa Connors and Impairment scales. Slightly over half of the children in the sample were female (52%), with a mean age of 10.27 years.

RESULTS

Of the 2434 participants screened for disruptive behaviors: 1) 6% (n = 136) scored positive on ODD and 2% (n = 42) scored positive on CD subscales of the DBD scale; 2) 9.61% (n = 234), and 2.67% (n = 65) were reported to have elevated symptoms of ODD and ADHD on the Iowa Connors caregiver report scale respectively. Twenty-five percent (n = 586) of children were described by their caregivers as having experienced some form of impairment in at least four domains of the Impairment scale.

CONCLUSION

The results indicate the presence of behavioral challenges and ADHD among school going children, aged 8-13 years, in Uganda. Given the negative outcomes associated with behavioral challenges as children transition to adolescence and adulthood, detecting these emerging behavioral challenges early is critical in developing appropriate interventions. School settings could be considered as one of the contextually-relevant, culturally-appropriate, and non-stigmatizing venues to implement screening procedures and to detect emerging behavioral challenges and to make necessary referrals.

Clinical Validation of Eye Vergence as an Objective Marker for Diagnosis of ADHD in Children

OBJECTIVE

ADHD youth show poor oculomotor control. Recent research shows that attention-related eye vergence is weak in ADHD children.

METHOD

To validate vergence as a marker to classify ADHD, we assessed the modulation in the angle of vergence of children ( n = 43) previously diagnosed with ADHD while performing an attention task and compared the results with age-matched clinical controls ( n = 19) and healthy peers ( n = 30).

RESULTS

We observed strong vergence responses in healthy participants and weak vergence in the clinical controls. ADHD children showed no significant vergence responses. Machine-learning models classified ADHD patients ( n = 21) from healthy controls ( n = 21) with an accuracy of 96.3% (false positive [FP]: 5.12%; false negative [FN]: 0%; area under the curve [AUC]: 0.99) and ADHD children ( n = 11) from clinical controls ( n = 14) with an accuracy of 85.7% (FP: 4.5%; FN: 19.2%, AUC: 0.90).

CONCLUSION

In combination with an attention task, vergence responses can be used as an objective marker to detect ADHD in children.

High-End Specificity of the Attention-Deficit/Hyperactivity Problems Scale of the Child Behavior Checklist for Ages 1.5-5 in a Sample of Young Children with Disruptive Behavior Disorders

In practice, ADHD is commonly assessed with parent-reports in the absence of diagnostic interviews or behavioral observations, yet little is known about how accurately rating scales can independently detect ADHD. We used receiver operating characteristic analysis to evaluate the CBCL 1.5-5 Attention-Deficit/Hyperactivity Problems scale's ability to correctly classify the presence/absence of ADHD within a sample of young children with disruptive behavior disorders (N = 44), offering a conservative test of the scale's ability to distinguish ADHD symptoms from neighboring problems (i.e., "high-end specificity"). Across cut scores, the scale accurately differentiated between children with and without co-occurring ADHD (AUC = 0.83, SE = 0.07). Applying a cut score in the range of 61-64 yielded the most favorable balance across diagnostic utility properties (i.e., sensitivity = 0.71, specificity = 0.91, positive predictive power = 0.88, negative predictive power = 0.78). Findings provide empirical support to bolster confidence regarding use of this scale to assess early child ADHD, even in the context of complex diagnostic profiles.

Longitudinal Trends in the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Stimulant Use in Preschool Children on Medicaid

OBJECTIVES

To describe trends in the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and prescribing of stimulants in preschool-age children receiving Medicaid and to identify factors associated with the receipt of psychosocial care.

STUDY DESIGN

Data were extracted from 2012-2016 Kentucky Medicaid claims for children aged <6 years. ADHD was identified using International Classification of Diseases, Tenth Revision codes F90.0, F90.1, F90.2, F90.8, and F90.9. Psychosocial therapy was defined as having at least 1 relevant Current Procedural Terminology code in a claim within the year. A generalized linear model with a logit link and binomial distribution was used to assess factors associated with receipt of psychosocial treatment in 2016.

RESULTS

More than 2500 (1.24%) preschool-aged children receiving Medicaid had a diagnosis of ADHD in 2016, with 988 (38.2%) of those receiving a stimulant medication. Children in foster care were diagnosed with and/or treated for ADHD 4 times more often than other Medicaid recipients. Of the 1091 preschoolers receiving stimulants, 99 (9%) did not have a diagnosis of ADHD. There were no significant differences in diagnoses by race/ethnicity, but children reported to be black, Hispanic, or other race/ethnicity received stimulants at a lower rate than white children. Positive predictors for receiving psychosocial therapy in 2016 included having the diagnosis but not receiving a stimulant, having at least 1 prescription written by a psychiatrist, having comorbidities, and age. The use of stimulants in children aged <6 years declined from 0.9% in 2012 to 0.5% in 2016.

CONCLUSIONS

Promising trends demonstrate a decreasing use of stimulants in preschoolers; however, continued vigilance is needed to promote the optimal use of psychosocial interventions.

Use of Negative Control Exposure Analysis to Evaluate Confounding: An Example of Acetaminophen Exposure and Attention-Deficit/Hyperactivity Disorder in Nurses' Health Study II

Frequent maternal use of acetaminophen in pregnancy has been linked to attention-deficit/hyperactivity disorder (ADHD) in children, but concerns regarding uncontrolled confounding remain. In this article, we illustrate use of the negative control exposure (NCE) approach to evaluate uncontrolled confounding bias in observational studies on pregnancy drug safety and explain the causal assumptions behind the method. We conducted an NCE analysis and evaluated the associations between maternal acetaminophen use during different exposure periods and ADHD among 8,856 children born in 1993-2005 to women enrolled in the Nurses' Health Study II cohort. Information on regular maternal acetaminophen use was collected prospectively in biennial questionnaires. A total of 721 children (8.1%) in the cohort had been diagnosed with ADHD as reported by the mothers. Our NCE analysis suggested that only acetaminophen use at the time of pregnancy was associated with childhood ADHD (odds ratio = 1.34, 95% confidence interval: 1.05, 1.72), and the effect estimates for the 2 NCE periods (about 4 years before and 4 years after the pregnancy) were null. Our findings corroborate those of prior reports suggesting that prenatal acetaminophen exposure may influence neurodevelopment. The lack of an association between acetaminophen use in the pre- and postpregnancy exposure periods and ADHD provides assurance that uncontrolled time-invariant factors do not explain this association.

