Screening for attention-deficit/hyperactivity disorder in a select sample of injured and uninjured pediatric patients

Risks Associated With Undiagnosed ADHD and/or Autism: A Mixed-Method Systematic Review

BACKGROUND

The two most prevalent neurodevelopmental disorders-Attention Deficit Hyperactivity Disorder (ADHD) and Autism (ASD)-(ASD/ADHD) strongly impact individuals' functions. This is worsened when individuals are undiagnosed and risks such as increased imprisonments, depression or drug misuse are often observed. This systematic review synthesizes the risks associated with late/undiagnosed ASD/ADHD.

METHODS

Four databases were searched (Medline, Scopus, PsychInfor, and Embase). Published studies exploring the impact of undiagnosed ASD/ADHD were included. Exclusion criteria included, lack of diagnosis status, studies not solely on ASD or ADHD, gray literature and studies not in English. The findings were summarize through a narrative synthesis.

RESULTS

Seventeen studies were identified, 14 on ADHD and three on ASD. The narrative synthesis identified three main themes: (1) Health, (2) Offending behavior, and (3) Day-to-day impact. The risks highlighted a significant impact on mental wellbeing and social interactions, higher risks of substance abuse, accidents and offending behavior as well as lower levels of income and education.

DISCUSSION

The findings suggest that undiagnosed ASD/ADHD is linked to many risks and negative outcomes affecting individuals, their families, and the wider society. The restricted number of studies on ASD are a limitation to the generalization of these findings Implications for research and practice are discussed, highlighting the importance of screening and acknowledging the possibility of ASD/ADHD in many settings such as psychiatric and forensic.

How does attention deficit hyperactivity disorder affect children's road-crossing? A case-control study

Objective: Children diagnosed with attention-deficit/hyperactivity disorder (ADHD) may have particularly high pedestrian injury risk given their deficits in attention, inhibition, and concentration. The aims of this study were a) to assess differences in pedestrian skill between children with ADHD and typically-developing children and b) to examine relations between pedestrian skill and attention, inhibition, and executive function among children with ADHD as well as among typically-developing children.Methods: A sample of 50 children with mean age of 9 years participated, 56% of them diagnosed with ADHD. Children completed IVA + Plus, an auditory-visual test evaluating impulse response control and attention and then engaged in a Mobile Virtual Reality (MVR) pedestrian task to assess pedestrian skills. Parents completed the Barkley's Deficits in Executive Functions Scale-Child & Adolescents (BDEFS-CA) to rate children's executive function. Children with ADHD engaged in the experiment off any ADHD medications.Results: Independent samples t-tests indicated significant differences between the two groups in all IVA + Plus and BDEFS_CA scores, supporting the clinical diagnoses of ADHD and the distinction between the two groups. Independent samples t-tests also indicated differences in pedestrian behavior: Children in the ADHD group had significantly higher numbers of unsafe crossings in the MVR environment. Partial correlations within samples stratified by ADHD status indicated that for both groups of children, there were positive correlations between unsafe pedestrian crossings and executive dysfunction. There were no relations between IVA + Plus attentional measures and unsafe pedestrian crossings in either group. A linear regression model predicting unsafe crossings was significant, with children with ADHD more likely to cross in a risky manner after controlling for executive dysfunction and child age.Conclusions: ADHD children exhibited riskier street-crossing behavior in the MVR, confirming an increased risk of pedestrian injury among children with ADHD compared to typically-developing children. Risky crossing among the typically-developing children and ADHD was related to deficits in executive function. Implications are discussed in relation to parenting and professional practice.

Road-Crossing Behavior in Complex Traffic Situations: A Comparison of Children With and Without ADHD

All children are vulnerable to pedestrian injuries, but previous research suggests children diagnosed with ADHD may have elevated risk. Child pedestrian injury risk also increases with increasing traffic volume and speed. The current study examined three hypotheses: (a) Pedestrian behavior of children with ADHD is riskier than that of typically-developing children; (b) Children's pedestrian behavior is riskier with increased traffic complexity; and (c) Pedestrian behavior of children with ADHD is influenced more by complex traffic situations than behavior of typically-developing children. A sample of 38 children ages 8-12 years, 45% diagnosed with ADHD, completed 21 virtual street-crossings, 7 in each of three levels of traffic complexity. Outcome measures included unsafe crossings, ratio of looking at traffic by time, start-delay to enter the road, time to contact with oncoming vehicles, and time waiting to cross. A repeated measure MANOVA and follow-up tests showed that all children had more unsafe crossings, shorter start-delays and shorter TTCs when exposed to increased traffic complexity compared to lighter traffic. Children with ADHD had more unsafe crossings than typically-developing children. Further, compared to typically-developing children, ADHD children had comparatively more unsafe crossings, lower time to contact and longer wait-time in more complex traffic environments. Executive function deficits among children with ADHD likely influence their behavior in complex traffic environments. Implications of the results for policy-making and preventive strategies are discussed.

