ADHD in children and youth: Part 1-Etiology, diagnosis, and comorbidity

Prediction of attention deficit hyperactivity disorder based on explainable artificial intelligence

Accurate assessment of Attention Deficit Hyperactivity Disorder (ADHD) is crucial for the effective treatment of affected individuals. Traditionally, psychometric tests such as the WISC-IV have been utilized to gather evidence and identify patterns or factors contributing to ADHD diagnosis. However, in recent years, the use of machine learning (ML) models in conjunction with post-hoc eXplainable Artificial Intelligence (XAI) techniques has improved our ability to make precise predictions and provide transparent explanations. The objective of this study is twofold: firstly, to predict the likelihood of an individual receiving an ADHD diagnosis using ML algorithms, and secondly, to offer interpretable insights into the decision-making process of the ML model. The dataset under scrutiny comprises 694 cases collected over the past decade in Spain, including information on age, gender, and WISC-IV test scores. The outcome variable is the professional diagnosis. Diverse ML algorithms representing various learning styles were rigorously evaluated through a stratified 10-fold cross-validation, with performance assessed using key metrics, including accuracy, area under the receiver operating characteristic curve, sensitivity, and specificity. Models were compared using both the full set of initial features and a well-suited wrapper-type feature selection algorithm (Boruta). Following the identification of the most suitable model, Shapley additive values were computed to assign weights to each predictor based on their additive contribution to the outcome and to elucidate the predictions. Strikingly, a reduced set of 8 out of the initial 20 variables produced results comparable to using the full feature set. Among the ML models tested, the Random Forest algorithm outperformed others on most metrics (ACC = 0.90, AUC = 0.94, Sensitivity = 0.91, Specificity = 0.92). Notably, the principal predictors, ranked by importance, included GAI - CPI, WMI, CPI, PSI, VCI, WMI - PSI, PRI, and LN. Individual case examples exhibit variations in predictions depending on unique characteristics, including instances of false positives and negatives. Our ML model adeptly predicted ADHD diagnoses in 90% of cases, with potential for further enhancement by expanding our database. Furthermore, the use of XAI techniques enables the elucidation of salient factors in individual cases, thereby aiding inexperienced professionals in the diagnostic process and facilitating comparison with expert assessments. It is important to note that this tool is designed to support the ADHD diagnostic process, where the medical professional always has the final say in decision-making.

The Effect of Ear Acupressure on Behavioral Problems in Children with Attention-Deficit/Hyperactivity Disorder: A Randomized Clinical Trial

Objective

Due to the limits on treatment for people with attention-deficit/hyperactivity disorder (ADHD), ear acupressure treatment has been considered. This study examined the effect of ear acupressure on behavioral problems of children with ADHD.

Materials and Methods

This randomized controlled trial was conducted in 70 children with ADHD who were randomized into 2 groups. The intervention group received ear acupressure in treatment points and the control group received massage at neutral points. Behavioral problems were measured 3 times: (1) baseline; week 4; and week 8. The last timepoint was a follow-up, using the Child Behavior Checklist.

Results

The intervention group had fewer behavioral problems at all 3 timepoints than the control group (Cohen's ∂ = 1.49; 95% confidence interval at week 4: 20.97, 47.43).The ear acupressure group had a large effect size with respect to reduction of attention problems at week 4 (∂ = 1.88) and week 8 (∂ = 1.48) than the control group.

Conclusions

Ear acupressure induced significant reduction of the behavioral problems of children with ADHD. Further research can evaluate the use and continuity of the effectiveness of this treatment as a complementary treatment in addition to the usual treatments for these children.

Expected changes in parenting after an online parent training for ADHD

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in children and adolescents. Treatments for this population should be multidisciplinary and must be initiated as early as possible. Non-pharmacological interventions for ADHD include psychoeducation, parent behavioural training programs and school interventions and accommodations. In response to the COVID-19 pandemic, we developed an online version of a combined psychoeducation and behavioural training program to facilitate access to mental health treatment and ensure continuity of care.

OBJECTIVE

The study assessed the acceptability of this online parent training program, among parents and caretakers of children and adolescents with ADHD.

METHODS

The program consisted of ten online sessions over the course of two consecutive days (five sessions a day). Satisfaction, usefulness and general comments about the program were assessed with open-ended questions and visual-analogous scales. Parents/caretakers' use of strategies to manage behavioural problems was assessed using the Parenting and Family Adjustment Scales.

RESULTS

A total of 206 parents participated in the online program 175 of whom completed the evaluation. Participants were satisfied with the content of the program. More than half of participants had already started using strategies included in the program. The engagement was high and no major obstacles were identified other than some internet connection issues.

DISCUSSION

In our survey, online delivery was described as more convenient, and participants were satisfied with the content of the program finding it beneficial for their child. Despite this, some difficulties in implementing new strategies were observed. Online BTP increased access to the BTP programs while being effective on ADHD symptoms and behavioural disturbances.

CONCLUSIONS

With these measures, we hope to improve engagement in online psychoeducation and behavioural therapy programs. Future research evaluating online behavioural training programs should focus on ways to make them more accessible and adaptable to families' obstacles.

Exploring telediagnostic procedures in child neuropsychiatry: addressing ADHD diagnosis and autism symptoms through supervised machine learning

Recently, there has been an increase in telemedicine applied to child neuropsychiatry, such as the use of online platforms to collect remotely case histories and demographic and behavioral information. In the present proof-of-concept study, we aimed to understand to what extent information parents and teachers provide through online questionnaires overlaps with clinicians' diagnostic conclusions on attention-deficit/hyperactivity disorder (ADHD). Moreover, we intended to explore a possible role that autism spectrum disorders (ASD) symptoms played in this process. We examined parent- and teacher-rated questionnaires collected remotely and an on-site evaluation of intelligence quotients from 342 subjects (18% females), aged 3-16 years, and referred for suspected ADHD. An easily interpretable machine learning model-decision tree (DT)-was built to simulate the clinical process of classifying ADHD/non-ADHD based on collected data. Then, we tested the DT model's predictive accuracy through a cross-validation approach. The DT classifier's performance was compared with those that other machine learning models achieved, such as random forest and support vector machines. Differences in ASD symptoms in the DT-identified classes were tested to address their role in performing a diagnostic error using the DT model. The DT identified the decision rules clinicians adopt to classify an ADHD diagnosis with an 82% accuracy rate. Regarding the cross-validation experiment, our DT model reached a predictive accuracy of 74% that was similar to those of other classification algorithms. The caregiver-reported ADHD core symptom severity proved the most discriminative information for clinicians during the diagnostic decision process. However, ASD symptoms were a confounding factor when ADHD severity had to be established. Telehealth procedures proved effective in obtaining an automated output regarding a diagnostic risk, reducing the time delay between symptom detection and diagnosis. However, this should not be considered an alternative to on-site procedures but rather as automated support for clinical practice, enabling clinicians to allocate further resources to the most complex cases.

Attitudes of parents of children with ADHD towards genetic testing: Data from a Turkish sample

This study aimed to examine the opinions of parents with children diagnosed with attention deficit/hyperactivity disorder about genetic tests. A total of 540 parents living in Turkey participated in the study face-to-face and online. A questionnaire form prepared by the researchers was used as the data collection instrument. Face-to-face data were collected in different institutions in the cities of İzmir, Bursa and Antalya, while online data were collected through Google Forms. The results revealed that parents' views on genetic testing differed according to the sex and age of the child, as well as the parents' level of education and income, and whether the parents had genetic testing during pregnancy (p < 0.05). In the analysis, it was determined that parents' knowledge and awareness levels about genetic tests were generally low, while parents who reported that they would consider having genetic tests had concerns about the storage of their DNA materials, family conflicts that could be caused by genetic tests, and the compatibility of genetic tests with their religious beliefs.