Unmet Need and Financial Impact Disparities for US Children with ADHD

OBJECTIVE

The 5.1million US children with attention-deficit/hyperactivity disorder (ADHD) have pronounced needs in education, occupational and speech therapy, and medical and behavioral treatments. Given known associations of ADHD diagnosis with race/ethnicity and parent education, this study aimed to assess how measures of socioeconomic status correlate with both adverse family financial impact of ADHD and disparities in unmet treatment need for ADHD.

METHODS

Secondary analysis of children ages 8 to 17years whose households participated in the 2014 National Survey of the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome. Using bivariate testing, we examined associations among measures of socioeconomic status with unmet ADHD treatment need and family financial impact. Logistic regression models estimated the odds of having unmet treatment need, adjusting for demographic factors and family financial impact.

RESULTS

Among US school-aged children with a current ADHD diagnosis, 44.3% experienced an adverse family financial impact from ADHD, and 11.6% had unmet need for ADHD treatment. Children with younger age at first ADHD diagnosis were more likely to experience adverse family financial impact. Children from non-English-speaking households were less likely to report unmet need compared to those from primarily English-speaking households. The adjusted odds of unmet need were twice as great among those who reported adverse family financial impact.

CONCLUSION

Deeper understanding of the influence of the household language is important in ADHD needs assessments. Considering overall family financial circumstances may also be pertinent, particularly as children age, because earlier diagnosiswas associated with adverse financial outcomes. These findings could shape future clinic policies for targeting community resources.

Autism Spectrum Disorders and ADHD: Overlapping Phenomenology, Diagnostic Issues, and Treatment Considerations

PURPOSE OF REVIEW

Autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) are both increasing in prevalence and commonly co-occur with each other. The goal of this review is to outline what has been published recently on the topics of ASD, ADHD, and the comorbid state (ASD+ADHD) with a particular focus on shared phenomenology, differential diagnosis, and treatment considerations.

RECENT FINDINGS

ASD and ADHD have shared genetic heritability and are both associated with shared impairments in social functioning and executive functioning. Quantitative and qualitative differences exist, however, in the phenotypic presentations of the impairments which characterize ASD and ADHD. For ASD interventions to be maximally efficacious, comorbid ADHD needs to be considered (and vice versa). The research on ASD and ADHD suggests some overlap between the two disorders yet enough differences to indicate that these conditions are sufficiently distinct to warrant separate diagnostic categories.

Audiovisual Multisensory Integration and Evoked Potentials in Young Adults With and Without Attention-Deficit/Hyperactivity Disorder

The purpose of this study was to assess how young adults with attention-deficit/hyperactivity disorder (ADHD) process audiovisual (AV) multisensory stimuli using behavioral and neurological measures. Adults with a clinical diagnosis of ADHD (n = 10) and neurotypical controls (n = 11) completed a simple response time task, consisting of auditory, visual, and AV multisensory conditions. Continuous 64-electrode electroencephalography (EEG) was collected to assess neurological responses to each condition. The AV multisensory condition resulted in the shortest response times for both populations. Analysis using the race model (Miller, 1982) demonstrated that those with ADHD had violation of the race model earlier in the response, which may be a marker for impulsivity. EEG analysis revealed that both groups had early multisensory integration (MSI) occur following multisensory stimulus onset. There were also significant group differences in event-related potentials (ERPs) in frontal, parietal, and occipital brain regions, which are regions reported to be altered in those with ADHD. This study presents results examining multisensory processing in the population of adults with ADHD, and can be used as a foundation for future ADHD research using developmental research designs as well as the development of novel technological supports.

The Effects of Methylphenidate (Ritalin) on the Neurophysiology of the Monkey Caudal Prefrontal Cortex

Methylphenidate (MPH), commonly known as Ritalin, is the most widely prescribed drug worldwide to treat patients with attention deficit disorders. Although MPH is thought to modulate catecholamine neurotransmission in the brain, it remains unclear how these neurochemical effects influence neuronal activity and lead to attentional enhancements. Studies in rodents overwhelmingly point to the lateral prefrontal cortex (LPFC) as a main site of action of MPH. To understand the mechanism of action of MPH in a primate brain, we recorded the responses of neuronal populations using chronic multielectrode arrays implanted in the caudal LPFC of two macaque monkeys while the animals performed an attention task (N = 2811 neuronal recordings). Over different recording sessions (N = 55), we orally administered either various doses of MPH or a placebo to the animals. Behavioral analyses revealed positive effects of MPH on task performance at specific doses. However, analyses of individual neurons activity, noise correlations, and neuronal ensemble activity using machine learning algorithms revealed no effects of MPH. Our results suggest that the positive behavioral effects of MPH observed in primates (including humans) may not be mediated by changes in the activity of caudal LPFC neurons. MPH may enhance cognitive performance by modulating neuronal activity in other regions of the attentional network in the primate brain.

Preventive effect of cyproheptadine on sleep and appetite disorders induced by methylphenidate: an exploratory randomised, double-blinded, placebo-controlled clinical trial

OBJECTIVES

Insomnia and loss of appetite are the most common side effects of methylphenidate in patients with attention deficit/hyperactivity disorder (ADHD). The adverse effects may limit optimal dosing and patients' compliance with treatment leading to the discontinuation of treatment. This research evaluates the preventive effects of cyproheptadine on sleeping and appetite disorders induced by methylphenidate in ADHD children.

METHODS

During this exploratory, randomised, double-blinded, placebo-controlled clinical trial, forty patients with ADHD diagnosis who had received methylphenidate randomly were assigned to participate in the cyproheptadine or the placebo group. Patients' weight and Pittsburgh Sleep Quality Index (PSQI) score were recorded at baseline, after four, six and eight weeks of treatment. The ADHD Parent Rating Scale-V score was also defined at the beginning and the end of study for each patient.

RESULTS

There was no significant difference between the cyproheptadine and the placebo groups regarding their weight, rate of growth and PSQI score in the monthly assessment. In addition, there was no significant difference in response to the therapy between the two groups.

CONCLUSIONS

Based on our findings, cyproheptadine does not have any considerable preventive effect on sleeping and appetite disorders induced by methylphenidate in ADHD children.

Direct medical costs of ADHD and its comorbid conditions on basis of a claims data analysis

Background:

ADHD is a highly prevalent disease in childhood which often persists into adulthood, then co-occurring with common adult conditions. Especially for adult ADHD, little is known about the costs of ADHD and the additional costs of comorbid conditions.

Aims:

To determine medical costs of ADHD and costs of comorbidities (mood, anxiety and substance use disorders, obesity), including their co-occurrence rates, stratified by age and gender.

