Remote assessment of ADHD in children and adolescents: recommendations from the European ADHD Guidelines Group following the clinical experience during the COVID-19 pandemic

The Impact of Age and Severity of Attention Deficit Hyperactivity Disorder (ADHD) Before COVID-19 on the Severity of ADHD During the COVID-19 Lockdowns, as Reported by the Mothers

OBJECTIVES

This cohort study aimed to better understand the relationship between attention deficit hyperactivity disorder (ADHD) severity predating the COVID-19 outbreak, in children with ADHD, and the severity of ADHD symptoms during the COVID-19 lockdowns.

METHODS

Age and clinical data, including ADHD-Rating Scale scores, of 30 children and adolescents with ADHD, aged 7-18 years, were collected from medical files, for the 6-month period that predated the COVID-19 outbreak. During the COVID-19 lockdowns, the children's ADHD severity was evaluated by the mothers using the Clinical Global Impression-Severity scale (CGI-S). The correlations of CGI-S scores with age and above-mentioned ADHD-Rating Scale scores that were collected before COVID-19 were then assessed.

RESULTS

Significant correlation was found between age of participants and CGI-S scores ( P = 0.034). Additionally, participants who continued ADHD pharmacological treatment ( P = 0.02) and used remote clinical treatment ( P = 0.008) demonstrated lower mother reported CGI-S scores.

CONCLUSIONS

In children with ADHD, younger age, ongoing stimulant-treatment and ongoing remote visits with a caretaker, seem to correlate with lower ADHD-symptom severity during COVID-19 lockdowns.

Preliminary results of the EPIDIA4Kids study on brain function in children: multidimensional ADHD-related symptomatology screening using multimodality biometry

Attention-deficit hyperactivity disorder (ADHD) occurs in 5.9% of youth, impacting their health and social conditions often across their lifespan. Currently, early diagnosis is constrained by clinical complexity and limited resources of professionals to conduct evaluations. Scalable methods for ADHD screening are thus needed. Recently, digital epidemiology and biometry, such as the visual, emotional, or digit pathway, have examined brain dysfunction in ADHD individuals. However, whether biometry can support screening for ADHD symptoms using a multimodal tech system is still unknown. The EPIDIA4Kids study aims to create objective measures, i.e., biometrics, that will provide a comprehensive transdiagnostic picture of individuals with ADHD, aligning with current evidence for comorbid presentations. Twenty-four children aged 7 to 12 years performed gamified tasks on an unmodified tablet using the XAI4Kids® multimodal system, which allows extraction of biometrics (eye-, digit-, and emotion-tracking) from video and touch events using machine learning. Neuropsychological assessments and questionnaires were administered to provide ADHD-related measures. Each ADHD-related measure was evaluated with each biometric using linear mixed-effects models. In contrast to neuro-assessments, only two digit-tracking features had age and sex effects (p < 0.001) among the biometrics. Biometric constructs were predictors of working memory (p < 0.0001) and processing speed (p < 0.0001) and, to a lower extent, visuo-spatial skills (p = 0.003), inattention (p = 0.04), or achievement (p = 0.04), where multimodalities are crucial to capture several symptomatology dimensions. These results illustrate the potential of multimodality biometry gathered from a tablet as a viable and scalable transdiagnostic approach for screening ADHD symptomatology and improving accessibility to specialized professionals. Larger populations including clinically diagnosed ADHD will be needed for further validation.

Attention-Deficit/Hyperactivity Disorder Symptoms and Later E-Cigarette and Tobacco Use in US Youths

Importance

Information about longitudinal associations of attention-deficit/hyperactivity disorder (ADHD) diagnosis, symptom severity, pharmacotherapy, and incident nicotine and tobacco use, including e-cigarettes, among US youths is limited.

Objective

To evaluate whether ADHD diagnosis, symptom severity, and pharmacotherapy are associated with incident e-cigarette and tobacco use over a 9-year period.

Design, Setting, and Participants

This longitudinal cohort study followed up a nationally representative sample of US youths and their parents in the Population Assessment of Tobacco and Study via questionnaires from wave 1 (September 2013 to December 2014) to waves 2 to 7 (October 2014 to April 2023). Participants were representative of the US civilian noninstitutionalized population. Youths aged 12 to 17 years at wave 1 (N = 13 572) and their parents were interviewed.