Variation in attitudes toward diagnosis and medication of ADHD: a survey among clinicians in the Norwegian child and adolescent mental health services

Prevalence and medication rates of ADHD vary geographically, both between and within countries. No absolute cutoff exists between ADHD and normal behavior, making clinician attitudes (leading to local practice cultures) a potential explanation for the observed variation in diagnosis and medication rates. The objective of this study was to describe variation in attitudes toward diagnosis and medication of ADHD among clinicians working in child and adolescent mental health services (CAMHS). We hypothesized that attitudes would vary along a spectrum from "restrictive" to "liberal". We also explored whether differences in attitudes between clinicians were related to professional background and workplace (clinic). A survey in the form of a web-based questionnaire was developed. All CAMHS outpatient clinics in Norway were invited. Potential respondents were all clinicians involved in diagnosing and treating children and adolescents with ADHD. To investigate the existence of attitudes toward diagnosis and medication as latent constructs, we applied confirmatory factor analysis (CFA). We further examined how much of variance in attitudes could be ascribed to profession and clinics by estimating intraclass correlation coefficients. In total, 674 respondents representing 77 (88%) of the clinics participated. We confirmed variation in attitudes with average responses leaning toward the "restrictive" end of the spectrum. CFA supported "attitude toward diagnosis" and "attitude toward medication" as separate, and moderately correlated (r = 0.4) latent variables, representing a scale from restrictive to liberal. Professional background and workplace explained only a small part of variance in these attitudes.

Promoting optimal mental health outcomes for children and youth

While paediatric care providers are often the first point of contact for children or youth experiencing mental health challenges, they may lack the resources (e.g., access to a multidisciplinary team) or training to adequately identify or manage such problems. This joint statement describes the key roles and competencies required to assess and address child and youth mental health problems, and the factors that optimize outcomes in this age group. Evidence-informed guidance on screening for and discussing mental health concerns with young people and families is provided. Preventive and therapeutic interventions with demonstrated efficacy in community care settings are discussed. This foundational statement also focuses on the changes to medical education, health systems, and health policy that are needed to improve clinical practice and advocacy efforts in Canada, including appropriate remuneration models, stepped-care approaches, targeted government funding, and professional training and education.

'It's like it is designed to keep me stressed'-Working sustainably with ADHD or autism

BACKGROUND

Adults with attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD) face multiple challenges in obtaining and maintaining employment.

AIMS

To identify and describe how adults with ADHD or ASD experienced their ability to work and what factors affected their ability to find a sustainable work situation over time.

METHODS

Individual in-depth interviews were performed with 20 purposively sampled participants with ADHD/ASD. Data were analysed inductively using reflexive thematic analysis.

RESULTS

Three themes were identified, describing (1) one's own cognitive abilities and challenges, (2) enablement by flexibility and acceptance in the work environment, and (3) accumulated stress that makes the work situation unsustainable over time.

CONCLUSIONS

Over time, a lack of continuity and predictability of support measures caused great stress and exhaustion, with severe consequences for working life and in life in general. Adaptations needed to be individually tailored and include nonoccupational factors.

SIGNIFICANCE

The study shows that adults with ADHD/ASD need long-term interventions that flexibly adapt to individual needs, as they vary over time. The findings suggest that occupational therapists and other health care providers, employers, employment services and other involved agencies should pay a greater deal of attention to stability and predictability over time.

Attention deficit hyperactivity disorder: Insights into underfunding in the private healthcare sector in South Africa

Background

Although the prevalence of attention deficit hyperactivity disorder (ADHD) has remained stable, the number of patients diagnosed with ADHD has increased in recent years owing to increased awareness. Despite this increase, medical schemes in South Africa have not improved their funding models for this condition.

Aim

The study aimed to provide an account of the funding that medical schemes provisioned for treating ADHD in South Africa during 2022.

Setting

All the South African medical schemes that were registered with the Council of Medical Schemes during 2022 (n = 72) and all their listed options were evaluated (n = 279).

Methods

The study analysed secondary data published on the medical schemes' websites in the public domain. Statistical minimum, average, maximum and correlation analyses were performed using Excel version 16.58.

Results

Attention deficit hyperactivity disorder is not regarded as a prescribed minimum benefit (PMB) condition and therefore each medical scheme used its own approach to providing its beneficiaries with some or no benefits for ADHD. It was evident that ADHD was underfunded and lacked structured or standardised funding approaches.

Conclusion

Attention deficit hyperactivity disorder is underfunded in the private healthcare sector in South Africa. Better funding models are needed or ADHD needs to be registered as a PMB condition.

Contribution

Findings from this study highlight the urgency for structured and sufficient ADHD-specific funding by medical schemes. Considerations based on these findings may be applied in the National Health Insurance and in other countries around the world.

Developmental signs of ADHD and autism: a prospective investigation in 3623 children

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are neurodevelopmental disorders with an early onset. Guidelines recommend a careful evaluation of developmental history when assessing the disorders, but it is unclear how children with ADHD and ASD differ from their peers growing up. In this study, physical, family, psychological, social, and educational information were examined in 3623 ethnically diverse children that were prospectively followed from birth to age 15 as part of the Fragile Families and Child Wellbeing Study. Fifteen-thousand variables were screened, and 506 variables included in the final analyses. Accuracy of the most indicative information to predict ADHD and ASD diagnoses in adolescence was evaluated. Adolescents with ADHD (n = 627) and ASD (n = 91) differed from their peers on a plethora of developmental signs, with signs closely related to the core symptoms of the disorders after age 5 being most indicative of the disorders. Predictive models correctly identified 66% of individuals with ADHD and 81% of those with ASD, but 62-88% of identified cases were false positives. The mean proportion of developmental deviations was 18.7% in the ADHD group, 20.0% in the ASD group, and 15.6% in peers; youth with both ADHD and ASD (n = 50) deviated on 21.8% of all developmental signs and had more pronounced deviations than those with ADHD or ASD alone. ADHD and ASD are characterized by broad and non-specific developmental deviations. Developmental information alone cannot be used to accurately predict diagnostic status in adolescence and false positives are likely if the diagnostic process relies heavily on such information. Developmental deviations are part of normal development and common in children without ADHD and ASD. Etiological heterogeneity and considerable temporal fluctuation in the core characteristics of ADHD and ASD may explain the lack of distinct developmental patterns.

The Relationship Between Cortical Thickness and Executive Function Measures in Children With and Without ADHD

OBJECTIVE

Attention Deficit Hyperactivity Disorder (ADHD) is characterized by inattention, hyperactivity, and impulsivity; however, other executive function dysregulation is common, including inhibition and working memory. This study aims to identify CT differences based on executive function performance in individuals with and without ADHD.

METHODS

Data for this study was acquired from the Adolescent Brain and Cognitive Development (ABCD) database (61 ADHD, and 61 age and sex matched controls). General linear models were used to assess relationships between measures, CT, and diagnosis.

RESULTS

We found a significant relation between CT and working memory scores in the right precentral area. Additionally, we found significant interactions between CT, diagnosis, and measure outcome in the Flanker assessment (in the left fusiform area) and the attention score of the CBCL (in the right precentral region).

CONCLUSION

This suggests that there may be different relationships that exist between CT and executive function in children with ADHD.

Infant sleep predicts trajectories of social attention and later autism traits

BACKGROUND

Children with neurodevelopmental disorders including autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) often experience sleep disturbances, but little is known about when these sleep differences emerge and how they relate to later development.

METHODS

We used a prospective longitudinal design in infants with a family history of ASD and/or ADHD to examine infant sleep and its relation to trajectories of attention and later neurodevelopmental disorders. We formed factors of Day and Night Sleep from parent-reported measures (including day/night sleep duration, number of naps in the day, frequency of night awakenings and sleep onset problems). We examined sleep in 164 infants at 5-, 10- and 14-months with/without a first-degree relative with ASD and/or ADHD who underwent a consensus clinical assessment for ASD at age 3.

RESULTS

By 14-months, infants with a first-degree relative with ASD (but not ADHD) showed lower Night Sleep scores than infants with no family history of ASD; lower Night Sleep scores in infancy were also associated with a later ASD diagnosis, decreased cognitive ability, increased ASD symptomatology at 3-years, and developing social attention (e.g., looking to faces). We found no such effects with Day Sleep.

CONCLUSIONS

Sleep disturbances may be apparent at night from 14-months in infants with a family history of ASD and also those with later ASD, but were not associated with a family history of ADHD. Infant sleep disturbances were also linked to later dimensional variation in cognitive and social skills across the cohort. Night Sleep and Social Attention were interrelated over the first 2 years of life, suggesting that this may be one mechanism through which sleep quality influences neurodevelopment. Interventions targeted towards supporting families with their infant's sleep problems may be useful in this population.

Exploring Co-Regulation-Related Factors in the Mothers of ADHD Children-Proof of Concept Study

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a complex neurological condition interfering with family relationships and co-regulation capabilities. Therefore, exploring factors underpinning parental co-regulation ability is crucial for future fostering relationships in families of children with ADHD.

OBJECTIVE

This preliminary study aims to characterize and compare the executive-functions, anxiety, self-efficacy, and sensory modulation in mothers of children with and without ADHD.