Method:

Claims data from a German Statutory Health Insurance database with approximately four million member-records per year were analysed. A total of 25,300 prevalent ADHD patients were identified by means of an ICD-10 GM diagnosis of ADHD. A 1:1 age and gender adjusted reference group without ADHD diagnosis was randomly selected. Total health claims and health care costs related to ADHD were analysed, in addition to more targeted analyses of the occurrence and costs of pre-defined common comorbidities of, in particular, adult ADHD (SUD, mood and anxiety disorders, obesity). Outcomes were mean costs per patient and occurrence rates of comorbid conditions. Surplus costs of a comorbid condition in persons with ADHD relative to costs of this condition in persons without ADHD were calculated. Subgroup analyses were conducted based on age (0–12 years, 13–17 years, 18–30years, 30+ years) and gender.

Results:

Patients with ADHD were €1500 more expensive annually than individuals without ADHD (p < 0.001). Main cost drivers were inpatient care, psychiatrists and psychotherapists. Mood, anxiety, substance use disorders and obesity were significantly more frequent in ADHD patients and additional costs resulting from the comorbid conditions amounted up to €2800. Costs were slightly higher in women than men and increased with age for both genders. In young adults (18–30 years) health care costs dropped notably, especially costs for the medical treatment of ADHD with stimulants and costs for psychiatrists, before rising again in the group of patients over 30 years who had higher comorbidity rates.

Conclusions:

Medical costs for ADHD are substantial, in part through frequently occurring comorbid conditions, and particularly in adulthood, and are likely to further accelerate in the coming years. A gap of care was found, starting with the transition age group of patients over 17 years, as indicated by reduced costs per person during young adulthood, as well as an overall strong drop in administrative prevalence. In the future, approaches to improve the situation of care and reduce costs at the same time, i.e. through managed care programmes, should be implemented and benefit from detailed knowledge on age and gender-specific cost-drivers.

Distinct Methylphenidate-Evoked Response Measured Using Functional Near-Infrared Spectroscopy During Go/No-Go Task as a Supporting Differential Diagnostic Tool Between Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder Comorbid Children

Attention deficit/hyperactivity disorder (ADHD) has been frequently reported as co-occurring with autism spectrum disorder (ASD). However, ASD-comorbid ADHD is difficult to diagnose since clinically significant symptoms are similar in both disorders. Therefore, we propose a classification method of differentially recognizing the ASD-comorbid condition in ADHD children. The classification method was investigated based on functional brain imaging measured by near-infrared spectroscopy (NIRS) during a go/no-go task. Optimization and cross-validation of the classification method was carried out in medicated-naïve and methylphenidate (MPH) administered ADHD and ASD-comorbid ADHD children (randomized, double-blind, placebo-controlled, and crossover design) to select robust parameters and cut-off thresholds. The parameters could be defined as either single or averaged multi-channel task-evoked activations under an administration condition (i.e., pre-medication, post-MPH, and post-placebo). The ADHD children were distinguished by significantly high MPH-evoked activation in the right hemisphere near the midline vertex. The ASD-comorbid ADHD children tended to have low activation responses in all regions. High specificity (86 ± 4.1%; mean ± SD), sensitivity (93 ± 7.3%), and accuracy (82 ± 1.6%) were obtained using the activation of oxygenated-hemoglobin concentration change in right middle frontal, angular, and precentral gyri under MPH medication. Therefore, the significantly differing MPH-evoked responses are potentially effective features and as supporting differential diagnostic tools.

The prevalence of childhood psychopathology in Turkey: a cross-sectional multicenter nationwide study (EPICPAT-T)

AIM

The aim of this study was to determine the prevalence of childhood psychopathologies in Turkey.

METHOD

A nation-wide, randomly selected, representative population of 5830 children (6-13 years-old) enrolled as a 2nd,3rd or 4th grade student in 30 cities were evaluated for presence of a psychiatric or mental disorder by a Sociodemographic Form, Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-PL), and DSM-IV-Based Screening Scale for Disruptive Behavior Disorders in Children and Adolescents scales. Impairment criterion was assessed via a 3 point-Likert scale by the parent and the teacher independently.

RESULTS

Overall prevalence of any psychopathology was 37.6% without impairment criterion, and 17.1% with impairment criterion. Attention-deficit hyperactivity disorder was the most frequent diagnosis, followed by anxiety (19.5% and 16.7% without impairment, 12.4% and 5.3% with impairment, respectively). Lower education level and presence of a physical or psychiatric problem of the parents were independent predictors of any psychopathology of the offspring.

CONCLUSION

This is the largest and most comprehensive epidemiological study to determine the prevalence of psychopathologies in children and adolescents in Turkey. Our results partly higher than, and partly comparable to previous national and international studies. It also contributes to the literature by determining the independent predictors of psychopathologies in this age group.

New stimulant formulations for pediatric attention-deficit/hyperactivity disorder: a case-based approach for the primary care provider

PURPOSE OF REVIEW

To provide an up-to-date clinical review of U.S. Food and Drug Administration (FDA)-approved stimulant medications for attention-deficit/hyperactivity disorder (ADHD), including a framework for individualized treatment by primary care pediatric providers.

RECENT FINDINGS

Stimulant medications are first-line agents for pediatric ADHD. Since 2012, 11 novel stimulant medications have been approved by the FDA for the treatment of ADHD. Because of an expanded formulary of available methylphenidate-based and amphetamine-based stimulants, primary care providers may be unfamiliar with some novel medications outside a select formulary.

SUMMARY

The current broad formulary of methylphenidate-based and amphetamine-based stimulants provides primary care clinicians with a greater opportunity for personalized medicine within the patient-centered medical home. Through a systematic review of prior relevant medication trials, a consideration of daily symptom burden and thoughtful pragmatics, primary care providers can offer a more precise, customized stimulant treatment.

Serum Interleukin-6 Level in Children With Attention-Deficit Hyperactivity Disorder (ADHD)

INTRODUCTION

Attention-deficit hyperactivity disorder (ADHD) is a common neurobehavioral disorder in children, but its specific etiology and pathophysiology are still incompletely understood.

OBJECTIVES

This case-control study aimed to measure the level of serum interleukin-6 (IL-6) as a predictor of the immunologic status in children with ADHD, and to study its correlation with severity of symptoms.

SUBJECTS AND METHODS

60 ADHD children who met the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria for ADHD and 60 control children were subjected to complete history taking, clinical examination, and psychometric tests. Serum interleukin-6 of ADHD patients and control children was measured by enzyme-linked immunosorbent assay.