Exposures

Time in years and history of ADHD diagnosis, symptom severity, and pharmacotherapy at wave 1 were used to construct 9 mutually exclusive subgroups of US youths, including those with ADHD diagnosis and pharmacotherapy, ADHD diagnosis without pharmacotherapy, and population controls without ADHD diagnosis; within each of these 3 subgroups, ADHD symptom severity was categorized as none, 1 to 2, or 3 to 4 symptoms.

Main Outcomes and Measures

Incident e-cigarette use, cigarette smoking, other tobacco use, and dual use (e-cigarette and cigarette and/or other tobacco use) in weighted percentages with 95% CIs.

Results

Of the 13 572 youths included in the analysis, 6967 (51.3%; 95% CI, 51.2%-51.5%) were male. An estimated 1881 participants (14.1%; 95% CI, 13.2%-15.0%) were diagnosed with ADHD. Multivariable logistic regression analyses indicated that the adjusted odds of incident e-cigarette use, cigarette smoking, other tobacco use, and dual use did not significantly differ between those with asymptomatic ADHD (with or without pharmacotherapy) compared with population controls. In contrast, all subgroups who had 3 or more ADHD symptoms (with or without pharmacotherapy) had significantly higher adjusted odds of e-cigarette use (adjusted odds ratio [AOR], 1.60; 95% CI, 1.34-2.04), cigarette smoking (AOR, 1.52; 95% CI, 1.22-1.89), other tobacco use (AOR, 1.61; 95% CI, 1.27-2.02), and dual use (AOR, 1.72; 95% CI, 1.38-2.14) compared with youths with asymptomatic ADHD or population controls. Among youths with ADHD, those with highly symptomatic ADHD were significantly more likely to initiate e-cigarette (AOR, 1.68; 95% CI, 1.16-2.44) and dual use (AOR, 1.82; 95% CI, 1.17-2.83) than youths without symptoms.

Conclusions and Relevance

In this cohort study of US youths, ADHD symptoms were associated with the onset of nicotine and tobacco use. Findings highlight the importance of early diagnosis and effective treatment of ADHD to alleviate symptoms and reduce the risk of later nicotine and tobacco use.

Prescription Stimulant Dispensing to US Children: 2017-2023

OBJECTIVE

To evaluate changes in prescription stimulant dispensing to children aged 5 to 17 years associated with the COVID-19 pandemic and the shortage of immediate-release mixed amphetamine salts (Adderall), which was announced in October 2022.

METHODS

We analyzed the 2017 to 2023 IQVIA Longitudinal Prescription Database, which captures 92% of US prescriptions. Using an interrupted time series design, we evaluated level and slope changes in the monthly stimulant-dispensing rate (number of children with stimulant dispensing per 100 000 children) in March 2020 and October 2022.

RESULTS

In March 2020, the monthly stimulant-dispensing rate to children declined -454.9 children per 100 000 (95% CI, -572.6 to -337.2), an 18.8% decrease relative to January 2017. After March 2020, this rate increased to 12.7 children per 100 000 per month (95% CI, 6.6-18.8). In October 2022, there was no level change (-39.7 children per 100 000; 95% CI, -189.9 to 110.5) or slope change (-12.1 children per 100 000 per month; 95% CI, -27.5 to 3.3), although estimates were negative. During October 2022, there was a level decrease in the monthly dispensing rate for immediate-release mixed amphetamine salts and a level increase in the monthly dispensing rate for dexmethylphenidate.

CONCLUSIONS

Stimulant dispensing to children declined after the pandemic began. Dispensing may also have declined after October 2022, but estimates were not significant, partly because decreased dispensing of immediate-release mixed amphetamine salts was offset by increased dispensing of other stimulants. Findings suggest the shortage may have prompted children to switch to alternative stimulants. Future research should evaluate whether any switches led to adverse events.