METHOD

Mothers of children with (study group) and without (control-comparison, group) ADHD completed online self-reports, measuring executive-functions; parental self-efficacy; anxiety; and sensory modulation.

RESULTS

The study group (N = 40) had lower self-efficacy compared to the control group (N = 27; p = 0.018), and the control group had lower sensory responsiveness (p = 0.025). Within both groups the Behavior Rating Inventory of Executive Function-Adult (BRIEF-A) Global Executive Function Composite score (GEC) and the Beck Anxiety Inventory (BAI) were moderately correlated. Further, within the study group correlations were found between the BRIEF-A-GEC and the Sensory Responsiveness Questionnaire (SRQ)-Aversive scores (r = 0.37, p ≤ 0.01), and between the BRIEF-A Behavioral-Rating-Index and the parental self-efficacy scores (r = 0.31, p ≤ 0.05). Within the control group, negative correlations were found between the BRIEF-A-GEC and SRQ-Hedonic scores (r= -0.44, p < 0.05).

CONCLUSION

Self-efficacy, executive-functions, high sensory responsiveness and anxiety traits are interwoven and may impact parental co-regulation ability.

Lack of functional brain connectivity was associated with poor inhibition in children with attention-deficit/hyperactivity disorder using near-infrared spectroscopy

Objectives

The present study aimed to evaluate the characteristics of functional brain connectivity in the resting state in children with attention deficit hyperactivity disorder (ADHD) and to assess the association between the connectivity and inhibition function using near-infrared spectroscopy (NIRS).

Methods

In total, 34 children aged 6-13 diagnosed with ADHD were recruited from Hangzhou Seventh People's Hospital. In comparison, 37 healthy children were recruited from a local primary school as controls matched by age and sex. We used NIRS to collect information on brain images. The Stroop test assessed inhibition function. We compared the differences in functional brain connectivity in two groups by analyzing the resting-state brain network. Pearson partial correlation analysis was applied to evaluate the correlation between functional brain connectivity and inhibition in all the children.

Results

Compared with the control group, results of NIRS images analysis showed that children with ADHD had significantly low functional brain connectivity in regions of the orbitofrontal cortex, left dorsolateral prefrontal cortex, left pre-motor and supplementary motor cortex, inferior prefrontal gyrus, and right middle temporal gyrus (p = 0.006). Inhibition function of children with ADHD was negatively correlated with functional brain connectivity (p = 0.009), while such correlation was not found in the control group.

Conclusion

The present study demonstrated that children with ADHD had relatively low connectivity in several brain regions measured at the resting state. Our results supported the evidence that lack of functional brain connectivity was associated with impaired inhibition function in children with ADHD.

Attention-deficit/hyperactivity disorder in children with hearing loss

OBJECTIVE

To evaluate rates of Attention-Deficit/Hyperactivity Disorder (AD/HD) diagnosis among pediatric patients with normal hearing (NH) and hearing loss (HL) with and without comorbidities.

STUDY DESIGN

Retrospective cohort study of NH and HL patients following chart review of all pediatric patients with a history of tympanostomy tube placement treated at the Cleveland Clinic Foundation between 2019 and 2022.

METHODS

Patient demographic information, hearing status (type of HL, laterality, severity), and comorbidities including prematurity, genetic syndromes, disorders with neurological impairment, and autism spectrum disorder (ASD) were collected. Rate of AD/HD amongst HL and NH cohorts with and without comorbidities were compared using Fisher's exact test. Covariate-adjusted analysis was also completed (sex, current age, age at tube placement, and OSA). The primary outcome of interest was rates of AD/HD among children with NH and HL, and the secondary outcome of interest was the impact of comorbidities on rates of AD/HD diagnosis in these cohorts.

RESULTS

Of the 919 screened patients between 2019 and 2022, there were 778 NH patients and 141 HL patients (80 bilateral, 61 unilateral). HL ranged from mild (n = 110) to moderate (n = 21) to severe/profound (n = 9). Overall, the rate of AD/HD was significantly higher in HL children (12.1% HL vs 3.6% NH, p < 0.001). Of the 919 patients, 157 had comorbidities. In children without comorbidities, HL children still had significantly higher rates of AD/HD compared to NH children (8.0% vs 1.9%, p = 0.02), but there was loss of significance after covariate adjustment (p = 0.72).

CONCLUSION

The rate of AD/HD among children with HL (12.1%) is higher than the rate of AD/HD in NH children (3.6%), consistent with previous findings. After excluding patients with comorbidities and adjusting for covariates, there are similar rates of AD/HD between HL and NH patients. Given high rates of comorbidities and AD/HD in HL patients and potential for augmented developmental challenges, clinicians should have a low threshold to refer children with HL for neurocognitive testing, particularly those with any of the comorbidities or covariates described in this study.

d-Amphetamine Transdermal System in Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: Secondary Endpoint Results and Post Hoc Effect Size Analyses from a Pivotal Trial

Objectives: Amphetamines are a preferred treatment for attention-deficit/hyperactivity disorder (ADHD), with the dextroamphetamine transdermal system (d-ATS) providing an alternative to oral formulations. A pivotal trial of d-ATS in children and adolescents with ADHD met primary and key secondary endpoints. This analysis reports additional endpoints and safety findings from the pivotal trial and evaluates effect size and number needed to treat (NNT) for d-ATS. Methods: In this study, a 5-week, open-label dose-optimization period (DOP) preceded a 2-week, randomized, crossover double-blind treatment period (DBP). Eligible patients received d-ATS 5 mg during the DOP, with weekly evaluations for increase to 10, 15, and 20 mg (equivalent to labeled doses of 4.5, 9, 13.5, and 18 mg/9 hours, respectively) until reaching and maintaining the optimal dose, which was utilized for the DBP. Secondary endpoints included assessment of Attention-Deficit/Hyperactivity Disorder Rating Scale IV (ADHD-RS-IV), Conners' Parent Rating Scale Revised Short Form (CPRS-R:S), and Clinical Global Impression (CGI) scores. NNT was calculated for ADHD-RS-IV and CGI-Improvement (CGI-I). Safety assessments included treatment-emergent adverse events (TEAEs) and dermal safety. Results: In total, 110 patients entered the DOP, with 106 patients randomized (DBP). During the DBP, the least-squares mean (95% confidence interval) difference for d-ATS versus placebo in ADHD-RS-IV total score was -13.1 (-16.2 to -10.0; p < 0.001), with effect size of 1.1 and NNT of 3 for ADHD-RS-IV remission, ≥30% improvement, and ≥50% improvement. Significant differences between placebo and d-ATS were also observed for CPRS-R:S and CGI-I scales (p < 0.001), with NNT of 2 for CGI-I response. Most TEAEs were mild or moderate, with three leading to study discontinuation in the DOP and none in the DBP. No patients discontinued due to dermal reactions. Conclusions: d-ATS was effective in treating ADHD in children and adolescents, meeting all secondary endpoints, with a large effect size and NNT of 2-3 to achieve a clinically meaningful response. d-ATS was safe and well tolerated, with minimal dermal reactions. Clinical Trial Registration: NCT01711021.

Discrimination of Borderline Personality Disorder (BPD) and Attention-Deficit/Hyperactivity Disorder (ADHD) in adolescents: Spanish version of the Borderline Personality Features Scale for Children-11 Self-Report (BPFSC-11) Preliminary results

BACKGROUND

Although the diagnosis of Borderline Personality Disorder (BPD) during adolescence has been questioned, many recent studies have confirmed its validity. However, some clinical manifestations of BPD could be identifiable in adolescents with other pathologies, such as Attention-Deficit/Hyperactivity Disorder (ADHD). The objective of the present study is to examine the capacity of the self-report Borderline Personality Features Scale Children-11 (BPFSC-11) to discriminate between BPD and ADHD adolescents.

METHODS

One hundred and forty-five participants were grouped based on their diagnosis: 58 with BPD, 58 with ADHD, and 29 healthy volunteers as a control group. Between-group differences and the ROC curve were performed to test if the total score for the BPFSC-11 and/or its factors can significantly discriminate between BPD and other adolescent groups.

RESULTS

The results show that the total BPFSC-11 score has good discriminant capacity among adolescents diagnosed with BPD, ADHD and healthy volunteers. However, different patterns of discriminative capacity were observed between the three groups for emotional dysregulation and impulsivity/recklessness factors.