RESULTS

The mean serum level of IL-6 was 22.35 (95% confidence interval [CI], 17.68-26.99) in ADHD patients, and it was 5.44 (95% CI, 4.81-6.06) in controls. A significantly higher level of IL-6 was reported in ADHD patients compared with controls ( P = .001). No significant correlation was found between serum IL-6 level and either the Intelligence Quotient (IQ) or the Conners' Parent Rating Scale score.

CONCLUSION

Serum IL-6 values were significantly higher in ADHD patients compared to healthy control children. Increased production of IL-6 may play a role in the pathogenesis of ADHD.

Student-Perceived School Climate Is Associated With ADHD Medication Treatment Among Adolescents in Medicaid

OBJECTIVE

The objective of this study was to evaluate the relationship between school climate and ADHD medication treatment among adolescents in Medicaid in Georgia.

METHOD

School climate and Medicaid claims data were aggregated for 159 GA counties. County-level school climate percentile and medicated ADHD prevalence were calculated. The t tests and regression models evaluated the relationship between school climate, medicated ADHD, and demographics, weighted by county population. Poorer 2008 school climate (<25th percentile) was regressed on 2011 medicated ADHD prevalence, controlling for potential confounders.

RESULTS

The prevalence of medicated ADHD was 7.8% among Medicaid-enrolled GA adolescents. The average county-level prevalence of medicated ADHD was 10.0% ( SD = 2.9%). Poorer school climate was associated with lower rates of medicated ADHD ( p < .0001); along with demographics, these factors accounted for 50% of the county variation in medicated ADHD.

CONCLUSION

School climate is associated with medicated ADHD among adolescents in Medicaid. Additional research may reveal whether high medicated ADHD may reflect a lack of access to non-pharmacological therapies in some communities.

Sibling Recurrence Risk and Cross-aggregation of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder

Importance

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are believed to partially share genetic factors and biological influences. As the number of children with these diagnoses rises, so does the number of younger siblings at presumed risk for ADHD and ASD; reliable recurrence risk estimates within and across diagnoses may aid screening and early detection efforts and enhance understanding of potential shared causes.

Objective

To examine within-diagnosis sibling recurrence risk and sibling cross-aggregation of ADHD and ASD among later-born siblings of children with either disorder.

Design, Setting, and Participants

Using data extracted from medical records of 2 large health care systems in the United States, estimates of recurrence risk and cross-aggregation in later-born siblings of children with ADHD or ASD were compared with later-born siblings of children without these diagnoses. One data set included children seen between January 1, 1995, and December 31, 2013; the other included children born between January 1, 1998, and May 17, 2010. Participants included 15 175 later-born siblings of children with ADHD, ASD, and no known diagnosis. The study was conducted from October 2, 2017, to August 14, 2018.

Main Outcomes and Measures

Diagnoses of ASD or ADHD in the later-born sibling, ascertained from medical records, were the primary outcomes of interest; moderators included sex, gestational age, and maternal age.

Results

A total of 15 175 later-born siblings were classified by familial risk status based on the older child's diagnostic status: ADHD risk (n = 730; male [51.92%]), ASD risk (n = 158; male [48.10%]), and no known risk (n = 14 287; male [50.73%]). Compared with later-born siblings of children without ADHD or ASD, later-born siblings of children with ASD were more likely to be diagnosed with ASD (odds ratio [OR], 30.38; 95% CI, 17.73-52.06) or ADHD in the absence of ASD (OR, 3.70; 95% CI, 1.67-8.21). Compared with later-born siblings of children without a diagnosis, later-born siblings of children with ADHD were more likely to be diagnosed with ADHD (OR, 13.05; 95% CI, 9.86-17.27) or ASD in the absence of ADHD (OR, 4.35; 95% CI, 2.43-7.79).

Conclusions and Relevance

Later-born siblings of children with ASD or ADHD appear to be at elevated risk for the same disorder, but also of being diagnosed with the other disorder. These findings provide further support for shared familial mechanisms underlying ASD and ADHD, which may be useful for genetic and prospective developmental studies. Later-born siblings of children with ADHD or ASD should be monitored for both conditions.

Prevalence and Predictors of Medication Use in Children with Attention-Deficit/Hyperactivity Disorder: Evidence from a Community-Based Longitudinal Study

OBJECTIVES

To determine, in a community-based sample of primary school-aged children meeting diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD), (1) the proportion of children with ADHD treated with medication; (2) predictors of medication use; and (3) the association between medication use and psychological service utilization.

METHODS

Grade 1 children with ADHD were recruited through 43 schools in Melbourne, Australia, using a two-stage screening and case confirmation procedure. Parent report of medication treatment, clinician diagnosis, and psychological service use were collected at ages 7 and 10 years. Medication use was analyzed by ADHD subtype. Predictors of medication treatment examined included ADHD symptom severity and persistence, externalizing comorbidities, poor academic performance, and social disadvantage. Unadjusted and adjusted logistic regression were used to identify the predictors of medication status.

RESULTS

One hundred seventy-nine children with ADHD were recruited. At baseline, 17.3% had been clinically diagnosed with ADHD, increasing to 37.7% at age 10 years. At baseline, 13.6% were taking ADHD medications, increasing to 25.6% at age 10. Children with the combined and hyperactive-impulsive subtypes were more likely to be taking medication than those with inattentive subtype (age 7: p = 0.002; age 10: p = 0.03). ADHD symptom severity (Conners 3 ADHD Index) at baseline was concurrently and prospectively associated with medication use at both ages (both p = 0.01), and ADHD symptom severity at age 10 was also associated with medication use at age 10 (p = 0.01). Baseline area-level disadvantage was associated with medication use at age 7 (p = 0.04). At 10 years, children receiving medication were more likely, compared with those who were not, to be receiving psychological services (p = 0.001).

CONCLUSIONS

In this study, only a minority of children meeting diagnostic criteria for ADHD were diagnosed clinically or treated with ADHD medication by age 10. The strongest predictors of medication treatment were ADHD symptom severity and area disadvantage.

ADGRL3 (LPHN3) variants predict substance use disorder

Genetic factors are strongly implicated in the susceptibility to develop externalizing syndromes such as attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder, conduct disorder, and substance use disorder (SUD). Variants in the ADGRL3 (LPHN3) gene predispose to ADHD and predict ADHD severity, disruptive behaviors comorbidity, long-term outcome, and response to treatment. In this study, we investigated whether variants within ADGRL3 are associated with SUD, a disorder that is frequently co-morbid with ADHD. Using family-based, case-control, and longitudinal samples from disparate regions of the world (n = 2698), recruited either for clinical, genetic epidemiological or pharmacogenomic studies of ADHD, we assembled recursive-partitioning frameworks (classification tree analyses) with clinical, demographic, and ADGRL3 genetic information to predict SUD susceptibility. Our results indicate that SUD can be efficiently and robustly predicted in ADHD participants. The genetic models used remained highly efficient in predicting SUD in a large sample of individuals with severe SUD from a psychiatric institution that were not ascertained on the basis of ADHD diagnosis, thus identifying ADGRL3 as a risk gene for SUD. Recursive-partitioning analyses revealed that rs4860437 was the predominant predictive variant. This new methodological approach offers novel insights into higher order predictive interactions and offers a unique opportunity for translational application in the clinical assessment of patients at high risk for SUD.