Attention Deficit Hyperactivity Disorder (ADHD) in Patients with and without Head Trauma

Purpose

Attention deficit hyperactivity disorder (ADHD) in adults is one of the psychological problems that can increase the risk of accidents and trauma, especially head trauma. Recent studies have reported the frequency of adult attention deficit hyperactivity disorder (ADHD) among trauma patients. Adult AD0HD has been reported in trauma patients. In the present study, we hypothesized that adult ADHD was more common among head trauma patients following an accident compared to a group without trauma.

Materials and Methods

In this case-control study, 230 patients with head injuries and 460 non-trauma patients were selected. The adult Connors self-report screening scale (CAARS-SV) was used to screen for ADHD. Three subscales as subscale A (attention deficit index), subscale B (hyperactivity index) and subscale D (ADHD index) were evaluated between the two groups. Using linear multiple regression analysis, the effect of group, age, gender, and socioeconomic variables on ADHD scores was evaluated.

Results

The total frequency of adult ADHD was 9.5%, which was equal to 1.6% in the trauma group and 9.5% in the non-trauma group. The experimental group had more drivers as the job (11.7% vs 3.7%, P<0.001) compared to the control group. Of the Connors subscales, only the D subscale was significantly lower in the case group than in the control group (6.35 6 5.11 vs 51.72 4 72.4, P=0.003). The prevalence of ADHD in patients with head trauma and non-trauma head injury was 6.1% and 5.9%, respectively, which did not show a statistically significant difference (P=0.9). Linear regression analysis showed that the subscale D only had a significant relationship with group and age. However, by entering variables in logistic regression analysis, it was observed that only the age variable was significant in the presence of other variables.

Conclusion

According to the results of the present study, the frequency of adult ADHD in trauma patients, as a screening diagnosis, was not found to be higher than non-traumatic patients.

Psychological Prophylaxis: An Integrated Psychological Services Program in Trauma Care

The primary medical goals of acute care are restoration of physical health and return to physical function. However, in response to traumatic events and injuries, psychological factors are critical to one's overall recovery. Both pre-morbid psychiatric comorbidities and post-injury psychological compromise affect physical and psychological recovery in inpatient trauma populations. The Psychological Services Program (PSP), a model trauma/acute care program, addresses these critical factors in a Level 1 Trauma Center. The program routinely treats over one-quarter of the trauma patients at any given time. The incorporation of the PSP into treatment team care ensures that patients in need of mental health support can be identified and treated during their recovery. This unique model is recommended as a potential injury prevention and recovery intervention strategy for the myriad mental health comorbidities that may function as risk factors for poor post-injury adaptation and also as risk factors for possible future traumatic injury.

Emergency department attendance for injury and behaviours suggestive of attention deficit hyperactivity disorder (ADHD): a cross-sectional study

Background

The study aimed to investigate if the behaviours suggestive of ADHD were more frequent in a population of children attending the Emergency Department (ED) for injuries, rather than for other causes.

Methods

A cross-sectional study was carried out. Patients, aged 6 to 17 years, attending the ED for acute injuries and other causes were considered cases and controls, respectively. We used a questionnaire, which investigates the presence in the child of inattention, hyperactivity, and impulsivity. The primary outcome was the number of children with behaviours suggestive of ADHD in cases and controls.

Results

Five hundred forty-five children were enrolled, 251 with injuries and 294 with other complains. Twenty two out of two hundred fifty one (9%) children visited for injuries, and 30 out of 294 (10%) visited for other causes had behaviours suggestive of ADHD (p = 0.661). Among these cases, children with evocative ADHD scores had a higher probability (OR 4.52; 95% CI 1.45–14.04; p = 0.009) of having had more than five previous ED accesses due to injury, compared to the others.