CONCLUSIONS

Our results support the hypothesis that the BPFSC-11 is an adequate instrument for discriminating between BPD and ADHD in adolescents, who can present significant psychopathological overlap. Tools to identify BPD in adolescence, as well as for better differential diagnosis, would improve the possibility of offering specific treatments targeting these populations.

Alterations in the Glycan Composition of Serum Glycoproteins in Attention-Deficit Hyperactivity Disorder

Changes in protein glycosylation are associated with most biological processes, and the importance of glycomic analysis in the research of disorders is constantly increasing, including in the neurodevelopmental field. We glycoprofiled sera in 10 children with attention-deficit hyperactivity disorder (ADHD) and 10 matching healthy controls for 3 types of samples: whole serum, sera after depletion of abundant proteins (albumin and IgG), and isolated IgG. The analytical methods used were a lectin-based glycoprotein microarray enabling high-throughput glycan analysis and matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) as a standard method for the identification of glycan structures. For microarray analysis, the samples printed on microarray slides were incubated with biotinylated lectins and detected using the fluorescent conjugate of streptavidin by a microarray scanner. In the ADHD patient samples, we found increased antennary fucosylation, decreased di-/triantennary N-glycans with bisecting N-acetylglucosamine (GlcNAc), and decreased α2-3 sialylation. The results obtained by both independent methods were consistent. The study's sample size and design do not allow far-reaching conclusions to be drawn. In any case, there is a strong demand for a better and more comprehensive diagnosis of ADHD, and the obtained results emphasize that the presented approach brings new horizons to studying functional associations of glycan alterations in ADHD.

Screening of attention deficit hyperactivity disorder among preschool children Gharbia Governorate, Egypt

BACKGROUND

Children who experience mental health issues, such as attention deficit hyperactivity disorder (ADHD), experience significant distress and impairment at home, at school, and in the community. Without adequate care or prevention, this frequently results in adulthood-long distress and impairment at large societal costs. Determining the prevalence of ADHD cases among preschoolers as well as some associated maternal and child risk factors was the aim of this study.

METHODS

An analytical cross-sectional study including 1048 preschool children aged 3-6 years was carried out in Tanta City, Gharbia Governorate. From March to April 2022, a proportionate stratified cluster random sample of them was picked. Data were gathered using a predesigned instrument that included sociodemographic information, family history, maternal and child risk factors, and the Arabic version of the ADHD Rating Scale IV questionnaire.

RESULTS

The prevalence of ADHD among preschoolers was 10.5%. The inattention type was the most common (5.3%), followed by the hyperactivity type (3.4%). There were statistically significant associations regarding positive family history of psychological and neurological symptoms (17.9% positive vs. 9.7% negative), family history of ADHD symptoms (24.5% positive vs. 9.4% negative), active smoking by the mother (21.1% positive vs. 5.3% negative), cesarean section delivery (66.4% positive vs. 53.9% negative), elevated blood pressure during pregnancy (19.1% positive vs. 12.4% negative), and history of taking drugs during pregnancy (43.6% positive vs. 31.7% negative). Significant child risk factors were: exposure to any source containing lead that causes slow poisoning (25.5% positive vs. 12.3% negative), children with cardiac health problems (38.2% positive vs. 16.6% negative), and hours spent by a child in front of the TV or mobile phone (any screens) per day (60.0% of those with positive screening spent more than 2 h/day vs. 45.7% negative).

CONCLUSION

In the Gharbia governorate, 10.5% of preschoolers suffer from ADHD. Significant maternal risk factors for ADHD included a positive family history of psychiatric and neurological symptoms, a family history of ADHD symptoms, active maternal smoking, caesarean section delivery, increased blood pressure during pregnancy, and a history of drug use during pregnancy. Youngsters who had cardiac health issues and who spent more time each day watching TV or using a mobile device (screen use) were at substantial risk.

Patient visits and prescriptions for attention-deficit/hyperactivity disorder from 2017-2021: Impacts of COVID-19 pandemic in primary care

OBJECTIVE

To determine whether more patients presented with Attention-deficit/hyperactivity disorder (ADHD)-related visits and/or sought care from family physicians more frequently during the COVID-19 pandemic.

METHODS

Electronic medical records from the University of Toronto Practice-Based Research Network were used to characterize changes in family physician visits and prescriptions for ADHD medications. Annual patient prevalence and visit rates pre-pandemic (2017-2019) were used to calculate the expected rates in 2020 and 2021. The expected and observed rates were compared to identify any pandemic-related changes.

RESULTS

The number of patients presenting for ADHD-related visits during the pandemic was consistent with pre-pandemic trends. However, observed ADHD-related visits in 2021 were 1.32 times higher than expected (95% CI: 1.05-1.75), suggesting that patients visited family physicians more frequently than before the pandemic.

CONCLUSION

Demand for primary care services related to ADHD has continued to increase during the pandemic, with increased health service use among those accessing care.

Higher treatment focus diffusion in Multisystemic Therapy is associated with less functional improvement over the course of treatment

PURPOSE

Treatment focus diffusion (TFD), dividing focus across multiple concerns during treatment, is common in public mental health care and differs from the more narrowly focused empirically supported treatments for youth reported in the literature. The present study examined whether and to what extent TFD is associated with youth functional improvement over the course of therapy.

METHOD

This study utilized multi-level modeling techniques to analyze 12 consecutive years of standardized routine clinical service data from youth receiving treatment in one of two intensive in-home service settings: (a) Multisystemic Therapy (MST; n = 776 youths, 99 therapists), an implemented evidence-based treatment based on ecological theories of behavior in which therapists work with the multiple systems a youth interacts with (school, community, family), and (b) a standards-based service (n = 1854 youth, 413 therapists). Both service settings operate in the context of a publicly funded mental health care system which serves youth and families who are typically from underserved and low-income backgrounds. Majority of youth in this sample identified as multi-ethnic and male, and they, on average, were approximately 13 years old with three co-occurring diagnoses.

RESULTS

A significant TFD by service format interaction on youth functional improvement (alone and in the overall model) and follow up simple effects indicated that higher TFD was associated with significantly poorer outcomes in MST. The parameter estimate for TFD on functional improvement in the standards-based service format was in the same direction, but not statistically significant.

CONCLUSION

Our findings suggest that maintaining a narrower treatment focus might be beneficial to clients, particularly in implemented evidence-based treatments. Likewise, TFD could be a helpful case monitoring tool for clinicians, supervisors, and systems leaders when reviewing intensive-in-home cases.

Incremental Validity of Multi-Method and Multi-Informant Evaluations in the Clinical Diagnosis of Preschool ADHD

OBJECTIVES

This study investigated the discriminative validity of various single or combined measurements of electroencephalogram (EEG) data, Conners' Kiddie Continuous Performance Test (K-CPT), and Disruptive Behavior Disorder Rating Scale (DBDRS) to differentiate preschool children with ADHD from those with typical development (TD).

METHOD

We recruited 70 preschoolers, of whom 38 were diagnosed with ADHD and 32 exhibited TD; all participants underwent the K-CPT and wireless EEG recording in different conditions (rest, slow-rate, and fast-rate task).

RESULTS

Slow-rate task-related central parietal delta (1-4 Hz) and central alpha (8-13 Hz) and beta (13-30 Hz) powers between groups with ADHD and TD were significantly distinct (p < .05). A combination of DBDRS, K-CPT, and specific EEG data provided the best probability scores (area under curve = 0.926, p < .001) and discriminative validity to identify preschool children with ADHD (overall correct classification rate = 85.71%).

CONCLUSIONS

Multi-method and multi-informant evaluations should be emphasized in clinical diagnosis of preschool ADHD.

A Paradigm for Targeting Functional Impairment as an Outcome in Attention-Deficit/Hyperactivity Disorder

Although functional impairment is required for a diagnosis in the DSM 5, the time frame and definition of functional impairment is ambiguous. We present a conceptual review clarifying the difference between functional impairment as a stable trait representing strength or disability in various domains, and functional impairment as secondary to emotional or behavior problems, which is a state sensitive to change with treatment intervention. Functional impairment as a measure of treatment outcome includes both change from baseline and status at the endpoint of treatment. When using a validated measure of function, functional improvement can be defined as the percentage of patients who achieve the Minimal Important Clinical Difference (MCID) and functional remission as the percentage of patients who normalize at treatment endpoint. True treatment remission should be defined as both symptomatic and functional remission.

Atypical functional connectivity during rest and task-related dynamic alteration in young children with attention deficit hyperactivity disorder: An analysis using the phase-locking value

AIM

The study investigated the electroencephalography (EEG) functional connectivity (FC) profiles during rest and tasks of young children with attention deficit hyperactivity disorder (ADHD) and typical development (TD).