High Spending Growth Rates For Key Diseases In 2000-14 Were Driven By Technology And Demographic Factors

We introduce a new source of detailed data on spending by medical condition to analyze US health care spending growth in the period 2000-14. We found that thirty conditions, which represented only 11.5 percent of all conditions studied, accounted for 42 percent of the real growth rate in per capita spending during this period, even though they accounted for only 13 percent of overall spending in 2000. Primary drivers of spending growth included the use of new technologies, a shift toward the provision of preventive-type services, and an aging and more obese population. The health benefits of many new technologies appeared to outweigh the associated expenditures on treatment, which indicates that these are cost-effective and provide a net value to society. However, while these technologies may be of value, new treatments are often more expensive than older ones.

Improvements in Attention Following Cognitive Training With the Novel "Decoder" Game on an iPad

Work and study increasingly rely on the use of technologies requiring individuals to switch attention rapidly between emails, texts and tasks. This has led to healthy people having problems of attention and concentration and difficulties getting into the “flow,” which impedes goal attainment and task completion. Possibly related to this, there is an increasing diagnosis of attention deficit hyperactivity disorder (ADHD) and prescriptions of drugs such as methylphenidate. In addition to ADHD, attention is impaired in other neuropsychiatric disorders, such as schizophrenia and in traumatic brain injury (TBI). Based on neuropsychological and neuroimaging evidence, we developed “Decoder,” a novel game for targeted cognitive training of visual sustained attention on an iPad. We aimed to investigate the effects of cognitive training in 75 healthy young adults randomly assigned to a Cognitive Training (8 h of playing Decoder over 4 weeks; n = 25), Active Control (8 h of playing Bingo over 4 weeks; n = 25) or Passive Control (continuation of activities of daily living; n = 25) group. Results indicated that cognitive training with Decoder was superior to both control groups in terms of increased target sensitivity (A’) on the Cambridge Neuropsychological Test Automated Battery Rapid Visual Information processing (CANTAB RVP) test, indicating significantly improved sustained visual attention. Individuals playing Decoder also showed significantly better performance on the Trail Making Test (TMT) compared with those playing Bingo. Significant differences in visual analogue scales were also found between the two gaming groups, such that Decoder received higher ratings of enjoyment, task-related motivation and alertness across all hours of game play. These data suggest that cognitive training with Decoder is an effective non-pharmacological method for enhancing attention in healthy young adults, which could be extended to clinical populations in which attentional problems persist.

The Influence of Demographic and Child Characteristics on Referral for Neuropsychological Evaluation

Objective

A number of studies have documented the benefits of neuropsychological evaluation as a tool for understanding brain-behavior relationships in various childhood disorders; however, little is known about the process by which children are referred for neuropsychological evaluation. From a systems perspective, it is important to understand whether there are identifiable referral patterns, and if so, how being aware of such patterns could shape the behavior of providers making those referrals. We aim to examine child characteristics that influence referral for neuropsychological evaluation.

Methods

Retrospective chart review of 773 children who received neuropsychological evaluation and were diagnosed with autism, attention-deficit/hyperactivity disorder, and/or anxiety was completed. Children were divided into groups based on referral source (professional or caregiver) and compared on demographic, behavioral, and medical characteristics.

Results

Overall, professionals were more likely than caregivers to refer children for neuropsychological evaluation. Though standardized measures suggested children referred by professionals and caregivers were similar, their clinical presentation appears to be different (i.e., those referred by professionals had more comorbidities and were more likely to be prescribed psychotropic medication than those referred by caregivers). Also, children with public insurance were more likely to be referred by a professional than by their caregiver.

Conclusions

Findings highlight the important role of professionals in identifying “at-risk” children and supporting families through the process of receiving further evaluation when indicated. This information can be used to create a more efficient system for evaluating children and developing treatment plans, providing neuropsychologists with direct information to share with referral sources.

Psychosocial Factors in Children and Youth With Special Health Care Needs and Their Families

Children and youth with special health care needs (CYSHCN) and their families may experience a variety of internal (ie, emotional and behavioral) and external (ie, interpersonal, financial, housing, and educational) psychosocial factors that can influence their health and wellness. Many CYSHCN and their families are resilient and thrive. Medical home teams can partner with CYSHCN and their families to screen for, evaluate, and promote psychosocial health to increase protective factors and ameliorate risk factors. Medical home teams can promote protective psychosocial factors as part of coordinated, comprehensive chronic care for CYSHCN and their families. A team-based care approach may entail collaboration across the care spectrum, including youth, families, behavioral health providers, specialists, child care providers, schools, social services, and other community agencies. The purpose of this clinical report is to raise awareness of the impact of psychosocial factors on the health and wellness of CYSHCN and their families. This clinical report provides guidance for pediatric providers to facilitate and coordinate care that can have a positive influence on the overall health, wellness, and quality of life of CYSHCN and their families.

Developmental influence of unconjugated hyperbilirubinemia and neurobehavioral disorders

Bilirubin-induced brain injury in the neonatal period has detrimental effects on neurodevelopment that persist into childhood and adulthood, contributing to childhood developmental disorders. Unconjugated bilirubin is a potent antioxidant that may be useful for protecting against oxidative injuries, but it becomes a potent neurotoxin once it crosses the blood brain barrier. Because bilirubin toxicity involves a myriad of pathological mechanisms, can damage most types of brain cells, and affects brain circuits or loops that influence cognition, learning, behavior, sensory, and language, the clinical effects of bilirubin-induced neurotoxicity are likely to be manifold. One possible effect that several experts have identified is bilirubin-induced neurological dysfunction (subtle kernicterus). However, the underlying biological mechanisms or pathways by which subtle kernicterus could lead to developmental disorders has not been elucidated previously. Our aim in this review is to describe a spectrum of developmental disorders that may reflect subtle kernicterus and outline plausible biological mechanisms for this possible association. We review existing evidence that support or refute the association between unconjugated hyperbilirubinemia and developmental disorders, and limitations associated with these studies.