Conclusions

This study did non shown a difference in behaviours suggestive of ADHD between cases and controls, but identified a population of children with behaviours suggestive of ADHD who more frequently access the ED for injuries.

Assessing causality in the association between attention-deficit/hyperactivity disorder and obesity: a Mendelian randomization study

BACKGROUND/OBJECTIVES

Attention-deficit hyperactivity disorder (ADHD), one of the most common neurodevelopmental disorders in childhood and adolescence, is associated with obesity in observational studies. However, it is unclear whether ADHD contributes to, results from or is merely correlated with obesity. This study evaluates the presence and direction of a causal effect between ADHD and obesity.

SUBJECTS/METHODS

We performed a bidirectional two-sample Mendelian randomization using summary data from consortia of genome-wide association studies to investigate if ADHD (N = 55,374) has a causal effect on body mass index (BMI) in childhood (N = 35,668) and adulthood (N = 322,154-500,000), and vice-versa. The main analysis was performed using the inverse variance weighted (IVW) method. As sensitivity analyses, we used other Mendelian randomization methods that are more robust to horizontal pleiotropy (i.e., MR-Egger, weighted mode, and penalized weighted median estimators), as well as stratified the analysis by the putative mechanisms of genetic instruments (i.e., pathways involved or not in neurological processes).

RESULTS

The IVW method indicated a positive causal effect of BMI on ADHD: β = 0.324 (95% CI 0.198 to 0.449, p < 0.001; expressed as change in ln(odds ratio) of ADHD per each additional SD unit of BMI). IVW estimates were directionally consistent with other methods. On the other hand, we did not find consistent evidence for a causal effect of ADHD genetic liability on BMI.

CONCLUSIONS

The results suggested that higher BMI increases the risk of developing ADHD, but not the other way around.

Prevalence of Attention Deficit Hyperactivity Disorder Symptoms in Children Who Were Treated at Emergency Service due to Unintentional Injury

AIM

Attention Deficit Hyperactivity Disorder (ADHD) is a developmental disorder characterized by severe inattention, hyperactivity, and impulsivity. This research aims to determine the frequency of ADHD symptoms in children who were treated in emergency paediatric services due to unintentional injuries.

METHOD

This study was carried out with children who were treated due to unintentional injuries in an Emergency Department. ADHD symptoms were evaluated using the DSM-IV-based Screening and Assessment Scale for Behavioural Disorders in Children and Adolescents.

RESULTS

The study sample consisted of 89 girls (40.1%) and 133 boys (59.9%)-a total of 222 children. The participants ranged from 5 to 18 years of age, and the mean age was found to be 11.5±3 years. According to medical evaluations, the most common diagnosis for the unintentional injuries was soft tissue trauma (41.9%). The mean ADHD and ODD (Oppositional Defiant Disorder) scores of our study sample were, respectively, 19.9±12 and 7.7±5.7. The prevalence of children with possible ADHD was as high as 81.6% (179) and, for ODD, was 62.6% (139), according to cut-off values.

CONCLUSION

Our results pointed out very high levels of ADHD and ODD symptoms among children who were treated at emergency services for accidental injuries. Appropriately screening for ADHD in children with accidental injuries and referring them to child psychiatry units may prevent later accidents and injuries.

Neurodevelopmental Disorders in the PICU Population

Attention deficit hyperactivity disorder (ADHD), affecting 11% of children and adolescents, increases risk for injury and may predispose children to illness. However, the prevalence of ADHD and other developmental disorders in the pediatric intensive care unit (PICU) has not been previously studied. We performed a single-center, prospective cohort study of children aged 6 to 12 years who were hospitalized in the PICU from May through August 2016. Parents described their child's educational and neurodevelopmental history, and completed ADHD and emotional/behavioral disorder screening on enrollment and 1 month after discharge. Twenty-four children were enrolled. Ten patients (42%) had a prior neurodevelopmental diagnosis, and 7 (29%) met study criteria for ADHD. Children hospitalized for critical illness have a high prevalence of neurodevelopmental disabilities and are more susceptible to the impact of critical illness on development and behavior. More research is needed to better understand how to support this vulnerable population after critical illness.