METHODS

In total, 78 children (aged 5-7 years) were enrolled in this study; 43 of them were diagnosed with ADHD and 35 exhibited TD. Four FC metrics, coherence, phase-locking value (PLV), pairwise phase consistency, and phase lag index, were computed for feature selection to discriminate ADHD from TD.

RESULTS

The support vector machine classifier trained by phase-locking value (PLV) features yielded the best performance to differentiate the ADHD from the TD group and was used for further analysis. In comparing PLVs with the TD group at rest, the ADHD group exhibited significantly lower values on left intrahemispheric long interelectrode lower-alpha and beta as well as frontal interhemispheric beta frequency bands. However, the ADHD group showed higher values of central interhemispheric PLVs on the theta, higher-alpha, and beta bands. Regarding PLV alterations within resting and task conditions, left intrahemispheric long interelectrode beta PLVs declined from rest to task in the TD group, but the alterations did not differ in the ADHD group. Negative correlations were observed between frontal interhemispheric beta PLVs and the Disruptive Behavior Disorder Rating Scale as rated by teachers.

CONCLUSIONS

These results, which complement the findings of other sparse studies that have investigated task-related brain FC dynamics, particularly in young children with ADHD, can provide clinicians with significant and interpretable neural biomarkers for facilitating the diagnosis of ADHD.

Social gradients in ADHD by household income and maternal education exposure during early childhood: Findings from birth cohort studies across six countries

Objective

This study aimed to examine social gradients in ADHD during late childhood (age 9–11 years) using absolute and relative relationships with socioeconomic status exposure (household income, maternal education) during early childhood (<5 years) in seven cohorts from six industrialised countries (UK, Australia, Canada, The Netherlands, USA, Sweden).

Methods

Secondary analyses were conducted for each birth cohort. Risk ratios, pooled risk estimates, and absolute inequality, measured by the Slope Index of Inequality (SII), were estimated to quantify social gradients in ADHD during late childhood by household income and maternal education measured during early childhood. Estimates were adjusted for child sex, mother age at birth, mother ethnicity, and multiple births.

Findings

All cohorts demonstrated social gradients by household income and maternal education in early childhood, except for maternal education in Quebec. Pooled risk estimates, relating to 44,925 children, yielded expected gradients (income: low 1.83(CI 1.38,2.41), middle 1.42(1.13,1.79), high (reference); maternal education: low 2.13(1.39,3.25), middle 1.42(1.13,1.79)). Estimates of absolute inequality using SII showed that the largest differences in ADHD prevalence between the highest and lowest levels of maternal education were observed in Australia (4% lower) and Sweden (3% lower); for household income, the largest differences were observed in Quebec (6% lower) and Canada (all provinces: 5% lower).

Conclusion

Findings indicate that children in families with high household income or maternal education are less likely to have ADHD at age 9–11. Absolute inequality, in combination with relative inequality, provides a more complete account of the socioeconomic status and ADHD relationship in different high-income countries. While the study design precludes causal inference, the linear relation between early childhood social circumstances and later ADHD suggests a potential role for policies that promote high levels of education, especially among women, and adequate levels of household income over children’s early years in reducing risk of later ADHD.

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most prevalent neurobehavioral disorder in childhood. The major components of this disorder are developmentally inappropriate levels of inattention and hyperactivity/impulsivity, which result in functional impairment in 1 or more areas of academic, social, and emotional function. In addition to the propensity for children to have some compromise of academic and emotional function, children with ADHD also have a higher frequency of co-occurring learning, cognitive, language, motor, and mental health disorders. Similarly, children with developmental disorders have a higher risk of co-occurring ADHD. The diagnosis of ADHD can be ascertained by a review of the risks for the condition, consideration of masquerading conditions, a careful history and physical examination, and the recognition of co-occurring disorders. The signs and symptoms of co-occurring disorders and the management of ADHD differ across early childhood, middle childhood, and adolescence. Management is largely limited to behavioral and pharmacologic interventions, and it favors behavioral strategies in early childhood, pharmacologic and behavioral strategies in middle childhood, and pharmacologic interventions in adolescence. This article offers an approach to the evaluation, presentation, and management of ADHD with a focus on guiding primary care pediatricians.

Efficacy and Safety of Dextroamphetamine Transdermal System for the Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: Results from a Pivotal Phase 2 Study

Objectives: To assess efficacy and safety of the new Dextroamphetamine Transdermal System (d-ATS) to treat children and adolescents (aged 6-17 years) with attention-deficit/hyperactivity disorder (ADHD). Methods: In this phase 2, randomized, placebo-controlled study, 4 d-ATS patches of differing doses (5, 10, 15, and 20 mg) were evaluated. Patients began a 5-week, open-label, stepwise dose-optimization period in which they received a 5-mg d-ATS patch (applied to hip) for 9 hours. During weekly visits, patients were evaluated for possible adjustments to the next dose level based on efficacy and safety. Once at the optimal dose, that dose was maintained during a 2-week, crossover double-blind treatment period. Primary endpoint was to assess efficacy of d-ATS versus placebo as measured by Swanson, Kotkin, Agler, M-Flynn, and Pelham Scale (SKAMP) total score; key secondary endpoints included assessing onset and duration of efficacy by SKAMP total score, and additional secondary endpoints included Permanent Product Measure of Performance (PERMP) scores. Safety was assessed throughout. Results: d-ATS treatment resulted in significant improvements versus placebo in ADHD symptoms as measured by SKAMP total score, with overall least-squares mean difference (95% confidence interval) versus placebo of -5.87 (6.76, -4.97; p < 0.001) over the 12-hour assessment period. Onset of efficacy was observed at 2 hours postdose (p < 0.001), and duration of effect continued through 12 hours (patch removed at 9 hours), with significant differences between d-ATS and placebo at all time points from 2 hours onward (all p ≤ 0.003). Significant improvements versus placebo in PERMP-A and PERMP-C scores were also observed from 2 to 12 hours postdose with d-ATS treatment. d-ATS was safe and well-tolerated, with a systemic safety profile similar to that observed with oral amphetamines. Conclusions: This study demonstrates that d-ATS is an effective and well-tolerated treatment for children and adolescents with ADHD. These data indicate that d-ATS can deliver sustained levels of efficacy along with the advantages of transdermal drug delivery, making it a beneficial new treatment option. Clinical Trial Registration no.: NCT01711021.

Childhood ADHD, Going Beyond the Brain: A Meta-Analysis on Peripheral Physiological Markers of the Heart and the Gut

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common neurodevelopmental disorder diagnosed in children. Questions regarding its increased diagnostic rates and pharmacological treatments in developing children have led to a more holistic review of the multi-system pathophysiology observed in ADHD. The dopaminergic neurotransmitter system, known for its influence on reward-motivated behaviors and motor control, and the frontostriatal systems, that mediate motor, cognition, and behavior, are associated with ADHD's development. However, studies have shown that these neural systems do not wholly account for ADHD's multilayered and heterogeneous symptom presentation. For instance, the literature suggests that emotional dysregulation, the inability to regulate one's emotional responses to provoking stimuli, is associated with increased risk for social impairment in ADHD. A broader examination of physiological systems in children with ADHD has found potential markers in the heart-brain and gut-brain axes that correspond with certain behaviors associated with emotional dysregulation in recent studies. Hence, the purpose of this meta-analysis is to aggregate ten applicable published case studies and analyze task-related heart rate reactivity (HRR; n = 5 studies) and gut microbiota (n = 5 studies) data in children with and without ADHD. Data from a total of 531 youth with ADHD and 603 youth without ADHD revealed significant small and medium effect sizes for higher Chao1 levels and Actinobacteria levels in the ADHD group, respectively, but no evidence of altered task-related HRR. Thus, further research into multi-system psychophysiological measures of emotional dysregulation and ADHD is warranted. The clinical, empirical, and educational implications of these findings are discussed.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier PROSPERO (CRD42021236819).

Automated classification of attention deficit hyperactivity disorder and conduct disorder using entropy features with ECG signals

BACKGROUND

The most prevalent neuropsychiatric disorder among children is attention deficit hyperactivity disorder (ADHD). ADHD presents with a high prevalence of comorbid disorders such as conduct disorder (CD). The lack of definitive confirmatory diagnostic tests for ADHD and CD make diagnosis challenging. The distinction between ADHD, ADHD + CD and CD is important as the course and treatment are different. Electrocardiography (ECG) signals may become altered in behavioral disorders due to brain-heart autonomic interactions. We have developed a software tool to categorize ADHD, ADHD + CD and CD automatically on ECG signals.

