Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population

Mental health and social-emotional functioning in children and adolescents with chronic kidney disease

For children and young adults, living with chronic kidney disease (CKD) poses physical, mental, and social challenges. The mental health functioning of children and adolescents with CKD plays an important role in the medical, educational, vocational, and quality of life outcomes, yet receives little systematic attention in the busy pediatric nephrology clinic. This article will provide an overview of the prevalence of mental illness and symptoms in children and young adults with CKD, strategies to assess for dysfunction, and the long-term outcomes associated with impaired functioning. While there is a relative dearth of literature regarding evidence-based interventions in this population to improve mental health functioning, we provide "best practice" strategies based on the available literature to address emotional and/or behavioral challenges once they are identified. More research is needed to define appropriate interventions to alleviate mental health issues and social-emotional distress, and this review of the literature will serve to provide directions for future research.

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of Well Parent Japan in routine care in Japan: The training and nurturing support for mothers (TRANSFORM) study

BACKGROUND

Well Parent Japan (WPJ) is a new hybrid group parent training programme combining sessions to improve mothers' psychological well-being with a culturally adapted version of the New Forest Parenting Programme (NFPP). This study investigates the effectiveness and cost-effectiveness of WPJ against treatment as usual (TAU) within Japanese child mental health services.

METHODS

TRANSFORM was a pragmatic multi-site randomised controlled trial (RCT) with two parallel arms. Altogether 124 mothers of 6-12-year-old children with DSM-5 ADHD were randomised to WPJ (n = 65) or TAU (n = 59). Participants were assessed at baseline, post-treatment and three-month follow-up. The primary outcome was parent-domain stress following intervention. Secondary outcomes included maternal reports of child-domain stress, parenting practices, parenting efficacy, mood, family strain, child behaviour and impairment. Objective measures of the parent-child relationship were collected at baseline and post-treatment. Data analysis was intention to treat (ITT) with treatment effects quantified through analysis of covariance (ANCOVA) via multilevel modelling. An incremental cost-effectiveness ratio (ICER) assessed WPJ's cost-effectiveness.

RESULTS

WPJ was superior to TAU in reducing parent-domain stress post-treatment (adjusted mean difference = 5.05, 95% CI 0.33 to 9.81, p = .036) and at follow-up (adjusted mean difference 4.82, 95% CI 0.09 to 9.55, p = .046). Significant WPJ intervention effects were also observed for parenting practices, parenting efficacy and family strain. WPJ and TAU were not significantly different post-intervention or at follow-up for the other secondary outcomes. The incremental cost of WPJ was 34,202 JPY (315.81 USD). The probability that WPJ is cost-effective is 74% at 10,000 JPY (USD 108.30) per one-point improvement in parenting stress, 92% at 20,000 JPY (216.60 USD). The programme was delivered with high fidelity and excellent retention.

CONCLUSIONS

WPJ can be delivered in routine clinical care at modest cost with positive effects on self-reported well-being of the mothers, parenting practices and family coping. WPJ is a promising addition to psychosocial interventions for ADHD in Japan.

A pre-visit video/question prompt list intervention to increase youth question-asking about attention deficit hyperactivity disorder during pediatric visits

OBJECTIVE

To conduct a pragmatic randomized controlled trial to test the effectiveness of an ADHD question prompt list with video intervention to increase youth question-asking and provider education about ADHD during visits.

METHODS

English-speaking youth ages 11-17 with ADHD and their caregivers were enrolled from two pediatric clinics. Youth were randomized to intervention or usual care groups. Intervention group adolescents watched the video and then completed an ADHD question prompt list before their visits. Multivariable regression was used to analyze the data.

RESULTS

Twenty-one providers and 102 of their patients participated. Intervention group youth were significantly more likely to ask one or more questions about ADHD and its treatment than usual care youth (odds ratio=5.4, 95 % Confidence Interval (CI)= 1.8, 15.9). Providers were significantly more likely to educate youth who asked one or more questions during visits about more ADHD medication areas (unstandardized beta=0.98, 95 % CI=0.31 to 1.64) and more non-medication strategies for ADHD (unstandardized beta=0.50, 95 % CI=0.13 to 0.88).

CONCLUSION

The intervention increased youth question-asking about ADHD and its treatment. Providers provided more education to youth who asked one or more questions about ADHD and its treatment.

PRACTICE IMPLICATIONS

Providers and practices should consider having youth complete ADHD question prompt lists and watch the video before visits to increase youth question-asking during visits.

Indirect effect of ADHD on parenting stress through increased child anxiety and decreased emotional regulatory coping

Parents of children with ADHD experience significantly more parenting stress in comparison to parents of typically developing children due to the emotional and behavioral difficulties related to ADHD. Additionally, approximately 30% of children with ADHD experience co-occurring anxiety. Parents of children with co-occurring anxiety and ADHD report increased stress due to role restriction and isolation compared to parents of children with ADHD alone. Poor emotional regulatory coping in children with ADHD has been linked to elevated negative affect and irritability, which also contributes to increased stress among parents. The present study examined the direct and indirect associations of child anxiety symptoms and emotional regulatory coping on elevated ADHD symptoms and parenting stress. Participants were 203 children aged 7-12-years-old and their parents. Parents completed a self-report measure of parenting stress and measures of their child's ADHD symptoms, anxiety, and emotional regulatory coping. Additionally, children completed self-report measures of emotional regulatory coping. Model testing indicated that the overall model demonstrated excellent fit to the data. Parameter testing supported an indirect effect of child ADHD symptoms on parenting stress through child anxiety symptoms and an indirect effect of child ADHD symptoms on parenting stress through child emotional regulatory coping. These results suggest that child anxiety and emotion dysregulation in children with ADHD have a negative impact on parental stress. The current study adds to the understanding of the important roles emotional regulatory coping and anxiety play in children with ADHD to contribute to increased parenting stress.

Sleep and internalizing problems in primary school children with attention-deficit hyperactivity disorder

BACKGROUND

Internalizing and externalizing problems have received great attention, and children with ADHD exhibit high rates of comorbid internalizing and externalizing disorders. This study aimed to explore the relationship between sleep and internalizing problems in children with attention-deficit hyperactivity disorder (ADHD) and the probable mediating role of externalizing problems.

METHODS

A total of 203 primary school children diagnosed with ADHD for the first time were recruited for this study. Children with ADHD were evaluated by Children's Sleep Habits Questionnaire (CSHQ), Strengths and Difficulties Questionnaire (SDQ). Internalizing problems were represented by emotional symptoms and peer problems of SDQ, and externalizing problems were represented by conduct problems and hyperactivity-inattention problems of SDQ. Multi-step linear regression analysis was used to investigate the mediating effect of externalizing problems on the relationship between sleep and internalizing problems.

RESULTS

Sleep in children with ADHD was associated with emotional problems in internalizing problems, and conduct problems in externalizing problems mediated the association between sleep and emotional problems.

CONCLUSION

For children with ADHD, when it is difficult to identify internalizing problems, especially emotional problems, we can take sleep and externalizing problems as clues to improve our clinical ability to recognize and deal with emotional problems.

IMPACT

1. We first explored the possible mediating role of conduct problems between sleep and emotional problems in primary school children with ADHD. 2. When it is difficult to identify internalizing problems, especially emotional problems, we can take sleep and externalizing problems as clues to improve our clinical ability to recognize emotional problems for children with ADHD. 3. For children with ADHD with potential internalizing problems, especially emotional problems, interventions for their sleep and externalizing problems may be the possible methods to deal with.

The diagnosis of ADHD in children and adolescents with epilepsy: a scoping review

Attention-deficit hyperactivity disorder (ADHD) is often diagnosed in children and adolescents with epilepsy, but clear clinical guidelines on how to make this diagnosis are still lacking. Without these guidelines, there is no consensus between specialists on how to proceed when assessing children with epilepsy for ADHD, which can negatively impact the quality of care being offered to this population. As a first step toward gaining more specific clinical guidelines, this scoping review was aimed at documenting the tools and procedures used to diagnose ADHD in children and adolescents with epilepsy over time and at determining whether the diagnoses were made in accordance with clinical guidelines and recommendations. The literature search was conducted using PsycINFO, PubMed, and CINAHL. Studies were included if conducted with children and adolescents aged between 4 and 18 years with epilepsy being evaluated for ADHD. Studies were clustered according to their publication date and the reported diagnostic procedures were identified. Forty-nine out of 3854 records were included. Results highlight discrepancies between how ADHD was diagnosed in reviewed studies and clinical guidelines or recommendations. Indeed, most studies did not use a multi-method and multi-informant approach when diagnosing ADHD in children with epilepsy, with no improvement over time. Future studies aimed at diagnosing ADHD in children and adolescents should ensure that they are following clinical guidelines and recommendations, in addition to adapting their diagnostic procedures to the presence of any neurological comorbidities, such as epilepsy.