Risk of unintentional injuries in children and adolescents with ADHD and the impact of ADHD medications: A systematic review and meta-analysis

A systematic review with meta-analyses was performed to: 1) quantify the association between ADHD and risk of unintentional physical injuries in children/adolescents ("risk analysis"); 2) assess the effect of ADHD medications on this risk ("medication analysis"). We searched 114 databases through June 2017. For the risk analysis, studies reporting sex-controlled odds ratios (ORs) or hazard ratios (HRs) estimating the association between ADHD and injuries were combined. Pooled ORs (28 studies, 4,055,620 individuals without and 350,938 with ADHD) and HRs (4 studies, 901,891 individuals without and 20,363 with ADHD) were 1.53 (95% CI=1.40,1.67) and 1.39 (95% CI=1.06,1.83), respectively. For the medication analysis, we meta-analysed studies that avoided the confounding-by-indication bias [four studies with a self-controlled methodology and another comparing risk over time and groups (a "difference in differences" methodology)]. The pooled effect size was 0.879 (95% CI=0.838,0.922) (13,254 individuals with ADHD). ADHD is significantly associated with an increased risk of unintentional injuries and ADHD medications have a protective effect, at least in the short term, as indicated by self-controlled studies.

Risk of unintentional injuries in children and adolescents with ADHD and the impact of ADHD medications: protocol for a systematic review and meta-analysis

INTRODUCTION

Attention-deficit hyperactivity disorder (ADHD) has been related to increased rates of unintentional injuries. However, the magnitude of the effect and to which extent variables such as sex, age or comorbidity can influence this relationship is unknown. Additionally, and importantly, it is unclear if, and to which degree, ADHD medications can decrease the number of unintentional injuries. Due to the amount of economic and social resources invested in the treatment of injuries, filling these gaps in the literature is highly relevant from a public health standpoint. Here, we present a protocol for a systematic review and meta-analysis to estimate the relationship between ADHD and unintentional injuries and assess the impact of pharmacological treatment for ADHD METHODS AND ANALYSIS: We will combine results from 114 bibliographic databases for studies relating ADHD and risk of injuries. Bibliographic searches and data extraction will be carried out independently by two researchers. The studies' risk of bias will be assessed using the Newcastle-Ottawa Scale. Articles reporting ORs or HRs of suffering an injury in ADHD compared with controls (or enough data to calculate them) will be combined using Robust Variance Estimation, a method that permits to include multiple non-independent outcomes in the analysis. All analyses will be carried out in Stata. Age, sex and comorbid conduct disorders will be considered as potential causes of variance and their effect analysed through meta-regression and subgroup analysis. Sensitivity analyses will exclude articles with longer follow-ups, non-stringent definitions of ADHD or controls and statistically uncontrolled/controlled outcomes. Studies implementing a self-controlled case series methodology to investigate if ADHD drugs reduce the risk of injuries will be combined with a generalised linear mixed model using the Poisson distribution and a log link function.

REGISTRATION DETAILS

PROSPERO-Prospective Register of Systematic Reviews (CRD42017064967).

A Multimodal Intervention for Children with ADHD Reduces Inequity in Health and Education Outcomes

OBJECTIVE

To evaluate whether a multimodal intervention for children with attention-deficit hyperactivity disorder (ADHD) resulted in better long-term health and education outcomes and reduced inequity across the socioeconomic gradient.

METHOD

We analyzed administrative data held in the Manitoba Population Research Data Repository describing recipients of a combined pharmacological/behavioural intervention for ADHD. The study cohort included children aged 5 to 17 years who visited the Manitoba Adolescent Treatment Centre's ADHD intervention service at least 3 times (2007-2012). Controls were matched on age, sex, year of ADHD diagnosis, and income quintile. We compared rates of hospital and emergency department visits, medication use and adherence, contact with child welfare services, and whether children were in their age-appropriate grade. We used concentration curves to estimate differences in outcomes between children from high- and low-income families.

RESULTS

Children who received the intervention ( n = 485) had higher rates of medication use (rate ratio [RR], 1.21; 95% CI, 1.08 to 1.36) and adherence (RR, 1.42; 95% CI, 1.03 to 1.96) and were more likely to be in their age-appropriate grade (RR, 1.33; 95% CI, 1.09 to 1.63) compared with controls ( n = 1884). The intervention was also associated with reduced inequity in these outcomes across income deciles. There was no difference in the rates of hospital or emergency department visits or contacts with child welfare services.

CONCLUSIONS

A multimodal ADHD intervention was associated with increased medication use and adherence and higher academic achievement. It was also related to lower inequity across the socioeconomic gradient. These results suggest that multimodal approaches may provide more equitable health and education outcomes for children with ADHD.