METHOD

ECG signals from participants were decomposed using empirical wavelet transform into various modes, from which entropy features were extracted. Robust ten-fold cross-validation with adaptive synthetic sampling (ADASYN) and z-score normalization were performed at each fold. Analysis of variance (ANOVA) technique was employed to determine the variability within the three classes, and obtained the most discriminatory features. Highly significant entropy features were then fed to classifiers.

RESULTS

Our model yielded the best classification results with the bagged tree classifier: 87.19%, 87.71% and 86.29% for accuracy, sensitivity and specificity, respectively.

CONCLUSION

The proposed expert system can potentially assist mental health professionals in the stratification of the three classes, for appropriate intervention using accessible ECG signals.

The Interventions for Sleep Disorders in Children with Attention Deficit and Hyperactivity Disorder: A Narrative Review

BACKGROUND: Attention deficit and hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in childhood. Children with ADHD have more frequent comorbid sleep disorders than healthy children. The current methods of treating sleep disorders in ADHD children are still focused on pharmacological interventions which in fact only provide little benefit. AIM: This study aims to identify existing studies regarding the types of nonpharmacological and complementary interventions for sleep disorders in children with ADHD using a narrative review approach. METHODS: This was a narrative review. Inclusion criteria included articles in English and Bahasa, full-text articles, primary studies, and children with ADHD aged 18 years with or without comorbidities as the research sample, and the article having been published in the last 10 years. Searches were performed in several databases: PubMed, Springer, Web of Science, and Google Scholar. RESULTS: The result showed that programs for managing sleep disorder in ADHD are behavioral therapy, behavioral parent training (BPT), behavioral sleep intervention, neurofeedback, mind-body therapy, L-theanine supplementation, horse milk supplementation, and play therapy. The programs are found to be effective in improving sleep. CONCLUSION: The program most comprehensive with a high level of ease of implementation was BPT.

A program to improve the assessment of a child for attention deficit hyperactivity disorder

PROBLEM

Due to the number of children diagnosed with attention deficit hyperactivity disorder (ADHD), increased risk of these children having comorbidities and/or an adverse childhood experience and insufficient documentation of the Diagnostic and Statistical manual of Mental Disorders, fifth edition (DSM-5) criteria for an ADHD diagnosis, an ADHD evaluation program was developed for a child presenting for an initial ADHD evaluation.

METHODS

A quantitative design method evaluated provider's documentation by the percentage of DSM-5 criteria met before and after the implementation of the ADHD program. Descriptive statistics evaluated the system change by the percentage of providers who utilized the ADHD template and the use of the unspecified ADHD International Statistical Classification of Diseases and Related Health Problems, 10th edition (ICD-10) code, F90.9 by the percentage of code use before and after implementation of the ADHD program.

FINDINGS

The two-tailed Mann-Whitney U test was significantly based on p < 0.001. Providers met 100% of the DSM-5 criteria after implementation of the ADHD program in the electronic health record, compared to 50% before implementation.

CONCLUSIONS

The ADHD program increased the provider's documentation and consistency to the DSM-5 criteria, decreasing the use of the unspecified ADHD ICD-10 code, allowing the provider to develop a more successful plan of care for children between the ages of 5 and 18.

Assessment, diagnosis, and management of developmental coordination disorder

Developmental coordination disorder (DCD) is a neurodevelopmental condition that affects 5% to 6% of school-aged children. DCD can significantly impact early development and life-long functioning. Evidence supports promising interventions for DCD, but the disorder continues to be under-recognized and under-diagnosed. Paediatricians play an important role in the identification and management of DCD. This practice point, with accompanying tables, assists and supports paediatricians in diagnosing and managing uncomplicated cases of DCD.

Three-dimensional analysis of upper airway and craniofacial morphology in orthodontic adolescents with Attention Deficit Hyperactivity Disorder (ADHD): A comparative retrospective study

PURPOSE

The aim of this study is to evaluate craniofacial characteristics and upper airway morphology in adolescents with Attention Deficit Disorder with Hyperactivity (ADHD) compared to controls (CON).

MATERIALS AND METHODS

Records from July 2014 to May 2018 of patients who were seeking orthodontic treatment at a single institute and had full pre-treatment orthodontic records including cone-beam computed tomography (CBCT) were reviewed. Comprehensive cephalometric variables were measured to determine craniofacial morphology. Upper airway volume (UAV), minimum cross-sectional area (MCA), and linear measurements were calculated at multiple planes.

RESULTS

A total of 87 adolescents (ADHD, 29; CON, 58) were included in the study. Overall, UAV and MCA in ADHA group were smaller than CON. Statistical significance was evident in airway widths at planes A (P=0.002), C (P=0.042), and D (P<0.001), and airway area at plane D (lower hypopharynx) (P<0.001), with the ADHD group showing narrower widths and area compared to CON. The most common skeletal classification in the ADHD group was sequenced as Class II, Class I then Class III, with percentages of (58.6%), (31%) and (10.3%), respectively. No significant differences were found between the groups for any of the skeletal, dental, and soft tissue cephalometric variables.

CONCLUSIONS

ADHD affected adolescents have similar craniofacial characteristics, but narrower upper airway dimensions compared to controls. Further investigations with larger samples are warranted to further elucidate the relationship between SDB and ADHD.

WISC-IV performance of children with Chronic Tic Disorder, Obsessive-Compulsive Disorder and Attention-Deficit/Hyperactivity Disorder: results from a German clinical study

BACKGROUND

Chronic Tic Disorder (CTD), Obsessive-Compulsive Disorder (OCD) and Attention-Deficit/Hyperactivity Disorder (ADHD) are complex neuropsychiatric disorders that frequently co-occur. The aim of this study was to examine WISC-IV performance of a clinical cohort of children with CTD, OCD and/or ADHD.

METHODS

N = 185 children aged 6 to 17 years from Germany with CTD, OCD and/or ADHD were examined with the WISC-IV that comprises four index scores (VCI: Verbal Comprehension Index, PRI: Perceptual Reasoning Index, WMI: Working Memory Index, PSI: Processing Speed Index) and a Full Scale Intelligence Quotient (FSIQ). WISC-IV profiles of children with CTD-only, OCD-only, ADHD-only, CTD+ADHD, CTD+OCD and CTD+OCD+ADHD were compared with the WISC-IV norm (N = 1650, M = 100 and SD = 15) and among each other.

RESULTS

Unpaired t-tests revealed that children with ADHD-only showed significant lower PSI scores, whereas children with CTD-only and OCD-only had significant higher VCI scores as compared to the German WISC-IV norm. One-way ANOVA revealed that children with ADHD-only showed significant lower WMI scores as compared to children with CTD+OCD.

CONCLUSIONS

We were able to confirm previous evidence on WISC-IV profiles in ADHD in a German clinical sample and contribute new findings on cognitive performance in children with (non-)comorbid CTD and OCD that have to be seen in light of the study's limitations.

Neural Dynamics for Facilitating ADHD Diagnosis in Preschoolers: Central and Parietal Delta Synchronization in the Kiddie Continuous Performance Test

The present study aimed to characterize children at risk of attention-deficit/hyperactivity disorder (ADHD) during preschool age and provide early intervention. The continuous performance test (CPT) and electroencephalography (EEG) can contribute additional valuable information to facilitate diagnosis. This study measured brain dynamics at slow and fast task rates in the CPT using a wireless wearable EEG and identified correlations between the EEG and CPT data in preschool children with ADHD. Forty-nine preschool children participated in this study, of which 29 were diagnosed with ADHD and 20 exhibited typical development (TD). The Conners Kiddie Continuous Performance Test (K-CPT) and wireless wearable EEG recordings were employed simultaneously. Significant differences were observed between the groups with ADHD and TD in task-related EEG spectral powers (central as well as parietal delta, P < 0.01), which were distinct only in the slow-rate task condition. A shift from resting to the CPT task condition induced overall alpha powers decrease in the ADHD group. In the task condition, the delta powers were positively correlated with the CPT perseveration scores, whereas the alpha powers were negatively correlated with specific CPT scores mainly on perseveration and detectability (P < 0.05). These results, which complement the findings of other sparse studies that have investigated within-task-related brain dynamics, particularly in preschool children, can assist specialists working in early intervention to plan training and educational programs for preschoolers with ADHD.