Implementing Measurement-Based Care in a Youth Partial Hospital Setting: Leveraging Feedback for Sustainability

This paper describes the successful implementation of Measurement-Based Care (MBC) within a Partial Hospitalization Program (PHP) for children and adolescents. Measurement-based care (MBC), the practice of using patient-reported measures routinely to inform decision-making, is associated with improved clinical outcomes for behavioral health patients (Jong et al., Clinical Psychology Review 85, 2021; Fortney & Sladek, 2015). MBC holds great promise in partial hospital programs (PHP) to improve outcomes, yet implementation strategies are as complex as the setting itself. This paper provides a case study example of MBC implementation in a PHP for youth. Over the course of 18 months, an interdisciplinary staff of approximately 20 behavioral health professionals provided partial hospitalization level of care to 633 (39% in-person, 61% telehealth) youth from ages 5 to 18 years old. MBC in this setting incorporated daily patient self-report and weekly caregiver-reported measurements. This descriptive reconstruction, which includes examples of the data that were used during the implementation project, illustrates specific barriers and facilitators in a successful implementation in the local PHP setting. Implementation strategies to address workflow integration, leadership and supervision, and coaching are described, including evolution of these strategies over the course of implementation. Practical considerations for implementing MBC in youth PHP settings are discussed. Finally, the authors explore the potential relationships between the data-driven MBC model of decision making and the development of resilient organizations.

Measure of Caregiver Attention-Deficit/Hyperactivity Disorder Knowledge Is Responsive to Decision Aid on Treatment for Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Adapt and test a measure of knowledge for caregivers of children with attention-deficit/hyperactivity disorder (ADHD) and evaluate the impact of the information component of a decision aid (DA) on participant knowledge.

METHODS

A set of seven knowledge items were created based on prior knowledge measures and clinical guidelines. As part of a larger cross-sectional survey study of caregivers of children diagnosed with ADHD, caregivers were randomized to one of two arms: 1) a DA arm, where participants reviewed the information component of the Cincinnati Children's Hospital's DA, and 2) a control arm, where participants were not shown a DA. All participants completed the seven knowledge items. Knowledge items were assessed for difficulty, quality of distractors, acceptability, and redundancy. Total knowledge scores (0-100) for the DA and control arm were compared.

RESULTS

Caregivers were assigned to the DA arm (n = 243) or the control arm (n = 260). All 7 knowledge items were retained as no items were too difficult or too easy, all response options were used, there were little missing data, and no items were redundant. The overall knowledge score was normally distributed, and almost covered the full range of scores (5-100). Those who received the DA component had higher knowledge scores (M=68, SD=23) than those who did not receive the DA component (M=60, SD=19, P < .01, d=0.4).

CONCLUSIONS

The Caregiver ADHD Knowledge (CAKe) measure was acceptable and demonstrated construct validity as those who were assigned to review the DA component demonstrated greater knowledge than those who were not assigned to review the DA component.

[Formula: see text] Beyond the rubicon: a continuum approach to investigating the impact of ADHD like characteristics on everyday executive function in children with Tourette Syndrome

Across a range of neurodevelopmental conditions, a diagnosis of attention deficit hyperactivity disorder (ADHD) has been shown to be associated with executive function impairment. However, the DSM-V emphasis upon viewing psychological characteristics as existing on a continuous distributed quantitative dimension has enabled the opportunity to consider the influence of sub-diagnostic or sub-referral levels of these psychological characteristics upon cognitive function. This study adopted a continuum approach to the consideration of this ADHD influence and examined the extent to which the difference in parental reported executive functions between children with Tourette syndrome (TS) or typically developing children could be mediated by a concurrent group difference in the possession of sub-referral levels of ADHD-like characteristics. A total of 146 children, 58 with reported TS diagnosis, participated. Parental report measures of ecological executive functioning, the Child Executive Functioning Inventory, and the Vanderbilt ADHD Diagnostic Parent Rating Scale were employed. The analyses with a full sample and a sub-referral sample revealed significant group differences in most of the key measures. In addition, these measures were highly correlated even when controlling for age and gender. A series of mediation analyses indicated that in all models, the ADHD-like measures significantly mediated the group difference in executive function. These results suggest that sub-referrals levels of ADHD-like characteristics continue to contribute to executive challenges in TS. Future intervention research targeting these executive functions should consider the presence of ADHD-like characteristics at sub-referral levels of possession.

Appetitive and psychological phenotypes of pediatric patients with obesity

BACKGROUND

Obesity is a heterogeneous disease with variable treatment response. Identification of the unique constellation of contributors to obesity may allow for targeted interventions and improved outcomes.

OBJECTIVE

Identify empirically derived phenotypes of pediatric patients with obesity based on appetitive and psychological correlates of obesity.

METHODS

This cross-sectional study included patients aged 5-12 years who were treated in a weight management clinic and completed standard intake questionnaires including Child Eating Behavior Questionnaire (CEBQ), Vanderbilt ADHD Scale and Pediatric Symptom Checklist. Phenotypes were elicited using latent profile analysis of 12 indicators: eight CEBQ subscales, inattention, hyperactivity/impulsivity, internalizing and externalizing symptoms.

RESULTS

Parents/guardians of 384 patients (mean age 9.8 years, mean BMI 30.3 kg/m2 ) completed the intake questionnaires. A 4-phenotype model best fits the data. Hedonic Impulsive phenotype (42.5%) exhibited high food enjoyment and hyperactivity/impulsivity. Inattentive Impulsive phenotype (27.4%) exhibited overall low food approach and high food avoid behaviours, and highest inattention. Hedonic Emotional phenotype (20.8%) scored the highest on food enjoyment, internalizing and externalizing symptoms. Picky Eating phenotype (9.3%) scored the lowest on food approach, inattention, hyperactivity/impulsivity, internalizing and externalizing symptoms.

CONCLUSION

Appetitive traits and psychological symptoms appear to cluster in distinct patterns, giving rise to four unique phenotypic profiles, which, if replicated, may help inform the development of tailored treatment plans.

Sensorimotor Features and Daily Living Skills in Autistic Children With and Without ADHD

Attention-deficit/hyperactivity disorder (ADHD) commonly co-occurs in autistic children. However, additional research is needed to explore the differences in motor skills and sensory features in autistic children with and without ADHD, as well as the impacts of these factors on daily living skills (DLS). This observational study sought to fill this gap with 67 autistic children (6.14-10.84 years-old), 43 of whom had ADHD. Autistic children with ADHD demonstrated higher sensory features and lower motor skills than autistic children without ADHD. In examining autism and ADHD features dimensionally, we found that overall sensory features, seeking, and hyporesponsiveness were driven by both autism and ADHD features, whereas motor skills, enhanced perception, and hyperresponsiveness were driven by only autism features. Additionally, in using these dimensional variables of autism and ADHD features, we found that differences in motor skills, sensory and autism features, but not ADHD features, impact DLS of autistic children, with autism features and motor skills being the strongest individual predictors of DLS. Together, these results demonstrate the uniqueness of motor skills and sensory features in autistic children with and without ADHD, as well as how autism features, sensory features, and motor skills contribute to DLS, emphasizing the importance of a comprehensive understanding of each individual and complexities of human development when supporting autistic children.

Parent Gender and Assessment of Children's Health

Caregiver-reported data on children's health are typically provided by mothers. We investigated whether measures of children's health would significantly differ between mother and father respondents to a nationally representative survey. This study used de-identified data on children age 0 to 17 years from the 2016-2019 National Survey of Children's Health (NSCH). The primary exposure was whether the survey was completed by the child's father (cases) or mother (controls). Outcome variables included general health, special health care needs (SHCN), and unmet health care needs. We identified 85 191 children meeting inclusion criteria, of whom 35.1% had a father respondent. After propensity score matching, 27 738 children with a father respondent were matched to an equal size group of children with a mother respondent. On conditional logistic regression analysis of the matched sample, we found that poor health, SHCN, and unmet health care needs were less likely to be reported for children in the sample by father respondents.

A Quality Improvement Initiative for Detection of Attention-Deficit/Hyperactivity Disorder in an Urban, Academic Safety Net Hospital

OBJECTIVE

Improve detection of Attention Deficit/Hyperactivity Disorder (ADHD) in a safety net, hospital-based, academic pediatric practice by optimizing screening with the Pediatric Symptom Checklist attention score (PSC-AS) and further evaluation with the Vanderbilt ADHD Diagnostic Rating Scale (VADRS).