Attention deficit/hyperactivity disorder and risk of injuries: A systematic review and meta-analysis

Background:

This study systematically reviewed the literature in order to determine the effect of Attention-Deficit Hyperactivity Disorder (ADHD) on injuries and assessed the magnitude of the potential association.

Methods:

A systematic review of the studies examining the association of ADHD and injuries was carried out across multiple databases. Odds ratios and standardized mean differences were pooled.

Results:

A total of 35 studies were selected for quantitative analysis. The association of ADHD and injuries was confirmed over the meta-analysis of eligible studies. The odds ratio pooled over all comparative studies was 1.96(95% CI: 1.6-2.4) using random effects model. Pooled odds ratio of 2.1 and 2.17 were calculated respectively when cohort and case-control studies or just cohort studies were included. The pooled odds ratio reduced to 1.8(CI:1.45-2.3) when studies on specific injuries were removed. For studies comparing scores of rating scales, the pooled standardized mean difference was 0.61(95% CI: 0.03-1.2).

Conclusions:

Those with ADHD are nearly two times more likely to be injured.

Accident Proneness in Children and Adolescents Affected by ADHD and the Impact of Medication

OBJECTIVE

This study aims to ascertain once and for all whether children and adolescents affected by ADHD show a higher risk for accidents, as well as investigating a possible association between the administration of ADHD-specific medication and the occurrence of accidents.

METHOD

Two exceptionally large sets of data were implemented in this analysis. Participants included children and adolescents representative of the entire German population. Data for Survey 1 was collected through extensive administration of questionnaires. Data for Survey 2 stemmed from the records of a leading German health insurance company. In terms of statistical analysis, chi-square tests as well as logistic regression analyses were applied and odds ratios (ORs) were determined.

RESULTS

Innovative results are presented showing a significantly higher likelihood for ADHD-affected youngsters to be involved in accidents compared with their nonaffected counterparts (Survey 1: OR = 1.60; Survey 2: OR = 1.89) but lacking an overall significant influence of medication regarding the occurrence of accidents (Survey 1: OR = 1.28; Survey 2: OR = 0.97). Frequency of accidents could be predicted by ADHD, gender, and age in both samples. Medication intake served as a weak predictor only in Survey 2.

CONCLUSION

It has been determined in two representative and independent German samples that youngsters with ADHD are at a significantly higher risk of being involved in accidents. In the future, this should always be considered when setting up a treatment plan to ensure a safer and healthier coming of age without relying solely on specific effects of medication. (J. of Att. Dis. 2016; 20(6) 501-509).

Individual-level predictors of inpatient childhood burn injuries: a case-control study

Background

Burn injuries are considered one of the most preventable public health issue among children; however, are a cause of significant morbidity and mortality in Iran. The aim of this study was to assess individual-level predictors of severe burn injuries among children leading to hospitalization, in East Azerbaijan Province, in North-West of Iran.

Methods

The study was conducted through a hospital based case–control design involving 281 burn victims and 273 hospital-based controls who were frequency matched on age, gender and urbanity. Both bivariate and multivariate methods were used to analyze the data.

Results

Mean age of the participants was 40.5 months (95 % CI: 37–44) with the majority of burns occurring at ages between 2 months-13.9 years. It was demonstrated that with increase in the caregiver’s age there was a decrease in the odds of burn injuries (OR = 0.94, 95 % CI: 0.92-0.97). According to the multivariate logistic regression there were independent factors associated with burn injuries including childhood ADHD (OR = 2.82, 95 % CI: 1.68 - 4.76), child’s age (OR = 0.73, 95%CI: 0.67 - 0.80), flammability of clothing (OR = 1.60, 95 % CI: 1.12 - 2.28), daily length of watching television (OR = 1.31, 95 % CI: 1.06 - 1.61), playing outdoors (OR = 1.32, 95 % CI: 1.16 - 1.50) and increment in the economic status (OR = 1.37, 95 % CI: 1.18 - 1.60).

Conclusion

Major risk predictors of burn injuries among the Iranian population included childhood ADHD, child’s age, watching television, playing outdoors, high economic status and flammable clothing.

Risky bicycling behavior among youth with and without attention-deficit hyperactivity disorder

BACKGROUND

Injury risk from car-bicycle collisions is particularly high among youth with attention-deficit hyperactivity disorder (ADHD). Here, we capitalized on advances in virtual environment technology to safely and systematically examine road-crossing behavior among child cyclists with and without ADHD.