Sex differences in psychiatric disorders: what we can learn from sex chromosome aneuploidies

The study of sexual dimorphism in psychiatric and neurodevelopmental disorders is challenging due to the complex interplay of diverse biological, psychological, and social factors. Males are more susceptible to neurodevelopmental disorders including intellectual disability, autism spectrum disorder, and attention-deficit activity disorder. Conversely, after puberty, females are more prone to major depressive disorder and anxiety disorders compared to males. One major biological factor contributing to sex differences is the sex chromosomes. First, the X and Y chromosomes have unique and specific genetic effects as well as downstream gonadal effects. Second, males have one X chromosome and one Y chromosome, while females have two X chromosomes. Thus, sex chromosome constitution also differs between the sexes. Due to this complexity, determining genetic and downstream biological influences on sexual dimorphism in humans is challenging. Sex chromosome aneuploidies, such as Turner syndrome (X0) and Klinefelter syndrome (XXY), are common genetic conditions in humans. The study of individuals with sex chromosome aneuploidies provides a promising framework for studying sexual dimorphism in neurodevelopmental and psychiatric disorders. Here we will review and contrast four syndromes caused by variation in the number of sex chromosomes: Turner syndrome, Klinefelter syndrome, XYY syndrome, and XXX syndrome. Overall we describe an increased rate of attention-deficit hyperactivity disorder and autism spectrum disorder, along with the increased rates of major depressive disorder and anxiety disorders in one or more of these conditions. In addition to contributing unique insights about sexual dimorphism in neuropsychiatric disorders, awareness of the increased risk of neurodevelopmental and psychiatric disorders in sex chromosome aneuploidies can inform appropriate management of these common genetic disorders.

Is preterm birth associated with asthma among children from birth to 17 years old? -A study based on 2011-2012 US National Survey of Children's Health

BACKGROUND

Preterm birth can interrupt lung development in utero and is associated with early life factors, which adversely affects the developing respiratory system. Studies on preterm birth and asthma risk are comparatively sparse and the results are not consistent.

METHODS

Multivariate analyses were performed on a cross-sectional data from the National Survey of Children's Health (NSCH) collected in 2011 to 2012. The NSCH was a nationally representative telephone survey sponsored by the Maternal and Child Health Bureau and conducted by the National Center for Health Statistics. A cross-sectional analysis using data from the US on 90,721 children was conducted to examine the relationship between preterm birth and asthma risk.

RESULTS

A total of 90,721 children under 17 years were included and 12% of the children were reported as preterm birth. The prevalence of diagnosed asthma was 15%, with a male to female ratio of 1.26:1. Children who were born preterm were 1.64 times (95% confidence interval: 1.45-1.84) more likely to develop asthma compared with those who were born term after controlling for confounders. Similarly, children who were low birth weight were 1.43 times (95% confidence interval: 1.25-1.63) more likely for asthma, and the odds ratio increased to 1.77 for those both preborn and low birth weight. Child's gender, race/ethnicity, age, family structure, family income levels, and household smoking were significantly associated with the odds of reported asthma.

CONCLUSIONS

Preterm birth was associated with increased risk of asthma among US children, supporting the notion that preterm birth may play a critical role in asthma development.

Maternal Pre-pregnancy Body Mass Index and Gestational Weight Gain in Relation to Autism Spectrum Disorder and other Developmental Disorders in Offspring

Most prior studies examining maternal pre-pregnancy body mass index (BMI) in relation to offspring autism spectrum disorders (ASD) have reported an association, though findings are not uniform and few have also examined gestational weight gain (GWG). Therefore, we examined both in the Study to Explore Early Development, a multi-site case-control study of children born in 2003-2006. Children identified from clinics, schools, and birth certificates were enrolled at ages 2-5 year and using standardized developmental evaluations, classified as: ASD, other developmental delays (DD), or population-based controls. Maternal height, weight, and GWG were self-reported during the telephone interview. Three primary weight risk factors were examined: (a) Pre-pregnancy BMI, classified as underweight to obese, (b) GWG continuous and categorized as quintiles, and (c) Institute of Medicine clinical weight-gain recommendations. Odds ratios adjusted (AOR) for sociodemographic and prenatal factors were calculated among term singletons, comparing the ASD (n = 540) or DD (n = 720) groups to the control group (n = 776). The AOR of ASD and maternal obesity was 1.37 (95%CI 0.98-1.92). Associations with higher GWG were stronger (Quintile5 vs. Quintile3 AOR = 1.58, 95%CI 1.08-2.31), and particularly so among overweight/obese women (AOR = 1.90, 95%CI 0.98-3.68). DD was associated with maternal overweight and obesity (obesity AOR = 1.48, 95%CI 1.08-2.02), but not with total GWG or clinical recommendations. High maternal BMI and GWG are risk factors for other pregnancy and child outcomes, and our results suggest they may also represent modifiable risk factors for neurodevelopmental outcomes. Autism Res 2019, 12: 316-327 © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: In a large, national study, we found that children with autism were more likely than unaffected children to have mothers with higher weight gain during pregnancy; risk of autism may be even stronger if mothers were also overweight before pregnancy. Children with other developmental delays were more likely to have mothers who were overweight or obese before pregnancy, but not who gained more weight during pregnancy. Overweight and weight gain may represent factors that could be modified.

Treatment Patterns and Costs Among Children Aged 2 to 17 Years With ADHD in New York State Medicaid in 2013

Objective: To identify children with ADHD enrolled in New York State (NYS) Medicaid and characterize ADHD-associated costs by treatment category. Method: In 2013, 1.4 million children aged 2 to 17 years were enrolled in NYS Medicaid. Medicaid claims and encounters were used to identify children with ADHD, classify them by type of treatment received, and estimate associated costs. Results: The ADHD cohort comprised 5.4% of all Medicaid-enrolled children, with 35.0% receiving medication only, 16.2% receiving psychological services only, 42.2% receiving both, and 6.6% receiving neither. The total costs for the ADHD cohort (US$729.3 million) accounted for 18.1% of the total costs for children enrolled in NYS Medicaid. Conclusion: This study underscores the importance of achieving a better understanding of children with ADHD enrolled in NYS Medicaid. A framework to categorize children with ADHD based on their treatment categories may help to target interventions to improve the quality of care and reduce costs.

The Coexistence of Disabling Conditions in Children Who Stutter: Evidence From the National Health Interview Survey

PURPOSE

Stuttering is a disorder that has been associated with coexisting developmental disorders. To date, detailed descriptions of the coexistence of such conditions have not consistently emerged in the literature. Identifying and understanding these conditions can be important to the overall management of children who stutter (CWS). The objective of this study was to generate a profile of the existence of disabling developmental conditions among CWS using national data.