METHODS

We implemented a multi-component intervention by (1) optimizing electronic medical record (EMR) features; (2) adjusting clinic operational workflow; and (3) creating a decision-making algorithm for pediatric primary care clinicians (PPCCs). We extracted 4 outcomes manually from the EMR (pediatrician acknowledgment of a positive PSC-AS, documentation of a plan for further evaluation, distribution of VADRS, and completion of at least 1 VADRS). Outcomes were measured monthly in run charts compared to the pre-intervention control period, and implementation was optimized with Plan-Do-Study-Act cycles.

RESULTS

PPCCs were significantly more likely to acknowledge a positive PSC-AS in the intervention versus control (65.3% vs 41.5%; p < 0.001), although this did not change documentation of a plan (70% vs 67.1%; p -value = 0.565). Significantly more children with a positive PSC-AS were distributed a parent or teacher VADRS in the intervention versus control (30.6% vs 17.7%; p -value = 0.0059), but the percentage of returned VADRS rating scales did not improve (12.9% vs 9.2%; p -value = 0.269).

CONCLUSION

Our ADHD detection quality improvement initiative improved use of the PSC-AS to identify attention problems and distribution of VADRS diagnostic rating scales, but additional interventions are needed to improve the completion of ADHD evaluations in primary care to ensure that children are appropriately identified and offered evidence-based care.

An Objective Assessment of Effect of Stimulants on Attention in Individuals With ADHD

INTRODUCTION

Currently, assessing ADHD treatment response to stimulants relies on rating scales and subjective questionnaires and sometimes a CPT. Such tools fall short of objective, quantifiable measurement of effect, especially in natural settings and can result in inconsistent treatment.

METHOD

We report results from two studies using a novel proof-of-concept approach. A preliminary trial of 10 individuals used a high-fidelity eye tracker; a second study of 100 individuals used webcams at the participants' homes.

RESULTS

Both studies evaluated stimulant effect using reading behavior analysis, being an ADHD symptom that stimulants affect and a major symptom patients want to improve. Both showed a significant change in reading behavior related to medication state, suggesting a clear, objective measure of stimulant effect.

CONCLUSION

Using ubiquitous hardware, investigators created a user-friendly treatment assessment platform where individuals can collect their own objective data within minutes in any setting where they have access to a web camera and computer.

Cognitive disengagement syndrome in pediatric spina bifida

The primary aim of this study was to characterize Cognitive Disengagement Syndrome (CDS) symptomatology in youth with spina bifida (SB). One hundred and sixty-nine patients aged 5-19 years old were drawn from clinical cases seen through a multidisciplinary outpatient SB clinic at a children's hospital between 2017 and 2019. Parent-reported CDS and inattention were measured using Penny's Sluggish Cognitive Tempo Scale and the Vanderbilt ADHD Rating Scale. Self-reported internalizing symptoms were measured with the 25-item Revised Children's Anxiety and Depression Scale (RCADS-25). We replicated Penny's proposed 3-factor structure of CDS with slow, sleepy, and daydreamer components. The slow component of CDS overlapped heavily with inattention, while the sleepy and daydreamer components were distinct from inattention and internalizing symptoms. Eighteen percent (22 of 122) of the full sample met criteria for elevated CDS, and 39% (9 of 22) of those patients did not meet criteria for elevated inattention. Diagnosis of myelomeningocele and presence of a shunt were associated with greater CDS symptoms. CDS can be measured reliably in youth with SB and can be discriminated from inattention and internalizing symptoms in this population. ADHD rating scale measures fail to identify a substantial portion of the SB population with attention-related challenges. Standard screening for CDS symptoms in SB clinics may be important to help identify clinically impairing symptoms and design targeted treatment plans.

Comorbidity of attention deficit hyperactivity disorder in a patient with epilepsy: Staring down the challenge of inattention versus nonconvulsive seizures

Epilepsy is a heterogeneous disorder of recurrent seizures which often is comorbid with anxiety, depression, attention deficit hyperactivity disorder (ADHD), intellectual disability (ID), and other psychiatric manifestations. Treating both epilepsy and behavioral symptoms from psychiatric disorders can result in polypharmacy with interactions of medications leading to both worsened efficacy of antiseizure medications due to psychotropic effects and worsening of psychiatric symptoms due to antiseizure medication side effects. We aim to suggest pragmatic strategies for the neurologist in the diagnosis and management of comorbid ADHD in patients with epilepsy based on the International League Against Epilepsy (ILAE) Pediatric Commission guidelines and additional literature review. The screening tool of choice for the symptoms of ADHD is validated in the country of practice and written in the language of the family, though various screening tools and advantages and disadvantages of each will be discussed. Once ADHD is diagnosed, recent safety data suggest that Methylphenidate, Amphetamine, and Atomoxetine are generally safe for patients with epilepsy. We present a case of a child with epilepsy and ADHD and discuss the clinical signs, symptoms, and strategies for treatment as well as when to refer to child psychiatry.

Incorporating emotion coaching into behavioral parent training program: evaluation of its effectiveness

Disruptive behaviors in childhood yield negative mental health outcomes. Both behavioral management and emotion coaching parenting programs were effective in reducing children's disruptive behaviors. This randomized control trial (RCT) study evaluated the effectiveness of a community clinic-based, parent training program that incorporated emotion coaching into behavioral training (BPEC) for 119 parents who expressed difficulty in handling their elementary school-aged children's disruptive behaviors. These parents were randomly assigned to the treatment group or waitlist control. Pre-tests, post-tests, and 3-month delayed post-tests were administered. Compared to those in the waitlist control group, participants in the BPEC group reported significantly (a) fewer child oppositional behaviors and ADHD symptoms and (b) more positive aspects of the parent-child relationship. Significant short-term effects were maintained after 3-month for parent-reported, child oppositional behaviors. Thus, BPEC effectively reduced the disruptive behaviors of children.

Atomoxetine Treatment of Attention Deficit/Hyperactivity Disorder Symptoms in 3-6-Year-Old Children with Autism Spectrum Disorder: A Retrospective Cohort Study

Atomoxetine is indicated for the management of attention deficit/hyperactivity disorder (ADHD) in children and adolescents aged 6 to 18 years. Few studies have assessed the safety and tolerability of atomoxetine in younger patients. This retrospective cohort study included 133 children aged 3-6 years who were diagnosed with ADHD comorbid with autism spectrum disorder (ASD). The primary endpoint was the evaluation of the safety profile of atomoxetine. In total, 50 patients (37.6%) experienced adverse events (AEs), which led to treatment discontinuation in 23 patients (17.3%). The most common AEs were gastrointestinal (24.1%), aggression or hostility (12.8%), and increased hyperactivity (9.0%). In the 23 patients who discontinued treatment, all the AEs resolved after treatment ceased. Among the 110 patients who completed at least 6 months' treatment, atomoxetine titrated to a dose of 1.2-1.8 mg/kg/day appeared to be well tolerated and effective. The Clinical Global Impression-Improvement score improved to 1 ("very much improved") and 2 ("much improved") in 62.4% and 20.3% of children, respectively, at their last visit. Overall, atomoxetine appeared to be well tolerated in younger children with comorbid ADHD and ASD. Nevertheless, close patient monitoring remains essential, and the study limitations necessitate caution in generalizing these findings to broader populations. Long-term prospective studies are required.

Learning from the past: How lessons from Hinman syndrome can inform the psychological management of lower urinary tract dysfunction

INTRODUCTION

Pediatric patients with lower urinary tract dysfunction (LUTD) experience a variety of medical and psychosocial concerns that can negatively impact their clinical management and quality of life. When initially described by Drs Hinman and Baumann, patients with a form of severe LUTD, later dubbed Hinman syndrome, were characterized as having a "general attitude of being failures." While this mention was noteworthy as it incorporated an understanding of the interplay between psychological factors and urologic conditions, there have been delays in implementing psychological intervention as a standard of care in patients with LUTD broadly, and perhaps too keen of a focus on youth diagnosed with Hinman syndrome specifically.

METHODS

A non-systematic reviewed of LUTD related to psychological management was performed. Clinical recommendations were developed by a multicenter and multidisciplinary team of care providers with topic expertise.

OBJECTIVE

The aim of this paper is to propose a systems thinking paradigm for how to involve psychology, or psychological principles, across the spectrum of patients with LUTD with the hope of improving attention to specific aspects of care that may improve clinical management.

DISCUSSION

Children across the spectrum of LUTD are likely to benefit from psychological interventions and would benefit from such involvement early on to mitigate the impact of psychosocial concerns on medical outcomes. Pediatric psychologists are well-suited to identify and provide individualized care to patients in greatest need of intervention, such as through pre-procedural preparedness, addressing non-adherence, and with the use of evidence-based, targeted mental health interventions. Psychologists are also apt at implementing interventions while taking into consideration the severity of LUTD, in the context of the patient's psychological, developmental, cultural, familial, and social determinants of health considerations. Youth with severe forms of LUTD, such as Hinman syndrome, likely exemplify the challenges of LUTD that benefit from multidisciplinary intervention.