METHODS

Sixty-three youth (26 with ADHD, 37 non-ADHD controls) ages 10-14 years crossed 12 intersections with continuous cross-traffic while riding a high-fidelity bicycling simulator. Traffic density (i.e., temporal gaps between vehicles) was manipulated to examine the impact of varying traffic density on behavioral indices of road crossing, including gap selection, timing of entry into the roadway, time to spare when exiting the roadway, and close calls with oncoming cars. In addition, parents filled out questionnaires assessing their child's ADHD symptomatology, temperamental characteristics, bicycling experience, and injury history.

RESULTS

ADHD youth largely chose the same size gaps as non-ADHD youth, although ADHD youth were more likely to select smaller gap sizes following exposure to high-density traffic. In addition, youth with ADHD demonstrated poorer movement timing when entering the intersection, resulting in less time to spare when exiting the roadway. Hyperactivity-impulsivity symptoms were specifically associated with selection of smaller gaps, whereas timing deficits were specifically associated with inattention and inhibitory control.

CONCLUSION

Findings highlight two related yet potentially dissociable mechanisms that may influence injury risk among youth with ADHD and provide a foundation for development of injury prevention strategies.

The Association Between Hospital-Treated Injuries and ADHD Symptoms in Childhood and Adolescence: A Follow-Up Study in the Northern Finland Birth Cohort 1986

OBJECTIVE

We examined the risk of hospital-treated injuries related to the symptoms/diagnosis of ADHD.

METHOD

The study population (N = 6,111) was composed from the Northern Finland Birth Cohort 1986. At the age of 8, symptoms of hyperactivity and at the age of 15, symptoms of ADHD were assessed by the parents while the clinical diagnoses of ADHD were set in adolescence. Information on injuries was obtained from national register.

RESULTS

The risk for hospital-treated injuries during ages 0 to 7 was 1.7-fold increased among those with symptoms of hyperactivity assessed at age 8. Also, injuries during ages 7 to 15 years were more common among those with symptoms of ADHD at age 15 with respect to any injury, fractures, and intracranial injuries, and among those with the diagnosis of ADHD with respect to any injury.

CONCLUSION

The present study shows an association between hospital-treated injuries and symptoms of ADHD in a large epidemiological sample of 0- to 15-year-old children.

Effect of neurocognition and concussion on musculoskeletal injury risk

Research regarding musculoskeletal injury risk has focused primarily on anatomical, neuromuscular, hormonal, and environmental risk factors; however, subsequent injury risk screening and intervention programs have been largely limited to neuromuscular factors and have faced challenges in both implementation and efficacy. Recent studies indicate that poor neurocognitive performance, either at baseline or in the aftermath of a concussion, is associated with elevated risk of musculoskeletal injury. Despite the relatively limited current understanding regarding the nature of the relationship between different aspects of neurocognitive performance and musculoskeletal injury risk, this is a promising area of research that may yield significant advances in musculoskeletal injury risk stratification, rehabilitation, and prevention.

Methylphenidate and the risk of trauma

BACKGROUND AND OBJECTIVE

Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are prone to sustaining trauma that requires emergency department (ED) admission. Methylphenidate (MPH) can reduce ADHD symptoms and may thus theoretically reduce the risk of trauma-related ED admission, but previous studies do not make this association clear. This study examines this association.

METHODS

A total of 17 381 patients aged 6 to 19 years who received MPH prescriptions were identified by using the Clinical Data Analysis & Reporting System (2001-2013). Using a self-controlled case series study design, the relative incidence of trauma-related ED admissions was compared with periods of patient exposure and nonexposure to MPH.

RESULTS

Among 17 381 patients prescribed MPH, 4934 had at least 1 trauma-related ED admission. The rate of trauma-related ED admission was lower during exposed periods compared with nonexposed periods (incidence rate ratio [IRR]: 0.91 [95% confidence interval (CI): 0.86-0.97]). The findings were similar only when the incident trauma episode was assessed (IRR: 0.89 [95% CI: 0.82-0.96]). A similar protective association was found in both genders. In validation analysis using nontrauma-related ED admissions as a negative control outcome, no statistically significant association was found (IRR: 0.99 [95% CI: 0.95-1.02]). All sensitivity analyses demonstrated consistent results.