A Review of Working Memory Training in the Management of Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Working memory deficits underlie many of the behavioural symptoms of ADHD. Alongside psychostimulant medications, strategies to improve working memory may play an important adjuvant role in the management of ADHD. In this study, we review the role of working memory deficits in ADHD, the evidence surrounding working memory training strategies in the management of the condition, and the factors affecting the success of these strategies in alleviating ADHD symptoms. More specifically, we review several non-pharmacological interventions that target working memory deficits in ADHD, with special emphasis on cognitive working memory training. We conclude that the development of evidence-based interventions such as computerised cognitive training (CCT) could provide an alternative or adjunct to the use of psychostimulants, especially in cases where side effects are a major issue.

Cortisol response to acute psychosocial stress in ADHD compared to conduct disorder and major depressive disorder: A systematic review

BERNHARD, A., J. S. Mayer, N. Fann, and C. M. Freitag. Cortisol response to acute psychosocial stress in ADHD compared to Conduct Disorder and Major Depressive Disorder: A systematic review. NEUROSCI BIOBEHAV REV XX(X) XXX-XXX, 2020. - Heterogeneous alterations of the cortisol stress response in Attention-deficit/hyperactivity Disorder (ADHD) were recently reported by a systematic literature review. To investigate the moderating effect of frequent psychiatric comorbidities, we systematically searched for studies on cortisol stress response to psychosocial stress in ADHD compared to Conduct Disorder (CD) and Major Depressive Disorder (MDD) following PRISMA guidelines. EBSCOhost and PubMed databases were searched in July 2020, employing relevant keywords. Nineteen studies met inclusion criteria. While blunted cortisol stress response was consistently reported in individuals with CD and/or Oppositional Defiant Disorder (ODD), alterations of cortisol stress response were less pronounced in ADHD. Consistently blunted cortisol stress response in ADHD was only found in children with comorbid CD/ODD. Results on cortisol stress response in children and adolescents with MDD were mixed, and no indication for influence of comorbid MDD on cortisol stress response in ADHD was found. Taken together, altered cortisol stress response in ADHD is driven by comorbidity with disruptive behavior disorders. Limitations of previous research and suggestions for future studies are discussed.

Prevalence of ADHD and Its Comorbidities in a Population-Based Sample

Objective: We aimed to investigate the prevalence of ADHD and its comorbidities and some associated demographic factors in a large sample population-based study. Method: As part of a population-based survey among 30,532 children and adolescents between 6 and 18 years, we used K-SADS-PL to screen and detect ADHD and its comorbidities. Results: The prevalence of ADHD was 4%, with more prevalence among boys (5.2% vs. 2.7%), younger participants, urban residents, and offspring of mothers who had a history of psychiatric hospitalization. Anxiety disorders (37.9%) and behavioral disorders (31%) are the most prevalent group of comorbidities, and oppositional defiant disorder (ODD) is the most prevalent comorbid disorder (26.1%). Mood disorders and anxiety disorders are more common among girls, but conduct disorder has a higher rate among boys. Conclusion: ADHD is a common neurodevelopmental disorder which is accompanied by several comorbid conditions. The high rate of comorbidities makes it complicated and difficult to manage.

The Roles of Serotonin in Neuropsychiatric Disorders

The serotonergic system extends throughout the central nervous system (CNS) and the gastrointestinal (GI) tract. In the CNS, serotonin (5-HT, 5-hydroxytryptamine) modulates a broad spectrum of functions, including mood, cognition, anxiety, learning, memory, reward processing, and sleep. These processes are mediated through 5-HT binding to 5-HT receptors (5-HTRs), are classified into seven distinct groups. Deficits in the serotonergic system can result in various pathological conditions, particularly depression, schizophrenia, mood disorders, and autism. In this review, we outlined the complexity of serotonergic modulation of physiologic and pathologic processes. Moreover, we provided experimental and clinical evidence of 5-HT's involvement in neuropsychiatric disorders and discussed the molecular mechanisms that underlie these illnesses and contribute to the new therapies.

Medications for attention-deficit/hyperactivity disorder in individuals with or without coexisting autism spectrum disorder: analysis of data from the Swedish prescribed drug register

Background

Clinical studies found that medication for attention-deficit/hyperactivity disorder (ADHD) is effective in coexisting autism spectrum disorder (ASD), but current research is based on small clinical studies mainly performed on children or adolescents. We here use register data to examine if individuals with ADHD and coexisting ASD present differences in the prescribing patterns of ADHD medication when compared to individuals with pure ADHD.

Methods

Data with information on filled prescriptions and diagnoses was retrieved from the Swedish Prescribed Drug Register and the National Patient Register. We identified 34,374 individuals with pure ADHD and 5012 individuals with ADHD and coexisting ASD, aged between 3 and 80 years. The first treatment episode with ADHD medications (≥ 2 filled prescriptions within 90 days) and daily doses of methylphenidate during a 3-year period was measured. Odds ratios (ORs) were calculated for the likelihood of being prescribed ADHD medication in individuals with and without ASD and Wilcoxon rank-sum test was used to compare group differences in dose per day.

Results

Individuals with ADHD and coexisting ASD were less likely to start continuous treatment with ADHD medication (ADHD 80.5%; ADHD with ASD 76.2%; OR, 0.80; 95% confidence interval, 0.75-0.86), were less likely to be prescribed methylphenidate, and were more commonly prescribed second line treatments such as dexamphetamine, amphetamine, or modafinil. No group difference was observed for atomoxetine. In adults with ADHD and coexisting ASD, methylphenidate was prescribed in lower daily doses over three years as compared to individuals with pure ADHD.

Conclusions

The findings indicate that there are differences in the medical treatment of individuals with or without ASD. If these differences are due to different medication responses in ASD or due to other factors such as clinicians’ perceptions of medication effects in patients with ASD, needs to be further studied.

Supplementary Information

The online version contains supplementary material available at 10.1186/s11689-020-09352-z.

Adolescent Polypharmacy and Serotonin Syndrome

OBJECTIVES

The objective of this study was to present a case and review serotonin syndrome and the risk of occurrence in children and adolescents on multiple psychotropic medications.

METHODS

The clinical history of a patient in the University of South Florida's child and adolescent psychiatry clinic is presented. Literature review on serotonin syndrome, attention-deficit/hyperactivity disorder (ADHD), and psychostimulants was conducted through PubMed.

RESULTS/DISCUSSION

We have presented a case of possible serotonin-related abnormal movements in an adolescent girl prescribed stimulants and multiple serotonergic medications. Serotonin syndrome may be precipitated through drug interactions that increase serum levels of psychotropic medications. Patients with ADHD often have comorbid psychiatric illness requiring treatment with medication. Amphetamine salts are an often-overlooked agent that potentiates serotonin through monoamine oxidase inhibitor (MAO) inhibition and neurotransmitter release. Children and adolescents on multiple psychotropic medications should be closely monitored for the triad of altered mental status, neuromuscular abnormalities, and autonomic hyperactivity.

CONCLUSIONS

Patients with ADHD often have comorbid psychiatric illness and are treated with multiple psychotropic medications. Given the effects of drug-drug interactions and the serotonergic effects of psychostimulants, clinicians should remain vigilant for the triad of altered mental status, neuromuscular abnormalities, and autonomic hyperactivity seen in serotonin syndrome.

Dental malocclusion among children with attention deficit hyperactivity disorder

INTRODUCTION

Children with attention deficit hyperactivity disorder (ADHD) have more sleep breathing problems and parafunctional oral habits than individuals without ADHD. However, there is scarce information on the correlation between their dental malocclusion and these functional disorders. The objective of this study was to assess the severity of malocclusion in patients with and without ADHD and to evaluate the correlation between their functional disorders and dental malocclusion.

METHODS

Eighty-eight patients aged 6-17 years were divided into 2 groups: ADHD (n = 44) and control (n = 44). A medical questionnaire to assess functional disorders and an orthodontic examination to evaluate malocclusion were completed for each patient. Distribution of the data was evaluated using Shapiro-Wilk test, whereas the 2 groups were compared with a t test, Mann-Whitney U test, Fisher exact test, and Spearman correlation. The association between parafunctional oral habits, ADHD drug intake, and malocclusion severity were assessed with a t test and Mann-Whitney U test.

RESULTS

Patients with ADHD had significantly higher severity of malocclusion (P = 0.042), more dental rotation (P = 0.021) and more parafunctional oral habits (P = 0.001), specifically bruxism (P = 0.005), and a history of pacifier use (P = 0.009), than the control group.