CONCLUSION

Medical and psychological collaboration are key to ensuring symptom mitigation and emotional support for patients across the entire spectrum of LUTD.

Measurement-Based Care for Depression in Youth: Practical Considerations for Selecting Measures to Assess Depression, Associated Features and Functioning

Identification and management of major depressive disorder (MDD) in children and adolescents remains a significant area of public health need. The process for identifying depression (e.g. screening) and management (e.g. measurement based care [MBC]) is substantially enhanced by utilization of clinical measures and rating scales. Measures can be self- or caregiver reported or clinician rated. They can aid recognition of at-risk individuals for future assessment and assist in clinical diagnosis and management of depression. In addition to assessing symptoms of depression, rating scales can be used to assess important associated features (e.g. anxiety, trauma) and functional outcomes (e.g. quality of life, performance/productivity). In this manuscript, we discuss practical considerations for clinicians and researchers when selecting rating instruments for assessing depression, associated factors, functioning, and treatment outcomes (i.e. adherence and side effects) as part of MBC in youth and provide a summary of rating scales commonly used in research and clinical settings.

A meta-analysis on the effect of telemedicine on the management of attention deficit and hyperactivity disorder in children and adolescents

INTRODUCTION

This study aims to report the effect sizes of telemedicine treatments on the symptom domains of paediatric ADHD.

METHODS

In this systematic review and meta-analysis, electronic databases, i.e. PubMed, Scopus, Web of Science and Embase, were searched for articles published up to December 2020. The inclusion criteria were as follows: children or adolescents diagnosed for ADHD or other hyperkinetic disorders; randomized controlled trials (RCTs); efficacy established with parents and teachers or self-rating scales at least for one of the following domains: inattention, cognitive function, hyperactivity, hyperactivity/impulsivity or oppositional behaviours. The risk of bias was assessed using the Cochrane risk of bias tool for RCTs.

RESULTS

From 310 records reduced to 228 after removing duplicates, overall 12 studies were fulfilled our inclusion criteria. They consisted of 708 participants (358 with telemedicine intervention and 350 controls). The telemedicine interventions varied from computerized training programmes with phone calls to videoconferencing programmes, virtual reality classrooms or games. The most applicable method consisted of computerized training programmes with phone calls. Pooling results of all studies with available data on each subscale showed a significant effect of telemedicine on inattention/cognitive function (standardized mean difference (SMD) = 0.26, 95% CI: 0.16, 0.36), hyperactivity/impulsivity (SMD = 0.29, 95% CI: 0.06, 0.52), and oppositional behaviours (SMD = 0.72, 95% CI: 0.24, 1.20) subscales in ADHD. Almost all studies had an overall unclear risk of bias. The source of outcome assessment (parents, teachers or self-report questionnaire) was addressed as a potential confounding factor. In almost all symptom domains, the satisfaction from the treatment was higher in parents than in teachers.

CONCLUSIONS

The clinical effects of telemedicine on the treatment of ADHD showed a small effect size for inattention/cognitive function, hyperactivity/impulsivity and oppositional behaviours.

Evidence-Based Assessment of DSM-5 Disruptive, Impulse Control, and Conduct Disorders

The assessment of oppositional defiant disorder, conduct disorder, antisocial personality disorder, and intermittent explosive disorder-the Disruptive, Impulse Control and Conduct Disorders-can be affected by biases in clinical judgment, including overestimating concerns about distinguishing symptoms from normative behavior and stigma associated with diagnosing antisocial behavior. Recent nosological changes call for special attention during assessment to symptom dimensions of limited prosocial emotions and chronic irritability. The present review summarizes best practices for evidence-based assessment of these disorders and discusses tools to identify their symptoms. Despite the focus on disruptive behavior disorders, their high degree of overlap with disruptive mood dysregulation disorder can complicate assessment. Thus, the latter disorder is also included for discussion here. Good practice in the assessment of disruptive behavior disorders involves using several means of information gathering (e.g., clinical interview, standardized rating scales or checklists), ideally via multiple informants (e.g., parent-, teacher-, and self-report). A commitment to providing a full and accurate diagnostic assessment, with careful and attentive reference to diagnostic guidelines, will mitigate concerns regarding biases.

Children with developmental coordination disorder have less variable motor unit firing rate characteristics across contractions compared to typically developing children

Introduction

Understanding the nuances of neuromuscular control is crucial in unravelling the complexities of developmental coordination disorder (DCD), which has been associated with differences in skeletal muscle activity, implying that children with DCD employ distinct strategies for muscle control. However, force generation and control are dependent on both recruitment of motor units and their firing rates and these fine details of motor function have yet to be studied in DCD. The purpose of this study was therefore to compare motor unit characteristics in a small muscle of the hand during low level, handgrip contractions in typically developing (TD) children and children with DCD.

Methods

Eighteen children (9 TD vs. 9 DCD) completed a series of manual handgrip contractions at 10 ± 5% of their maximum voluntary contraction. High density surface electromyography was used to record excitation of the first dorsal interosseus muscle. Recorded signals were subsequently decomposed into individual motor unit action potential trains. Motor unit characteristics (firing rate, inter-pulse interval, and action potential amplitude) were analysed for contractions that had a coefficient variation of <10%.

Results and Discussion

This study found few differences in average motor unit characteristics (number of motor units: TD 20.24 ± 9.73, DCD 27.32 ± 14.00; firing rate: TD 7.74 ± 2.16 p.p.s., DCD 7.86 ± 2.39 p.p.s.; inter-pulse interval: TD 199.72 ± 84.24 ms, DCD 207.12 ± 103 ms) when force steadiness was controlled for, despite the DCD group being significantly older (10.89 ± 0.78 years) than the TD group (9.44 ± 1.67 years). However, differences were found in the variability of motor unit firing statistics, with the children with DCD surprisingly showing less variability across contractions (standard deviation of coefficient of variation of inter-pulse interval: TD 0.38 ± 0.12, DCD 0.28 ± 0.11). This may suggest a more fixed strategy to stabilise force between contractions used by children with DCD. However, as variability of motor unit firing has not been considered in previous studies of children further work is required to better understand the role of variability in motor unit firing during manual grasping tasks, in all children.

Mind wandering in anxiety disorders: A status report

Many investigations have targeted the subject of worry in anxiety disorders. Worry can be regarded as a subtype of mind wandering (MW), which is undeliberate, perseverative, negatively-valenced, and mainly future-oriented. Nevertheless, until now only a few studies have explored the role of overall MW in the origin and course of anxiety disorders. To foster progress in this field, we briefly describe and discuss relevant studies addressing MW in subjects with anxiety disorders or symptoms or disorders associated with anxiety symptoms. Provisional synthesis suggests that: a) the overall amount of MW is positively correlated with anxiety symptoms; b) MW characteristics reflecting worry and rumination appear to be relevant in anxiety; c) comorbid depressive and ADHD symptoms may contribute to excessive MW in anxiety; d) MW-related therapeutic interventions may be useful as complementary treatments in anxiety disorders. However, more studies related to MW in anxiety disorders or symptoms are necessary to corroborate and extend these initial findings. Such investigations should ideally combine experience sampling with self-rating assessments of both MW and worry/rumination.

Quantifying Potential Bias Resulting From Child Age on Screening for Hyperactive/Impulsive Presentations of ADHD

OBJECTIVE

This study aims to quantify the potential age bias in screening of hyperactive/impulsive presentations of ADHD in children ages 5 to 12 through comparison of age-based and overall percentiles in screening.

METHOD

A referred clinical sample of 307 children ages 5 to 12 with behavioral concerns completed the Vanderbilt Attention Deficit-Hyperactivity Disorder Diagnostic Parent Rating Scale (VADPRS) and were formally evaluated for ADHD with a diagnostic interview. Analysis utilizing logistic regression and receiver operating characteristic (ROC) curves was performed to compare the screening performance of agebased and overall percentiles.

RESULTS

The age-based percentiles demonstrated no improvement in the analyzed models compared to overall percentiles in hyperactive presentation ADHD screening. This finding was present in the overall sample and in the sub analysis of the 5 to 6 year old children.

CONCLUSIONS

This study identifies no improvement in modeling of hyperactive/impulsive ADHD screening when considering a child's age using age-based percentiles.