CONCLUSIONS

This study supports the hypothesis that MPH is associated with a reduced risk of trauma-related ED admission in children and adolescents. A similar protective association was found in both male and female patients. This protective association should be considered in clinical practice.

Legg-Calvé-Perthes disease and the risk of ADHD, depression, and mortality

BACKGROUND AND PURPOSE

Hyperactive behavior pattern (such as attention deficit hyperactivity disorder (ADHD)) is proposed to be present in individuals with Legg-Calvé-Perthes disease (LCPD). We investigated whether individuals with LCPD have a higher risk of ADHD, depression, and mortality.

SUBJECTS AND METHODS

We identified 4,057 individuals with LCPD in Sweden during the period 1964-2011. 40,570 individuals without LCPD were randomly selected from the Swedish general population and matched by year of birth, sex, and region (control group). We used Cox proportional hazard regression to estimate the relative risks.

RESULTS

Compared to the control group, individuals with LCPD had a raised hazard ratio (HR) of 1.5 (95% CI: 1.2-1.9) for ADHD. The risks were higher for female individuals (HR = 2.1, CI: 1.3-3.5) than for male individuals (HR = 1.4, CI: 1.1-1.8). Individuals with LCPD had a modestly higher hazard ratio for depression (HR = 1.3, CI: 1.1-1.5) than the control group. Furthermore, individuals with LCPD had a slightly higher mortality risk than the control group (HR = 1.2, CI: 1.0-1.4) INTERPRETATION: Individuals with LCPD have a higher risk of ADHD. Hyperactivity could expose the femoral head to higher mechanical stress and contribute to the etiology of LCPD. The higher risk of depression may be due to the burden of LCPD itself or could reflect neurobehavioral aspects of ADHD changing into depression later in life. Individuals with LCPD have a higher mortality risk, with higher risk of suicide and cardiovascular diseases.

Gender and injuries predict stimulant medication use

OBJECTIVE

The purpose of this article was to examine whether injuries in early childhood and gender predict prescriptions of stimulant medication in three groups of children: With attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and other psychiatric disorders (OPD).

METHODS

This was a population-based study with prospective and complete follow-up of children with ADHD (n=11,553), ASD (n=9698), and OPD (n=48,468), of whom 61%, 16%, and 3%, respectively, were treated with stimulants. For all 69,719 individual children data on psychiatric diagnoses, injuries, and drug prescriptions were obtained from national registers and merged.

RESULTS

Having sustained an injury before 5 years of age increased the likelihood of later stimulant treatment, in children with ADHD (odds ratio [OR]=1.09; 95% confidence interval [CI]=1.01-1.21), ASD (OR=1.19; 95% CI=1.02-1.40), and OPD (OR=1.24; 95% CI=1.08-1.42), with each injury increasing the likelihood by 3%, 10%, and 7%, respectively. Head injury did not increase the likelihood of later stimulant treatment. Within each of the three groups, ADHD, ASD, and OPD boys were more likely than girls to receive stimulant medication, OR=1.17 (95% CI=1.07-1.28); OR=1.71 (95% CI=1.47-2.01), and OR=2.41 (95% CI=2.16-2.71), respectively.

CONCLUSIONS

To our knowledge, this is the first prospective study assessing early life predictors of later ADHD medication in children with a psychiatric disorder, taken from a national cohort with complete follow-up of all cases. We found that the number of injuries prior to diagnosis was associated with initiation of stimulant treatment in all three groups of patients. In addition, male gender predicted treatment with ADHD medications. Our results suggest that the number of injuries early in life prior to diagnosis is associated with stimulant treatment, and may serve as a proxy for the level of later severity of ADHD symptoms, as it is universally associated with pharmacological treatment for ADHD.

Attention-deficit/hyperactivity disorder increased the risk of injury: a population-based follow-up study

AIM

To explore the frequency and risk for injury among children with Attention-deficit/hyperactivity Disorder (ADHD) in Taiwan through a population-based study.

METHODS

A total of 3616 subjects aged between four and twelve years diagnosed with ADHD were selected along with a comparison cohort comprising 18 080 subjects. Each subject was individually traced for a three-year period from their index date to identify those subjects who subsequently received a diagnosis of injury. We used stratified Cox proportional hazards regressions to examine the three-year injury-free survival rates between the two cohorts.