METHOD

Six years of data from the National Health Interview Survey (2010-2015) were analyzed for this project. The sample consisted of children whose respondents clearly indicated the presence or absence of stuttering. Chi-square tests of independence were used for comparing categorical variables; and independent-samples t tests, for comparing continuous variables. Multiple logistic regression analyses were used for determining the odds of having a coexisting disabling developmental condition.

RESULTS

This study sample included 62,450 children, of which 1,231 were CWS. Overall, the presence of at least 1 disabling developmental condition was 5.5 times higher in CWS when compared with children who do not stutter. The presence of stuttering was also associated with higher odds of each of the following coexisting developmental conditions: intellectual disability (odds ratio [OR] = 6.67, p < .001), learning disability (OR = 5.45, p < .001), attention-deficit hyperactivity disorder/attention-deficit disorder (OR = 3.09, p < .001), seizures (OR = 7.52, p < .001), autism/Asperger's/pervasive developmental disorder (OR = 5.48, p < .001), and any other developmental delay (OR = 7.10, p < .001).

CONCLUSION

Evidence from the National Health Interview Survey suggests a higher prevalence of coexisting developmental disabilities in CWS. The existence of coexisting disabling developmental conditions should be considered as part of an overall management plan for CWS.

Increased risk of diseases of the basal ganglia and cerebellum in patients with a history of attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity and involves dysregulated dopaminergic pathways. Dopaminergic agents (i.e., amphetamine and methylphenidate) are thus prescribed to treat ADHD. As little is known regarding long-term consequences of either ADHD or its treatment, the objective of this study was to determine if either alters the risk of diseases of the basal ganglia and cerebellum, including Parkinson's disease. Statewide medical records from 1996 to 2016 were retrieved from the Utah Population Database to conduct a retrospective cohort study. Participants included ADHD patients (International Classification of Diseases, 9th revision (ICD-9) diagnosis codes 314.0-314.2, 314.8, 314.9) and 5:1 random sex-matched and age-matched subjects with no ADHD diagnosis history. Both patients and non-ADHD subjects met the following eligibility criteria: (1) no prior diagnosis of Parkinson's disease, secondary parkinsonism, basal ganglia disease, or essential tremor (ICD-9 codes 332.0, 332.1, 333.0, 333.1), (2) born in 1950 or later and age ≥20 years at last follow-up, and (3) no history of substance abuse (illicit drugs or alcohol). Outcomes were measured as time to diagnosis of diseases of the basal ganglia and cerebellum, death, or study-end. A Cox model incorporating a competing risk of death was used to provide hazard ratio estimates. Patients with ADHD (N = 31,769) had a 2.4-fold increased risk of basal ganglia and cerebellum diseases (95% confidence interval (CI): 2.0-3.0; P < 0.0001) compared with 158,790 non-ADHD persons, after controlling for sex and age and adjusting for tobacco use and psychotic conditions. In 4960 ADHD patients prescribed psychostimulants, risk of basal ganglia and cerebellum diseases between ages 21 and 49 years was especially pronounced, at 8.6-fold (95% CI: 4.8-15.6; P < 0001). The association of ADHD patients prescribed psychostimulants with higher risk of diseases of the basal ganglia and cerebellum may reflect a more severe ADHD phenotype rather than a direct association between prescribed stimulant use and basal ganglia or cerebellum disorders. Future studies to assess and stratify patient risk so as to inform treatment are warranted.

Association Between Altitude and Regional Variation of ADHD in Youth

OBJECTIVE

The purpose of this study was to evaluate the effect of altitude on rates of ADHD. As decreased dopamine (DA) activity has been reported with ADHD and hypoxia has shown to be associated with increased DA, we hypothesized that states at higher altitudes would have lower rates of ADHD.

METHOD

State estimates from the 2007 National Survey of Children's Health (NSCH) report and 2010 National Survey of Children with Special Health Care Needs (NS-CSHCN) report were used to extract the percentages of youth ages 4 to 17 diagnosed with ADHD.

RESULTS

Both the datasets independently revealed that the prevalence of ADHD decreases with increasing altitude ( R2 = .38, p < .001; R2 = .31, p < .001), respectively. This study controlled for potential confounds (e.g., low birth weight, ethnicity, and household size).

CONCLUSION

These findings suggest a need for further investigation into the extent by which altitude may serve as a protective factor for ADHD.

The Multisensory Attention Assessment Protocol (MAAP): Characterizing individual differences in multisensory attention skills in infants and children and relations with language and cognition

Multisensory attention skills provide a crucial foundation for early cognitive, social, and language development, yet there are no fine-grained, individual difference measures of these skills appropriate for preverbal children. The Multisensory Attention Assessment Protocol (MAAP) fills this need. In a single video-based protocol requiring no language skills, the MAAP assesses individual differences in three fundamental building blocks of attention to multisensory events-the duration of attention maintenance, the accuracy of intersensory (audiovisual) matching, and the speed of shifting-for both social and nonsocial events, in the context of high and low competing visual stimulation. In Experiment 1, 2- to 5-year-old children (N = 36) received the MAAP and assessments of language and cognitive functioning. In Experiment 2 the procedure was streamlined and presented to 12-month-olds (N = 48). Both infants and children showed high levels of attention maintenance to social and nonsocial events, impaired attention maintenance and speed of shifting when competing stimulation was high, and significant intersensory matching. Children showed longer maintenance, faster shifting, and less impairment from competing stimulation than infants. In 2- to 5-year-old children, duration and accuracy were intercorrelated, showed increases with age, and predicted cognitive and language functioning. The MAAP opens the door to assessing developmental pathways between early attention patterns to audiovisual events and language, cognitive, and social development. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Maternal Gestational Diabetes Mellitus, Type 1 Diabetes, and Type 2 Diabetes During Pregnancy and Risk of ADHD in Offspring

OBJECTIVE

To examine the relative importance of maternal preexisting type 1 diabetes (T1D), preexisting type 2 diabetes (T2D), and gestational diabetes mellitus (GDM) on risk of attention deficit/hyperactivity disorder (ADHD) in offspring.

RESEARCH DESIGN AND METHODS

This retrospective birth cohort study included 333,182 singletons born in 1995-2012 within Kaiser Permanente Southern California hospitals. Children were prospectively followed through electronic medical records from age 4 years. Relative risks of ADHD associated with diabetes exposures in utero were estimated by hazard ratios (HRs) using Cox regression with adjustment for potential confounders. For GDM, timing of exposure was evaluated by gestational age at diagnosis and severity was assessed by the need for antidiabetes medication treatment during pregnancy.