Virtual Collaborative Behavioral Health Model in a Community Pediatric Network: Two-Year Outcomes

Due to the pervasive shortage of behavioral health (BH) specialists, collaborative partnerships between pediatric primary care practitioners (PPCPs) and BH specialists can enhance provision of BH services by PPCPs. We aimed to create a new model of collaborative care that was mostly virtual, affordable, and scalable. The pilot program was implemented in 18 practices (48 PPCPs serving approximately 150 000 patients) in 2 consecutive cohorts. Outcomes were assessed by administering pre-program and post-program surveys. Across the 18 practices, PPCPs reported significantly increased confidence in their BH knowledge and skills, and significantly increased their provision of target BH services. Barriers to BH service provision (resources, time, and staff) were unchanged. This compact, mostly virtual model of BH collaboration appears to be beneficial to PPCPs while also offering convenience to patients and affordability and scalability to the practice network.

Systematic Review: Child Psychiatry Access Program Outcomes

Objective

There has been an increase in Child Psychiatry Access Programs (CPAP) across the United States to address the national child and adolescent psychiatry workforce shortage by supporting pediatric primary care providers (PCPs) in providing mental health services. The objective of this systematic review is to synthesize the expanding literature on CPAPs.

Method

A systematic literature search was conducted in PubMed, PsycInfo, Embase, and Web of Science databases to identify articles published from database inception to April 6, 2022, to identify CPAPs, defined as programs with mental health specialists providing rapid remote mental health consultation services to pediatric PCPs. Study outcomes included program adoption, provider experience, patient and caregiver experience, program cost, and patient mental health.

Results

None of the 33 included studies were randomized controlled trials. Most of the studies (n = 30) focused on program adoption and provider experience (n = 18). Few studies examined patient and caregiver experience (n = 2), program cost(n = 4), or patient mental health (n = 4) outcomes. CPAPs showed year-over-year growth in adoption and were generally well-received by providers and caregivers. Health care provision costs were quite varied. No articles reported on changes in patient mental health according to validated measures. Heterogeneity in the methodological quality, study design, and outcomes used to evaluate CPAPs hindered comparison among programs.

Conclusion

Rigorous research on the impact of CPAPs is lacking. Findings show high provider satisfaction with CPAPs, yet few studies examine patient-level mental health outcomes. CPAPs and funding agencies should consider prioritizing and investing in research to build the evidence base for CPAPs.

Diversity & Inclusion Statement

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science.

Clinical trial registration information

Child Psychiatry Access Programs: A Systematic Review; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020146410; CRD42020146410.

Impact of Emotions on Test of Variables of Attention(TOVA) Performance in a Pediatric Clinical Population: A Retrospective Study

BACKGROUND

Continuous Performance Tests, like the Test of Variables of Attention (TOVA), are commonly used to assess attention processes in clinical settings. Although a few previous studies have explored the effects of emotions on the outcome of such tests, the results are scarce and contradictory at times.

OBJECTIVE

Through this retrospective study, we  aimed to explore the correlation between performance on the TOVA and parent-reported emotional symptoms in youth.

METHODS

We used preexisting datasets of Mood and Feelings Questionnaire, Screen for Child Anxiety Related Disorders, and Vanderbilt Attention-Deficit/Hyperactivity Disorder Diagnostic Rating Scale as well as preexisting results from the TOVA test from 216 patients aged between 8 and 18 years. Pearson's correlation coefficients, as well as linear regression models, were computed to examine the association between depressive and anxiety symptoms and the four indices of TOVA (response time variability, response time, commission errors, and omission errors). Additionally, we used generalized estimating equations to determine whether the reported emotional symptoms affect the TOVA outcome differently as the test progresses.

RESULTS

Our results showed no significant effect of the reported emotional symptoms on the TOVA results even when controlling for sex or reported inattention and hyperactivity.

CONCLUSION

TOVA results do not seem to be affected by emotional symptoms in youth. This being said, future studies should also explore other factors that can affect the performance on the TOVA, like motor disability, sleepiness, or neurodevelopmental disorders affecting cognitive abilities.

Multi-method examination of cognitive disengagement syndrome and ADHD inattentive symptoms in relation to early adolescents' academic functioning

Cognitive disengagement syndrome (CDS), previously referred to as sluggish cognitive tempo, is a set of symptoms characterized by excessive daydreaming, mental fogginess, and slowed behavior/thinking. Studies examining the association between CDS and academic functioning have reported mixed findings and have relied upon limited measures of CDS, broad ratings of academic impairment, and/or focused only on elementary-aged children. The current study examined the relationship between CDS and academic functioning in adolescents using a comprehensive, multi-informant, multi-method design. Participants were 302 adolescents (Mage = 13.17 years; 44.7% female; 81.8% White; 52% with ADHD) recruited in the fall of their 8th grade. Above and beyond ADHD inattentive symptoms, CDS symptoms were related to poorer homework performance, lower math fluency, and lower daily academic motivation across multiple informants, and teacher-reported CDS symptoms were related to lower grades. Findings were not moderated by ADHD diagnosis, suggesting that associations between CDS and academic outcomes do not differ for adolescents with and without ADHD. Findings demonstrate that CDS symptoms are uniquely associated with daily academic difficulties as well as global indices of academic performance. These findings have implications for assessing and monitoring CDS symptoms in interventions aiming to improve the academic functioning in adolescents with and without ADHD.

Physical and Extracurricular Activity in Adolescents With and Without ADHD: Examining Group Differences and the Role of Cognitive Disengagement Syndrome Symptoms

OBJECTIVE

This study examined extracurricular and physical activity related to ADHD (diagnosis and symptoms) and cognitive disengagement syndrome (CDS) symptoms.

METHODS

Participants were 302 adolescents (ages 12-14) with and without ADHD and primary caregivers. ADHD diagnosis was determined with parent interview. Questionnaires provided information on parent-reported demographic characteristics, ADHD symptoms, and extracurricular activity involvement; and adolescent-reported ADHD and CDS symptoms and indices of physical activity.

RESULTS

Although ADHD diagnosis and symptom dimensions were correlated with less extracurricular and physical activity involvement, CDS symptoms were most often independently associated with these outcomes. Females and adolescents from lower income homes also often had less involvement in extracurricular and physical activity.

CONCLUSIONS

Findings point to the need for more research in this area, careful assessment of risk factors (i.e., CDS symptoms, economic burden), and interventions that address inactivity in adolescents with ADHD, including those that address inequity related to income and sex.

Do Externalizing and Internalizing Symptoms Moderate Medication Response in Preschool Attention-Deficit/Hyperactivity Disorder? A DBPNet Study

OBJECTIVES

This study aimed to determine whether parent ratings of attention-deficit/hyperactivity disorder (ADHD) symptom severity or externalizing symptoms (EXT) or internalizing symptoms (INT) moderate response to stimulants (STIM) and alpha-2 adrenergic agonists (A2As) in preschool ADHD.

METHODS

Health records for children treated with medication for ADHD and with parent rating scale data available (N = 309; age <72 months) were reviewed at 7 Developmental-Behavioral Pediatric Research Network sites. Severity of ADHD was defined as the number of ADHD symptoms occurring often or very often on DSM-IV-based parent rating scales. EXT or INT from standardized rating scales were categorized as T score <60, 60 to <70, or ≥70. Ordinal logistic regression models predicting response to medication were calculated.

RESULTS

The median (interquartile range) age at ADHD diagnosis was 59 (54-65) months. One hundred eighty-three participants had ADHD symptom severity, and 195 had EXT or INT data. ADHD severity was not associated with medication response. Both EXT and INT were associated with medication response but with significant medication class by EXT/INT interactions. Children with higher EXT were less likely to respond to STIM, with percentage of nonresponders for T-score categories <60, 60 to <70, and ≥70 being 3.6%, 25.7%, and 33.3% (p = 0.016) and, for A2As, being 60%, 50%, and 33.3% (p = 0.55), respectively. A similar pattern was observed for INT categories: STIM 19.4%, 22.5%, and 50.0% (p = 0.002) and A2As 42.3%, 30%, and 42.3% (p = 0.48), respectively.

CONCLUSION

For preschool ADHD, low ratings of EXT or INT are associated with a high likelihood of response to STIM. By contrast, response rates to STIM and A2As are more similar for children with high levels of EXT or INT.