The ADHD Assessment Quality Assurance Standard for Children and Teenagers (CAAQAS)

Around 5% of the children and teenagers worldwide are affected by Attention-Deficit/Hyperactivity Disorder [ADHD], making it a major public health concern. Recently, demand for assessments has substantially increased, putting strain on healthcare and waiting lists. There is concern that pressure to clear service bottlenecks is leading to variable quality and reliability of ADHD assessments in this population. The ADHD Assessment Quality Assurance Standard for Children and Teenagers [CAAQAS] aims to address this by proposing a quality framework for ADHD assessments in this population. CAAQAS is intended to complement formal training, provide support to clinicians, inform commissioners, and empower children, teenagers, and caregivers on what to expect from an assessment and assessment report. Our goal is to promote evidence-based high-quality assessments, improve diagnostic accuracy, and reduce the risks of overdiagnosis, misdiagnosis, and underdiagnosis. Seven key topics were identified by authors which guided the development of this expert consensus statement. It was agreed that a high-quality diagnostic assessment of ADHD in this population commences with advance preparation to facilitate engagement of the child or teenager and caregivers. The consensus agreed that the minimum/essential standards for assessing and diagnosing ADHD adopt a systematic approach from pre-assessment through assessment to post-diagnostic stage, enabling ADHD to be disentangled from differential diagnoses. The process applies multi-source information to inform an assessment of development history and early risk factors, history of physical, mental health and other neurodevelopmental conditions, family, educational, and social histories. Assessment of core ADHD symptoms should include specific developmentally appropriate examples of associated difficulties and impairments. Neuropsychiatric and physical comorbidities should be assessed and identified. Recommendations for report writing are intended to facilitate effective communication between ADHD specialists and other services, and we highlight the importance of linking the diagnosis to an appropriate post-diagnostic discussion. Further, we discuss core competencies required to conduct a diagnostic assessment of ADHD in children and teenagers.

The use of telehealth in attention-deficit/hyperactivity disorder: a survey of parents and caregivers

The use of telehealth became widespread during the COVID-19 pandemic, including in child and adolescent attention-deficit/hyperactivity disorder (ADHD) services. Telehealth is defined as live, synchronous phone and video appointments between a healthcare provider and a parent and/or child with ADHD. There is a dearth of research on the use of telehealth within this population. The aim of this study was to examine parents' and caregivers' perceptions of telehealth for children and adolescents with ADHD. A cross-sectional survey design was employed. Recruitment of parents and caregivers of children and adolescents with ADHD was conducted online. The survey asked participants about their views of telehealth, previous experience, and willingness to use telehealth. Quantitative data were analysed using STATA. Qualitative data were analysed using content analysis. One hundred and twelve respondents participated in the survey. Participants were mostly female (n = 97, 86.6%) and aged between 45 and 54 (n = 64, 57.1%). Of the 61 (54.5%) participants with experience of telehealth, the majority reported that that they were at least satisfied with telehealth visits (n = 36, 59%), whilst approximately half rated their quality more poorly than in-person visits (n = 31, 50.8%). The majority of respondents (n = 91, 81.3%) reported that they would be willing to use telehealth for their child's future appointments. Most common reasons selected for wanting to use telehealth included saving time, improvements to the family routine, and reducing costs. Reasons selected for not wanting to use telehealth included not being able to receive hands-on care, belief that the quality of care is poorer than in-person consultations, and distraction of the child during telehealth visits. The study demonstrates that parents recognise deficits and benefits of telehealth, suggesting a need to build their trust and confidence in remote ADHD care.

ADHD in children and adolescents: Guideline-based online assessment in the consortium project INTEGRATE-ADHD

Background

The consortium project INTEGRATE-ADHD compared administrative data on the presence of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents with the results of a parent survey and a comprehensive clinical assessment based on the S3 guideline of the Association of the Scientific Medical Societies in Germany (AWMF). Due to the COVID-19 pandemic, the clinical assessment was carried out online.

Methods

The article describes how a guideline-based clinical assessment of ADHD can be implemented in an online setting. A specially developed diagnostic matrix is presented to illustrate the assessment procedures and the diagnostic decision-making process. The matrix is intended to help the diagnostician to gain an overview of the numerous individual findings that have been collected using different assessment perspectives and methods (e.g. diagnostic interviews, rating scales, performance tests) in order to make a well-founded and transparent diagnostic decision.

Discussion

The consortium project INTEGRATE-ADHD has shown that an online assessment can be implemented in a guideline-compliant manner and allows a valid clinical decision. The diagnostic strategy is discussed with reference to international guidelines and recommendations for online diagnostics (e.g. aspects of feasibility, acceptability and safety of the assessment procedures). The challenges and opportunities of using online assessments in clinical practice are also described.