RESULTS

A total of 37,878 (11.4%) children were exposed to diabetes (522 exposed to T1D, 7,822 T2D, and 29,534 GDM). During a median of 4.9 years (interquartile range 2.2, 9.6) of follow-up after age 4 years, 17,415 (5.2%) children were diagnosed with ADHD. ADHD risk was not associated with GDM taken as a whole (P = 0.50) or with gestational age at GDM diagnosis (P = 0.16). However, the risk was significantly greater for the GDM requiring versus not requiring antidiabetes medications (P < 0.001). Compared with children unexposed to diabetes, the adjusted HRs for ADHD in children were 1.57 (95% CI 1.09-2.25) for exposure to T1D, 1.43 (1.29-1.60) for T2D, 1.26 (1.14-1.41) for GDM requiring antidiabetes medications, and 0.93 (0.86-1.01) for GDM not requiring medications.

CONCLUSIONS

The hierarchy of risks suggests that severity of maternal diabetes (T1D vs. T2D vs. GDM requiring antidiabetes medications) influences the risk of ADHD in offspring of mothers with diabetes.

Age-Related Changes in Distractibility: Developmental Trajectory of Sustained Attention in ADHD

OBJECTIVE

This study investigated age-related changes in sustained attention in children with ADHD and in their typically developed peers.

METHOD

The study used a Continuous Performance Test (CPT) that includes visual and auditory stimuli serving as distractors. The rate of omission errors was used as a measurement of difficulty in sustained attention. Participants were children and adolescents aged 7 to 18 years (478 with ADHD and 361 without ADHD).

RESULTS

Both groups of adolescents (with and without ADHD) showed reduced distractibility than younger children from the same group. However, distractibility tended to diminish in non-ADHD adolescents, but not in adolescents with ADHD.

CONCLUSION

Although part of the difficulties in ADHD could be explained by developmental delay that improves with time, other deficits, such as increased distractibility causing more omission errors, do not show a clear developmental trajectory. The results suggest that deficits in inhibitory control might be the core of ADHD.

Attention Deficit-Hyperactivity Disorder and Month of School Enrollment

BACKGROUND

Younger children in a school grade cohort may be more likely to receive a diagnosis of attention deficit-hyperactivity disorder (ADHD) than their older peers because of age-based variation in behavior that may be attributed to ADHD rather than to the younger age of the children. Most U.S. states have arbitrary age cutoffs for entry into public school. Therefore, within the same grade, children with birthdays close to the cutoff date can differ in age by nearly 1 year.

METHODS

We used data from 2007 through 2015 from a large insurance database to compare the rate of ADHD diagnosis among children born in August with that among children born in September in states with and states without the requirement that children be 5 years old by September 1 for enrollment in kindergarten. ADHD diagnosis was determined on the basis of diagnosis codes from the International Classification of Diseases, 9th Revision. We also used prescription records to compare ADHD treatment between children born in August and children born in September in states with and states without the cutoff date of September 1.

RESULTS

The study population included 407,846 children in all U.S. states who were born in the period from 2007 through 2009 and were followed through December 2015. The rate of claims-based ADHD diagnosis among children in states with a September 1 cutoff was 85.1 per 10,000 children (309 cases among 36,319 children; 95% confidence interval [CI], 75.6 to 94.2) among those born in August and 63.6 per 10,000 children (225 cases among 35,353 children; 95% CI, 55.4 to 71.9) among those born in September, an absolute difference of 21.5 per 10,000 children (95% CI, 8.8 to 34.0); the corresponding difference in states without the September 1 cutoff was 8.9 per 10,000 children (95% CI, -14.9 to 20.8). The rate of ADHD treatment was 52.9 per 10,000 children (192 of 36,319 children; 95% CI, 45.4 to 60.3) among those born in August and 40.4 per 10,000 children (143 of 35,353 children; 95% CI, 33.8 to 47.1) among those born in September, an absolute difference of 12.5 per 10,000 children (95% CI, 2.43 to 22.4). These differences were not observed for other month-to-month comparisons, nor were they observed in states with non-September cutoff dates for starting kindergarten. In addition, in states with a September 1 cutoff, no significant differences between August-born and September-born children were observed in rates of asthma, diabetes, or obesity.

CONCLUSIONS

Rates of diagnosis and treatment of ADHD are higher among children born in August than among children born in September in states with a September 1 cutoff for kindergarten entry. (Funded by the National Institutes of Health.).

Trends in use of prescription stimulants in the United States and Territories, 2006 to 2016

BACKGROUND

Stimulants are considered the first-line treatment for Attention Deficit Hyperactivity Disorder (ADHD) in the US and they are used in other indications. Stimulants are also diverted for non-medical purposes. Ethnic and regional differences in ADHD diagnosis and in stimulant use have been identified in earlier research. The objectives of this report were to examine the pharmacoepidemiological pattern of these controlled substances over the past decade and to conduct a regional analysis.

METHODS

Data (drug weights) reported to the US Drug Enforcement Administration's Automation of Reports and Consolidated Orders System for four stimulants (amphetamine, methylphenidate, lisdexamfetamine, and methamphetamine) were obtained from 2006 to 2016 for Unites States/Territories. Correlations between state level use (mg/person) and Hispanic population were completed.

RESULTS

Amphetamine use increased 2.5 fold from 2006 to 2016 (7.9 to 20.0 tons). Methylphenidate use, at 16.5 tons in 2006, peaked in 2012 (19.4 tons) and subsequently showed a modest decline (18.6 tons in 2016). The consumption per municipality significantly increased 7.6% for amphetamine and 5.5% for lisdexamfetamine but decreased 2.7% for methylphenidate (all p < .0005) from 2015 to 2016. Pronounced regional differences were also observed. Lisdexamfetamine use in 2016 was over thirty-fold higher in the Southern US (43.8 mg/person) versus the Territories (1.4 mg/person). Amphetamine use was about one-third lower in the West (48.1 mg/person) relative to the Northeastern (75.4 mg/person, p < .05) or the Midwestern (69.9 mg/person, p ≤ .005) states. States with larger Hispanic populations had significantly lower methylphenidate (r(49) = -0.63), lisdexamfetamine (B, r(49) = -0.49), and amphetamine (r(49) = -0.43) use.

CONCLUSIONS

Total stimulant usage doubled in the last decade. There were dynamic changes but also regional disparities in the use of stimulant medications. Future research is needed to better understand the reasons for the sizable regional and ethnic variations in use of these controlled substances.