Understanding the Perspective of Youths on Undergoing Metabolic Monitoring While on Second-Generation Antipsychotics: Challenges, Insight, and Implications

Introduction: Prescription of second-generation antipsychotics (SGAs) in youths is rapidly increasing globally, despite the potential for significant adverse effects and long-term health consequences. A known adverse reaction resulting from SGAs is metabolic syndrome (MS). Youths exposed to antipsychotics are at higher risk than adults for adverse drug reactions, including adverse events such as MS (with weight gain as the most significant adverse outcome) and other long-term endocrinological abnormalities. This study aimed to explore the experiences of young patients on factors impacting barriers to metabolic monitoring of SGAs and the strategies to address those barriers thereby providing further guidance on policy and service delivery. Methods: Semi-structured interviews were conducted with patients (youths who were prescribed SGAs) who attended Child and Youth Mental Health Services. The interviews focused on barriers to monitoring and strategies to enhance rates of monitoring that could be customized across study sites. Results: Young patients revealed that none of them had any concerns or objections to receiving anthropometric metabolic measurements. However, they seemed concerned to undergo blood tests as part of the metabolic monitoring process. Specifically, youths cited their fear of the needles as barrier to undergo the required blood tests. Youths have also reported that their dislike to healthy foods and exercise being the most common challenge they face while trying to engage in a healthy lifestyle to manage the SGAs resulted weight gain. Conclusion: Prescribers are recommended to actively engage young patients about the expected SGAs-induced adverse effects, the importance of conducting metabolic monitoring, and how to prevent and minimize the expected adverse effects from the start of initiating SGAs. This could be a vital step toward a successful treatment as the insight of youths into the details of the chosen treatment can play a significant role into treatment adherence and recovery.

Implementation resources to support teachers' use of behavioral classroom interventions: protocol of a randomized pilot trial

BACKGROUND

Teacher-delivered behavioral classroom management interventions are effective for students with or at-risk for attention-deficit/hyperactivity disorder (ADHD) or other disruptive behavior challenges, but they can be difficult for teachers to use in the classroom. In this study, we will pilot test a package of implementation strategies to support teachers in using behavioral classroom interventions for students with ADHD symptoms.

METHODS

We will use a 2-group, randomized controlled trial to compare outcomes for teachers who receive Positive Behavior Management Implementation Resources (PBMIR), a theory and data-driven implementation resource package designed to increase teacher implementation of behavioral classroom management interventions, with those who do not receive this additional implementation support. We will measure teacher implementation outcomes (e.g., observed fidelity to behavioral classroom interventions) and student clinical outcomes (e.g., ADHD-related impairment, ADHD symptoms, student-teacher relationship, academic performance) before and after an 8-week intervention period for both groups; we will also measure teacher-reported acceptability, appropriateness, and feasibility for the PBMIR group following the intervention period.

DISCUSSION

If there is preliminary evidence of feasibility and effectiveness, this pilot study will provide the foundation for evaluation the PBMIR at a larger scale and the potential to improve outcomes for students with or at risk for ADHD.

TRIAL REGISTRATION

This clinical trial was registered at ClinicalTrials.gov. ( https://clinicaltrials.gov/ ) on 8/5/2022 which was prior to the time of first participant enrollment. The registration number is: NCT05489081.

Estimating the Risk of Attention Deficit Hyperactivity Disorder (ADHD) in Parents of Children with ADHD and the Association with Their Children's Disease Severity and Adherence to Medication

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is characterised by inattentiveness, hyperactivity, and impulsivity. Up to half of the affected children have a parent with ADHD. In this study, the risk of ADHD among parents of ADHD children was estimated. The associations between parental ADHD and child ADHD severity and medication adherence were determined.

METHODOLOGY

Parents of children and adolescents diagnosed with ADHD attending the University Kebangsaan Malaysia Medical Centre (UKMMC) were recruited between June to August 2022 and the administered Conners' Adult ADHD Rating Scale (CAARS) self-report short form, Vanderbilt ADHD Parent Rating Scale (performance section), and Medication Adherence Report Scale (MARS).

RESULTS

Forty-five children with ADHD were recruited and 15 out of 45 (33%) parents were detected to have ADHD. ADHD severity was worse in children with ADHD parents for total severity (mean of 34.67 vs. 29.13, p = 0.047) and difficult behaviours at home (mean of 7.87 vs. 6.27, p = 0.036). The children's academic performance and behavioural challenges at home and school were positively correlated with the parental ADHD scores for 'inattention' and 'problems with self-care' subscales.

CONCLUSIONS

A total of 33% of ADHD children had parents with ADHD. ADHD children with ADHD parents were more likely to have behavioural problems at home and more severe ADHD. However, no statistical significance was noted with medication adherence.

COGMED working memory training in children with Attention Deficit/Hyperactivity Disorder (ADHD): A feasibility study in Saudi Arabia

Working memory training has been proven effective for improving cognitive functioning in patients with Attention Deficit/Hyperactivity Disorder (ADHD). However, the feasibility of this type of training for children in Saudi Arabia has not been previously explored. We investigated the feasibility of implementing Cogmed Working Memory Training (CWMT) in a sample of 29 Saudi children with ADHD. We found no significant demographic or clinical differences between compliant and noncompliant children. Although compliant children were initially better at following instructions and reported better improvements in working memory and math skills compared to those who did not complete the CWMT, all children who participated in the program showed improvements in performing the CWMT tasks. Most parents found the Cogmed training feasible for their children, were satisfied and keen to continue with the program, and felt the training helped them to address their problems. Most children did not encounter any difficulties in using the software, and many families were, therefore, likely to continue using the techniques from the program. We conclude that CWMT for children with ADHD is feasible in Saudi Arabia. Larger case-controlled studies are needed to thoroughly investigate the effects of CWMT compared to other interventions in Saudi children with ADHD.

Benefits of a 12-Week Non-Drug "Brain Fitness Program" for Patients with Attention-Deficit/Hyperactive Disorder, Post-Concussion Syndrome, or Memory Loss

Background

Non-pharmacologic interventions can potentially improve cognitive function, sleep, and/or mood in patients with attention-deficit/hyperactive disorder (ADHD), post-concussion syndrome (PCS), or memory loss.

Objective

We evaluated the benefits of a brain rehabilitation program in an outpatient neurology practice that consists of targeted cognitive training, lifestyle coaching, and electroencephalography (EEG)-based neurofeedback, twice weekly (90 minutes each), for 12 weeks.

Methods

223 child and adult patients were included: 71 patients with ADHD, 88 with PCS, and 64 with memory loss (mild cognitive impairment or subjective cognitive decline). Patients underwent a complete neurocognitive evaluation, including tests for Verbal Memory, Complex Attention, Processing Speed, Executive Functioning, and Neurocognition Index. They completed questionnaires about sleep, mood, diet, exercise, anxiety levels, and depression-as well as underwent quantitative EEG-at the beginning and the end of the program.

Results

Pre-post test score comparison demonstrated that all patient subgroups experienced statistically significant improvements on most measures, especially the PCS subgroup, which experienced significant score improvement on all measures tested (p≤0.0011; d_z≥0.36). After completing the program, 60% to 90% of patients scored higher on cognitive tests and reported having fewer cognitive and emotional symptoms. The largest effect size for pre-post score change was improved executive functioning in all subgroups (ADHD d_z= 0.86; PCS d_z= 0.83; memory d_z= 1.09).

Conclusion

This study demonstrates that a multimodal brain rehabilitation program can have benefits for patients with ADHD, PCS, or memory loss and supports further clinical trials in this field.

Quantifying attention span across the lifespan

Introduction

Studies examining sustained attention abilities typically utilize metrics that quantify performance on vigilance tasks, such as response time and response time variability. However, approaches that assess the duration that an individual can maintain their attention over time are lacking.

Methods

Here we developed an objective attention span metric that quantified the maximum amount of time that a participant continuously maintained an optimal "in the zone" sustained attention state while performing a continuous performance task.

Results

In a population of 262 individuals aged 7-85, we showed that attention span was longer in young adults than in children and older adults. Furthermore, declines in attention span over time during task engagement were related to clinical symptoms of inattention in children.

Discussion

These results suggest that quantifying attention span is a unique and meaningful method of assessing sustained attention across the lifespan and in populations with inattention symptoms.

Network Analysis of ADHD Symptoms and Cognitive Profiles in Children

Purpose

Although many studies have reported the cognitive profiles in attention-deficit/hyperactivity disorder (ADHD), the interactions between ADHD symptoms and the patients' cognitive profiles have not been carefully examined through the network analysis. Here, in this study, we systematically analyzed the ADHD patents' symptoms and cognitive profiles, and identified a set of interactions between ADHD symptoms and cognitive domains using the network approach.

Patients and Methods

A total of 146 children with ADHD, 6 to 15 years of age, were included in the study. All participants were assessed by the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) test. The patients' ADHD symptoms were evaluated by the Vanderbilt ADHD parent and teacher rating scales. GraphPad Prism 9.1.1 software was used for descriptive statistics and R 4.2.2 was used for network model construction.

Results

The ADHD children in our sample showed lower scores for full scale intelligence quotient (FSIQ), verbal comprehension index (VCI), processing speed index (PSI) and working memory index (WMI). Among all the ADHD core symptoms and comorbid symptoms, the academic ability, inattention symptoms and mood disorder showed direct interaction with the cognitive domains of WISC-IV. In addition, oppositional defiant of the ADHD comorbid symptoms, and perceptual reasoning of the cognitive domains exhibited the highest strength centrality in the ADHD-Cognition network based on parent ratings. Classroom behaviors of the ADHD functional impairment, and verbal comprehension of the cognitive domains exhibited the highest strength centrality in the network based on teacher ratings.