RESULTS

Of the subjects, the incidence rate of injury during the three-year follow-up period was 7.97 (95% CI = 7.45-8.51) and 5.36 (95% CI = 5.17-5.56) for the study and comparison cohort, respectively. After adjusting for geographic region, the hazard ratio (HR) of injury for subjects with ADHD was 1.64 (95% CI = 1.50-1.79) that of comparison subjects. In addition, we found children with ADHD aged between four and 6 years to demonstrate a greater HR (1.98, 95% CI = 1.72-2.28) than those aged between seven and twelve (HR = 1.46, 95% CI = 1.31-1.63).

CONCLUSIONS

Children with ADHD appear to be at a higher risk for injury than children that are not diagnosed with ADHD.

Attention-deficit/hyperactivity disorder and adverse health outcomes

Attention-deficit/hyperactivity disorder (ADHD) is defined by extreme levels of inattention-disorganization and/or hyperactivity-impulsivity. In DSM-IV, the diagnostic criteria required impairment in social, academic, or occupational functioning. With DSM-5 publication imminent in 2013, further evaluation of impairment in ADHD is timely. This article reviews the current state of knowledge on health-related impairments of ADHD, including smoking, drug abuse, accidental injury, sleep, obesity, hypertension, diabetes, and suicidal behavior. It concludes by suggesting the need for new avenues of research on mechanisms of association and the potential for ADHD to be an early warning sign for secondary prevention of some poor health outcomes.

Legg-Calvé-Perthes disease and the risk of injuries requiring hospitalization: a register study involving 2579 patients

BACKGROUND AND PURPOSE

Previous studies have suggested that Legg-Calvé-Perthes disease (LCPD) is associated with repetitive trauma, coagulation problems and anatomical abnormalities of the blood supply to the femoral head. The hypothesis that repetitive trauma can affect the blood supply of the femoral head, leading to LCPD, is supported by an animal model. For evidence of an increased risk of repetitive trauma, we investigated whether patients with LCPD have a higher risk for severe injuries requiring hospitalization.

PATIENTS AND METHODS

We identified 2579 patients with LCPD in Sweden during the period 1964-2005. 13,748 individuals without LCPD were randomly selected from the Swedish general population, matched by year of birth, sex and region (control group). Cox proportional hazard regression estimated the risks.

RESULTS

Compared to the control group, patients with LCPD had a modestly raised hazard ratio (HR) of 1.2 (95% CI 1.1-1.3) for injury requiring hospitalization. The risks were slightly higher for soft tissue injuries (HR = 1.3, 95% CI:1.1-1.4) than for fractures (HR = 1.1, 95% CI: 1.0-1.3) and more pronounced among females. Compared to the control group, the higher risk for injury only applied to the lower extremities (HR = 1.2, 95% CI: 1.0-1.4) in patients with LCPD.

INTERPRETATION

Patients with LCPD are vulnerable to injuries which could be interpreted as a marker of hyperactive behavior. It could also implicate that anatomical changes in the bone formation or blood supply of the femoral head - increasing its sensibility for trauma - contribute to the etiology of LCPD.

Road trauma in teenage male youth with childhood disruptive behavior disorders: a population based analysis

BACKGROUND

Teenage male drivers contribute to a large number of serious road crashes despite low rates of driving and excellent physical health. We examined the amount of road trauma involving teenage male youth that might be explained by prior disruptive behavior disorders (attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder).

METHODS AND FINDINGS

We conducted a population-based case-control study of consecutive male youth between age 16 and 19 years hospitalized for road trauma (cases) or appendicitis (controls) in Ontario, Canada over 7 years (April 1, 2002 through March 31, 2009). Using universal health care databases, we identified prior psychiatric diagnoses for each individual during the decade before admission. Overall, a total of 3,421 patients were admitted for road trauma (cases) and 3,812 for appendicitis (controls). A history of disruptive behavior disorders was significantly more frequent among trauma patients than controls (767 of 3,421 versus 664 of 3,812), equal to a one-third increase in the relative risk of road trauma (odds ratio  =  1.37, 95% confidence interval 1.22-1.54, p<0.001). The risk was evident over a range of settings and after adjustment for measured confounders (odds ratio 1.38, 95% confidence interval 1.21-1.56, p<0.001). The risk explained about one-in-20 crashes, was apparent years before the event, extended to those who died, and persisted among those involved as pedestrians.

CONCLUSIONS

Disruptive behavior disorders explain a significant amount of road trauma in teenage male youth. Programs addressing such disorders should be considered to prevent injuries.