Impact of COVID-19 pandemic on prescription stimulant use among children and youth: a population-based study

COVID-19 associated public health measures and school closures exacerbated symptoms in some children and youth with attention-deficit hyperactivity disorder (ADHD). Less well understood is how the pandemic influenced patterns of prescription stimulant use. We conducted a population-based study of stimulant dispensing to children and youth ≤ 24 years old between January 1, 2013, and June 30, 2022. We used structural break analyses to identify the pandemic month(s) when changes in the dispensing of stimulants occurred. We used interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected stimulant use. Our main outcome was the change in the monthly rate of stimulant use per 100,000 children and youth. Following an initial immediate decline of 60.1 individuals per 100,000 (95% confidence interval [CI] - 99.0 to - 21.2), the monthly rate of stimulant dispensing increased by 11.8 individuals per 100,000 (95% CI 10.0-13.6), with the greatest increases in trend observed among females, individuals in the highest income neighbourhoods, and those aged 20 to 24. Observed rates were between 3.9% (95% CI 1.7-6.2%) and 36.9% (95% CI 34.3-39.5%) higher than predicted among females from June 2020 onward and between 7.1% (95% CI 4.2-10.0%) and 50.7% (95% CI 47.0-54.4%) higher than expected among individuals aged 20-24 from May 2020 onward. Additional research is needed to ascertain the appropriateness of stimulant use and to develop strategies supporting children and youth with ADHD during future periods of long-term stressors.

Assessing the Impact of Evidence-Based Mental Health Guidance During the COVID-19 Pandemic: Systematic Review and Qualitative Evaluation

BACKGROUND

During the COVID-19 pandemic, the Oxford Precision Psychiatry Lab (OxPPL) developed open-access web-based summaries of mental health care guidelines (OxPPL guidance) in key areas such as digital approaches and telepsychiatry, suicide and self-harm, domestic violence and abuse, perinatal care, and vaccine hesitancy and prioritization in the context of mental illness, to inform timely clinical decision-making.

OBJECTIVE

This study aimed to evaluate the practice of creating evidence-based health guidelines during health emergencies using the OxPPL guidance as an example. An international network of clinical sites and colleagues (in Australia, New Zealand, and the United Kingdom) including clinicians, researchers, and experts by experience aimed to (1) evaluate the clinical impact of the OxPPL guidance, as an example of an evidence-based summary of guidelines; (2) review the literature for other evidence-based summaries of COVID-19 guidelines regarding mental health care; and (3) produce a framework for response to future global health emergencies.

METHODS

The impact and clinical utility of the OxPPL guidance were assessed using clinicians' feedback via an international survey and focus groups. A systematic review (protocol registered on Open Science Framework) identified summaries or syntheses of guidelines for mental health care during and after the COVID-19 pandemic and assessed the accuracy of the methods used in the OxPPL guidance by identifying any resources that the guidance had not included.

RESULTS

Overall, 80.2% (146/182) of the clinicians agreed or strongly agreed that the OxPPL guidance answered important clinical questions, 73.1% (133/182) stated that the guidance was relevant to their service, 59.3% (108/182) said that the guidelines had or would have a positive impact on their clinical practice, 42.9% (78/182) that they had shared or would share the guidance, and 80.2% (146/182) stated that the methodology could be used during future health crises. The focus groups found that the combination of evidence-based knowledge, clinical viewpoint, and visibility was crucial for clinical implementation. The systematic review identified 2543 records, of which 2 syntheses of guidelines met all the inclusion criteria, but only 1 (the OxPPL guidance) used evidence-based methodology. The review showed that the OxPPL guidance had included the majority of eligible guidelines, but 6 were identified that had not been included.

CONCLUSIONS

The study identified an unmet need for web-based, evidence-based mental health care guidance during the COVID-19 pandemic. The OxPPL guidance was evaluated by clinicians as having a real-world clinical impact. Robust evidence-based methodology and expertise in mental health are necessary, but easy accessibility is also needed, and digital technology can materially help. Further health emergencies are inevitable and now is the ideal time to prepare, including addressing the training needs of clinicians, patients, and carers, especially in areas such as telepsychiatry and digital mental health. For future planning, guidance should be widely disseminated on an international platform, with allocated resources to support adaptive updates.