Conclusion

We highlighted the importance of considering the interactions between the ADHD symptoms and cognitive properties when designing the intervention plans for the ADHD children.

Stimulant Medication Treatment in Children with Congenital Heart Disease and Attention-Deficit/Hyperactivity Disorder: Cardiovascular Outcomes

OBJECTIVE

Children with congenital heart disease (CHD) are at increased risk for attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to determine whether children with CHD and ADHD clinically treated with stimulant medication were at increased risk for changes in cardiovascular parameters or death compared with CHD-matched controls.

METHODS

In this retrospective cohort study, patients with CHD + ADHD treated with stimulant medication (exposed group [EG]) were matched by CHD diagnosis and visit age to patients not on stimulants (nonexposed group [NEG]). Cardiovascular parameters (heart rate [HR] and systolic and diastolic blood pressure [SBP and DBP]) and electrocardiograms (ECGs) from medical records over 12 months were compared using mixed effects models.

RESULTS

Cardiovascular parameters for 151 children with CHD (mean age 8 ± 4 years) were evaluated (N = 46 EG and N = 105 NEG). Stimulant medication use was not associated with sudden cardiac death. HR and SBP did not significantly change over time in the EG and remained similar between groups. EG children had higher DBP compared with NEG children over time ( p = 0.001). Group × time interactions for HR, SBP, and DBP were not different between the EG and NEG. QTc was not significantly different between the EG and NEG (447 ms vs 439 ms, p = 0.23). EG children demonstrated improvement in ADHD symptoms.

CONCLUSION

Stimulant medication use in children with CHD was not associated with clinically significant changes in cardiovascular parameters compared with controls. Stimulants should be considered for ADHD treatment in children with CHD when prescribed with appropriate monitoring and coordination with the cardiologist.

Enhancing attention in children using an integrated cognitive-physical videogame: A pilot study

Inattention can negatively impact several aspects of a child's life, including at home and school. Cognitive and physical interventions are two promising non-pharmaceutical approaches used to enhance attention abilities, with combined approaches often being marketed to teachers, therapists, and parents typically without research validation. Here, we assessed the feasibility of incorporating an integrated, cognitive-physical, closed-loop video game (body-brain trainer or 'BBT') as an after-school program, and also evaluated if there were attention benefits following its use. Twenty-two children (7-12 years of age) with a range of attention abilities were recruited to participate in this proof of concept, single-arm, longitudinal study (24 sessions over 8 weeks, ~30 min/day). We interrogated attention abilities through a parent survey of their child's behaviors, in addition to objective performance-based and neural measures of attention. Here we observed 95% compliance as well as, significant improvements on the parent-based reports of inattention and on cognitive tests and neural measures of attention that were comparable in scale to previous work. Exploratory measures of other cognitive control abilities and physical fitness also showed similar improvement, with exploratory evaluation of retained benefits on the primary attention-related outcomes being present 1-year later. Lastly, there was no correlation between the baseline parent-rated inattention score and the improvement on the primary task-based measures of attention, suggesting that intervention-based benefits were not solely attained by those who stood the most to gain. These pilot findings warrant future research to replicate and extend these findings.

Heated Behaviour in the Classroom for Children with FASD: The Relationship between Characteristics Associated with ADHD, ODD and ASD, Hot Executive Function and Classroom Based Reward Systems

Possession of characteristics related to Attention Deficit Hyperactive Disorder, Oppositional Defiance Disorder, and Autism Spectrum Disorder in children prenatally exposed to alcohol contributes to challenges within the diagnostic pathway for Foetal Alcohol Spectrum Disorder (FASD). The presentation of these characteristics, though problematic for the children affected, may not result in referral for diagnosis; focusing on diagnostic thresholds masks the dimensional nature of these characteristics. Children with traits which are undiagnosed may not receive effective support and are often identified as exhibiting challenging behaviour. In the UK, children with undiagnosed Special Educational Needs (SEN) are more likely to experience school exclusion. Common across each condition are challenges to executive function associated with emotional regulation (hot-executive function). This study explored the relationship between characteristics of Attention Deficit Hyperactive Disorder, Oppositional Defiance Disorder, Autistic-Like Traits, and hot executive functions on the helpfulness of reward-based interventions for children with suspected or diagnosed FASD. Data were collected online using caregiver referral questionnaire screeners for each measure (Child Autism Quotient Questionnaire, Vanderbilt ADHD Parental Rating Scale and The Childhood Executive Functioning Inventory) for children aged 6–12 years with suspected or diagnosed FASD (n = 121). Between-group comparisons showed no significant difference in the reporting of Attention Deficit Hyperactive Disorder characteristics, Oppositional Defiance Disorder characteristics, Autistic-Like Traits, and executive function, regardless of diagnostic state. Multiple regression analyses indicated that these personality characteristics and executive functions were associated with the perception of the reward system helpfulness. However, this pattern was qualified by both the type of hot executive function challenged (significant for Regulation not Inhibition) and whether the child had an FASD diagnosis. Thus, a dimensional approach may strengthen our understanding of the child’s classroom experience and help overcome barriers to effective intervention and support.

Harmonizing DSM-IV and DSM-5 Versions of ADHD "A Criteria": An Item Response Theory Analysis

The transition from Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) to Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) attention deficit/hyperactivity disorder (ADHD) checklists included item wording changes that require psychometric validation. A large sample of 854 adolescents across four randomized trials of psychosocial ADHD treatments was used to evaluate the comparability of the DSM-IV-TR and DSM-5 versions of the ADHD symptom checklist. Item response theory (IRT) was used to evaluate item characteristics and determine differences across versions and studies. Item characteristics varied across items. No consistent differences in item characteristics were found across versions. Some differences emerged between studies. IRT models were used to create continuous, harmonized scores that take item, study, and version differences into account and are therefore comparable. DSM-IV-TR ADHD checklists will generalize to the DSM-5 era. Researchers should consider using modern measurement methods (such as IRT) to better understand items and create continuous variables that better reflect the variability in their samples.

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015.

OBJECTIVES

To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate.

SELECTION CRITERIA

We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non-serious, general behaviour, and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel-group trials and first-period data from cross-over trials formed the basis of our primary analyses. We undertook separate analyses using end-of-last period data from cross-over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach.

MAIN RESULTS

We included 212 trials (16,302 participants randomised); 55 parallel-group trials (8104 participants randomised), and 156 cross-over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross-over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male-female ratio was 3:1. Most trials were carried out in high-income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias.

PRIMARY OUTCOMES

methylphenidate versus placebo or no intervention may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -0.88 to -0.61; I² = 38%; 21 trials; 1728 participants; very low-certainty evidence). This corresponds to a mean difference (MD) of -10.58 (95% CI -12.58 to -8.72) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD-RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68).

SECONDARY OUTCOMES

methylphenidate may cause more adverse events considered non-serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher-rated general behaviour versus placebo (SMD -0.62, 95% CI -0.91 to -0.33; I² = 68%; 7 trials 792 participants; very low-certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI -0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The majority of our conclusions from the 2015 version of this review still apply. Our updated meta-analyses suggest that methylphenidate versus placebo or no-intervention may improve teacher-rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non-serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non-serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes.

High rate of attention deficit hyperactivity disorder among children 6 to 17 years old in Southwest Ethiopia findings from a community-based study

BACKGROUND

Attention-deficit/hyperactivity disorder is among the common neuropsychiatric disorders affecting children and adolescents. The disorder affects the life of children, their parents, and the community when left untreated. Although evidence indicated a high prevalence of attention-deficit/hyperactivity disorder in the developed world, there is limited evidence in developing countries, particularly, Ethiopia. Therefore, this study aimed to determine the prevalence and associated factors of attention deficit hyperactivity disorder among Ethiopian children aged 6 to 17 years.

METHODS

A community-based cross-sectional study was conducted from August to September 2021 among children aged 6 to 17 years in Jimma town. A multistage sampling technique was applied to select 520 study participants. Data were collected by using the Vanderbilt Attention Deficit Hyperactivity Disorder- Parent Rating scale as a modified, semi-structured, and face-to-face interview. The association between independent variables and the outcome variable was investigated using bi-variable and multivariable logistic regression. The final model level of significance was set at a p-value of < 0.05.