CONCLUSIONS

It is important to be aware of the increased risk of parafunctional oral habits and dental malocclusion among ADHD patients to develop preventive programs, as well as therapeutic strategies for them.

Approach to diagnosis and management of childhood attention deficit hyperactivity disorder

OBJECTIVE

To provide primary care clinicians with an approach to the diagnosis and management of attention deficit hyperactivity disorder (ADHD) by reviewing and summarizing the relevant practice guidelines and recent evidence from the literature.

SOURCES OF INFORMATION

Published guidelines on the management of ADHD were reviewed. A PubMed search was conducted with the MeSH terms attention deficit disorder and family practice. Results were limited to articles published in English within the past 15 years.

MAIN MESSAGE

Attention deficit hyperactivity disorder is a common neurodevelopmental disorder. Guidelines agree that diagnosis and management of ADHD is appropriate within primary care. Attention deficit hyperactivity disorder is diagnosed by applying the criteria defined within the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, and is supplemented by validated rating scales. Behavioural management is first-line management in all patients, and stimulant medications are first-line management in patients 6 years of age and older. The Canadian ADHD Resource Alliance provides free resources to help clinicians care for patients with ADHD.

CONCLUSION

Most patients with ADHD can be managed by family physicians. It is a chronic condition that requires ongoing follow-up. Attention deficit hyperactivity disorder that is complicated by comorbidities might require referral to a specialist.

[Not Available]

Objectif

Proposer aux médecins de première ligne une approche diagnostique et de prise en charge du trouble déficitaire de l’attention avec hyperactivité (TDAH) en examinant et en résumant les lignes directrices pertinentes de pratique clinique et les données récentes relevées dans les publications scientifiques.

Sources d’information

Nous avons examiné les lignes directrices publiées sur la prise en charge du TDAH. Une recherche a été réalisée dans PubMed à l’aide des motsclés anglais attention deficit disorder et family practice. Les résultats étaient limités aux articles publiés en anglais au cours des 15 dernières années.

Message principal

Le trouble déficitaire de l’attention avec hyperactivité est un trouble neurodéveloppemental courant. Les lignes directrices s’entendent pour dire qu’il est approprié de poser un diagnostic et d’entreprendre la prise en charge du TDAH en première ligne. Le trouble déficitaire de l’attention avec hyperactivité est diagnostiqué en appliquant les critères définis dans le Manuel diagnostique et statistique des troubles mentaux, 5^e édition, qu’on complète avec les scores aux échelles validées. La prise en charge comportementale est l’intervention de première intention chez tous les patients, et les stimulants sont l’intervention de première intention chez les patients de 6 ans et plus. La Canadian ADHD Resource Alliance fournit gratuitement des ressources aux médecins pour les aider à soigner les patients atteints du TDAH.

Conclusion

La plupart des patients atteints du TDAH peuvent être pris en charge par les médecins de famille. Le TDAH est une affection chronique qui exige un suivi continuel. Les cas de trouble déficitaire de l’attention avec hyperactivité qui sont compliqués par des comorbidités pourraient nécessiter une recommandation à un spécialiste.

eMental Health Literacy and Knowledge of Common Child Mental Health Disorders among Parents of Preschoolers

The purpose of the study was to assess the eMental health literacy of parents of preschool children and explore the relationships between their eMental health literacy skills and their knowledge of common child mental health disorders and their child difficulties. Online survey data were collected using Mechanical Turk (MTurk). Parents of preschool children completed questionnaires related to internet-based mental health information seeking behavior, knowledge of common child mental health disorders using case vignettes, and child difficulties. Data were analyzed using descriptive statistical methods. eMental health literacy of parents was high but knowledge of the child mental health disorders was low. Only 14% of parents correctly identified all three disorders; 41.1% identified attention deficit hyperactivity disorder (ADHD), 64.9% recognized autism spectrum disorder (ASD), and 19.1% identified separation anxiety disorder (SAD). Parents with high eMental health literacy (≥30) were more likely to endorse professional help and seek information on how to manage problem behaviors for all three disorders. Parents with low eMental health literacy (<30) were more likely to have a child with a high risk of a mental health disorder. The findings will be used to inform educational initiatives on the use of online resources and recognition of child mental health disorders to promote early intervention and appropriate help seeking.

Association Between Greenness Surrounding Schools and Kindergartens and Attention-Deficit/Hyperactivity Disorder in Children in China

IMPORTANCE

Few studies have investigated the association between greenness and childhood attention-deficit/hyperactivity disorder (ADHD).

OBJECTIVE

To evaluate the association between greenness surrounding schools or kindergartens and symptoms of ADHD in children.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study was performed between April 2012 and January 2013 in 7 cities in northeastern China. This analysis included 59 754 children (aged 2-17 years) from 94 schools and kindergartens, who had resided in the study area for 2 years or longer. Data were analyzed from April 15, 2019, to October 10, 2019.

EXPOSURES

Greenness surrounding each child's school or kindergarten was estimated using 2 satellite image-derived vegetation indexes: the normalized difference vegetation index and the soil-adjusted vegetation index.

MAIN OUTCOMES AND MEASURES

Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) scales were used to measure ADHD symptoms (9 inattention symptoms and 9 hyperactivity-impulsivity symptoms). Parents or guardians rated the frequency of each of 18 ADHD symptoms during the preceding 6 months. Children with 6 or more symptoms of either inattention or hyperactivity-impulsivity were defined as having ADHD symptoms. Generalized linear mixed models were applied to estimate the association between greenness and ADHD symptoms.

RESULTS

The mean (SD) age of the 59 754 study participants was 10.3 (3.6) years, and 29 494 (49.4%) were girls. A total of 2566 participants (4.3%) had ADHD symptoms. Greenness levels differed substantially across schools and kindergartens. The normalized difference vegetation index within 500 m of a school or kindergarten ranged from -0.09 to 0.77. Greater greenness levels were associated with lower odds of ADHD symptoms. In covariate-adjusted models, a 0.1-unit increase in normalized difference vegetation index or soil-adjusted vegetation index within 500 m of a school or kindergarten was significantly associated with lower odds of ADHD symptoms (odds ratios, 0.87 [95% CI, 0.83-0.91] and 0.80 [95% CI, 0.74-0.86], respectively; P < .001 for both). The associations were robust in a series of sensitivity analyses.

CONCLUSIONS AND RELEVANCE

These findings suggest that there may be a beneficial association between school-based greenness and ADHD symptoms in Chinese children. Future longitudinal and mechanistic studies are needed to confirm the findings of this cross-sectional analysis and further explore potential mechanisms of this association.

The Effect of Vitamin D Supplementation on Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective: A systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted to assess the benefits and harms of vitamin D supplementation for attention-deficit/hyperactivity disorder (ADHD) patients. Methods: We followed the standard methodological procedures of the Cochrane Handbook for Systematic Reviews of Intervention. PubMed, Embase, the Cochrane Central Register of Controlled Trials, Science and Conference Proceedings Citation Index-Social Science and Humanities (Web of Science), ClincalTrials.gov, and World Health Organization's International Clinical Trials Registry Platform were searched for RCTs in January 2019. Independently, two authors (J.G., T.X.) extracted data, assessed the risk of bias, combined the data, and graded evidence quality using the Grading of Recommendations Assessment, Development, and Evaluation approach. Our primary outcomes were assessed through rating scales of ADHD severity. Secondary outcomes measured were the possible adverse effects of vitamin D supplementation and vitamin D status after supplementation for ADHD. Results: We included four RCTs with 256 children addressing vitamin D supplementation as adjunctive therapy to methylphenidate on ADHD symptoms. Vitamin D supplementation demonstrated a small but statistically significant improvement in ADHD total scores, inattention scores, hyperactivity scores, and behavior scores. The improvement was likely limited due to the low to very low quality of evidence in the literature. There was no statistically significant improvement in oppositional scores. Reported adverse events in the vitamin D group were mild and not significantly different from the control group. Vitamin D supplementation increased serum vitamin D levels and the ratio of patients with sufficient vitamin D levels. Conclusions: Vitamin D supplementation as adjunctive therapy to methylphenidate appeared to reduce ADHD symptoms without serious adverse events, associated with improved vitamin D status. However, considering the generally low strength of evidence, well-designed RCTs are needed to determine the efficacy and safety of vitamin D supplementation for both children and adults with ADHD, especially in the setting of a combination of vitamin D and other ADHD treatments.