RESULT

A total of 504 participants were involved in the study with a response rate of 96.9%. The overall prevalence of attention deficit hyperactivity disorder in this study was (9.9%, n = 50). Maternal complication during pregnancy (Adjusted odds ratio (AOR) = 3.56, 95% CI = 1.44-8.79, mothers illiteracy (AOR = 3.10, 95% CI = 1.24-7.79), attending primary school (AOR = 2.97, 95% CI = 1.32-6.73), history of head trauma (AOR = 3.20, 95% CI = 1.25-8.16), maternal alcohol use during pregnancy (AOR = 3.54, 95% CI = 1.26-10), bottle feeding during first six months (AOR = 2.87, 95% CI = 1.20-6.93) and child's age 6-11 years (AOR = 3.86, 95% CI = 1.77-8.43) were significantly associated with attention deficit hyperactivity disorder.

CONCLUSION

In this study, one in ten children and adolescents in Jimma town had attention deficit hyperactivity disorder. Therefore, the prevalence of attention deficit hyperactivity disorder was high. For this reason, there is a need to pay increased attention to control associated factors of attention deficit hyperactivity disorder and reduce its prevalence.

Deficits in Parent Knowledge of Behavior Management Skills is Strongly Associated with CD Symptoms but Not ODD Symptoms

We conducted secondary analyses of existing data to examine the association between parent scores on the Knowledge of Effective Parenting Test (KEPT) and child symptoms of Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD). Parent knowledge of behavior management skills and child behavior symptoms were assessed in a nationally representative sample of parents/guardians (N = 1,570) of children aged 5-12 from all 50 states. Results showed consistent and robust correlations between parent knowledge of behavior management skills and CD symptoms but not ODD symptoms. These findings suggest that parent knowledge of behavior management may be a greater risk factor for CD than ODD, with implications for taxonomy and understanding the etiology of these two disorders. We also discuss the implications of these findings for the prevention and treatment of these two disorders which are often grouped together in treatment trials.

Effect of Co-occurring Psychiatric Disorders on Treatment of Children with Autism Spectrum Disorder and Anxiety

Co-occurring psychiatric diagnoses are very common in individuals with ASD. Little is known about the effect that co-occurring psychiatric conditions may have on treatment response to CBT for children with ASD and anxiety. The present study examined the relationship between co-occurring psychiatric diagnoses and response to CBT for anxiety in ninety youth with ASD. Psychiatric complexity did not appear to differentially impact treatment response. A notable portion of youth with anxiety and externalizing disorders such as ADHD, no longer met criteria for those externalizing diagnoses following intervention. Results indicate that youth with ASD and anxiety present with complex psychiatric profiles and CBT for anxiety may positively affect co-occurring diagnoses. In addition, thorough and nuanced assessment of psychiatric symptoms in youth with ASD is needed to ensure the differentiation between diagnoses of anxiety and other co-occurring psychiatric symptoms.

censusADHD Study: An Australian-wide medication-based recruitment study for Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Attention-deficit/hyperactivity disorder affects over 5% of children and is characterised by a persistent pattern of problems with focussing or maintaining attention and/or hyperactivity-impulsivity. The censusADHD Study is a richly phenotyped nationwide cohort of Australian children with attention-deficit/hyperactivity disorder. The overarching aims of the study are to examine attention-deficit/hyperactivity disorder medication utilisation patterns and treatment response, the impact of children's attention and behavioural problems on caregivers, and costs related to attention-deficit/hyperactivity disorder.

METHODS

Families of potential attention-deficit/hyperactivity disorder cases aged between 6 and 11 years were identified using Pharmaceutical Benefits Scheme prescription records for attention-deficit/hyperactivity disorder medications held by Services Australia and sent a study information letter. Data were collected from 1574 primary caregivers via online survey in 2015, including the behavioural profile of the child, the child's medication use and experiences with side effects and the impact of the child's behaviour on the caregiver. Approximately 81% of caregivers also consented to record linkage of the child's Pharmaceutical Benefits Scheme and Medicare Benefits Schedule claims to directly assess prescription dispensing history and health service usage to estimate costs to the family and Medicare health system.

RESULTS

Boys were diagnosed with attention-deficit/hyperactivity disorder earlier (p = 0.021), more likely to present as the combined and predominantly hyperactive subtypes (p = 0.001) and at higher risk of experiencing a school suspension (p < 0.001) or expulsion (p = 0.043). Overall, children presenting as the combined subtype had higher rates of psychiatric comorbidities (p < 0.001). Finally, prescription costs for each family and the Pharmaceutical Benefits Scheme significantly increased in the year following attention-deficit/hyperactivity disorder diagnosis (p < 0.001).

CONCLUSION

Research examining the psychosocial and financial impact of attention-deficit/hyperactivity disorder on Australian children and their families is needed. Our findings demonstrate the importance of examining both gender and attention-deficit/hyperactivity disorder subtype presentation in future studies.

Is S100B Involved in Attention-Deficit/Hyperactivity Disorder (ADHD)? Comparisons with Controls and Changes Following a Triple Therapy Containing Methylphenidate, Melatonin and ω-3 PUFAs

BACKGROUND

Increasing evidence supports a neuroinflammatory basis in ADHD damaging glial function and thereby altering dopaminergic (DA) neurotransmission. Previous studies focusing on the S100B protein as a marker of glial function have shown contradictory results. We conducted a clinical trial to investigate differences in S100B levels between ADHD patients and controls, as well as observe gradual changes in S100B concentrations after a triple therapy (TT) containing methylphenidate (MPH), melatonin (aMT) and omega-3 fatty acids (ω-3 PUFAs).

METHODS

62 medication-naïve children with ADHD (ADHD-G) and 65 healthy controls (C-G) were recruited. Serum S100B was measured at baseline (T0) in ADHD-G/C-G, and three (T3) and six months (T6) after starting TT in the ADHD-G, together with attention scores.

RESULTS

A significant increase in S100B was observed in the ADHD-G vs. C-G. In the ADHD-G, significantly higher S100B values were observed for comparisons between T0-T3 and between T0-T6, accompanied by a significant improvement in attention scores for the same timepoint comparisons. No significant differences were found for S100B between T3-T6.

CONCLUSION

Our results agree with the hypothesis of glial damage in ADHD. Further studies on the link between DA and S100B are required to explain the transient increase in S100B following TT.

Why Don't Adolescents Wear Their Brace? A Prospective Study Investigating Psychosocial Characteristics That Predict Scoliosis Brace Wear

BACKGROUND

Although bracing for adolescent idiopathic scoliosis can prevent curve progression and reduce the risk for future surgery, children frequently do not wear their braces as prescribed. The purpose of this study is to investigate how a broad array of psychosocial characteristics predict future compliance with scoliosis brace wear.

METHODS

This was a single institution, prospective cohort study. All adolescents prescribed a first-time brace for adolescent idiopathic scoliosis were eligible. Patients and their parents completed a separate series of questionnaires that assessed baseline psychosocial characteristics across 6 domains: (1) brace-specific attitudes; (2) body image and self-esteem; (3) school performance and social relationships; (4) psychological health; (5) family functioning; and (6) demographics and scoliosis-specific details (242 total questions across 12 validated questionnaires). Objective brace compliance was collected using temperature-sensitive monitors. Defining compliance as percentage of brace prescription completed, comparative analyses were performed to identify baseline psychosocial characteristics that were associated with future wear. A composite measure (Bracing Fidelity Follow-Up Scale [BFFS]) of the 12 most predictive individual questions across all domains (both parent and adolescent) was constructed to help assess which adolescents were at highest risk of failure to wear their brace. Total BFFS score for each parent-adolescent dyad who completed all the included surveys was then determined by awarding one point for each factor that positively influenced future brace wear (maximum 12 points), and a correlation was calculated between total score and percent adherence to prescribed brace wear.

RESULTS

A total of 41 patients were included. On average, patients with high self-esteem, above average peer relationships and poor brace-specific attitudes had lower brace compliance, although patients with increased loneliness and parental religiousness had higher compliance. Body image, socioeconomic status, family dynamics, and school performance had no significant relationship with brace use. Total score on the Bracing Fidelity Follow-Up Scale (BFFS) was significantly associated with improved brace wear (r=0.687, P <0.001). Those with a score of 6 or above (n=15/33 [45%], median compliance 96%) were more reliable users (15/15 with compliance >75%), and those with a score of 5 or less (n=18/33 [55%], median compliance 50%) had less consistent brace wear (9/18 with compliance <50%).

CONCLUSION

This prospective study identifies numerous baseline psychosocial factors that are associated with future compliance with scoliosis brace wear. Although in need of further validation before widespread clinical application, the novel BFF scale offers a potential opportunity to partially discriminate between compliant and noncompliant scoliosis brace users such that supportive resources (eg, supportive counseling, peer-support groups, additional provider-based education, etc.) can be targeted to those patients most likely to benefit.

LEVEL OF EVIDENCE

II.