The Children's Attention Project: a community-based longitudinal study of children with ADHD and non-ADHD controls

The longitudinal relationship between socioemotional difficulties and irritability in ADHD

BACKGROUND

Despite higher rates of irritability and socioemotional symptoms in ADHD, consensus is lacking regarding their developmental relationship and whether it differs by ADHD status. This longitudinal study sought to evaluate how peer and emotional difficulties relate to irritability in ADHD and control groups.

METHODS

A community sample of 336 participants (45 % ADHD) were recruited for the Children's Attention Project. Participants completed the Affective Reactivity Index and the Strengths and Difficulties Questionnaire's emotional and peer difficulties scales at baseline (mean age 10.5 years) and 18-month follow-up. Latent Change Score models assessed how emotional and peer difficulties related to irritability at baseline and longitudinally.

RESULTS

For both groups, more severe baseline difficulties were associated with higher concurrent irritability, and reductions in emotional and peer difficulties were associated with declining irritability. Baseline emotional difficulties predicted change in irritability for the ADHD group, while baseline peer difficulties predicted change in irritability for both groups. Baseline irritability did not predict change in emotional or peer difficulties for either. The ADHD group showed elevated irritability, emotional, and peer difficulties, and stronger baseline correlation between peer difficulties and irritability.

LIMITATIONS

Only two timepoints were captured, and associations with ADHD symptom severity and presentation were not investigated. Doing so may facilitate additional insights.

CONCLUSIONS

Change in irritability corresponded to change in socioemotional difficulties, and was driven by earlier levels of socioemotional difficulties. ADHD exacerbated aspects of the relationship between socioemotional difficulties and irritability. Socioemotional difficulties drive irritability, so may represent targets for clinical interventions.

Modeling the development of cognitive reserve in children: A residual index approach

OBJECTIVE

To model cognitive reserve (CR) longitudinally in a neurodiverse pediatric sample using a residual index approach, and to test the criterion and construct validity of this index.

METHOD

Participants were N = 115 children aged 9.5-13 years at baseline (MAge = 10.48 years, SDAge = 0.61), and n = 43 (37.4%) met criteria for ADHD. The CR index represented variance in Matrix Reasoning scores from the WASI that was unexplained by MRI-based brain variables (bilateral hippocampal volumes, total gray matter volumes, and total white matter hypointensity volumes) or demographics (age and sex).

RESULTS

At baseline, the CR index predicted math computation ability (estimate = 0.50, SE = 0.07, p < .001), and word reading ability (estimate = 0.26, SE = 0.10, p = .012). Longitudinally, change in CR over time was not associated with change in math computation ability (estimate = -0.02, SE = 0.03, p < .513), but did predict change in word reading ability (estimate = 0.10, SE = 0.03, p < .001). Change in CR was also found to moderate the relationship between change in word reading ability and white matter hypointensity volume (estimate = 0.10, SE = 0.05, p = .045).

CONCLUSIONS

Evidence for the criterion validity of this CR index is encouraging, but somewhat mixed, while construct validity was evidenced through interaction between CR, brain, and word reading ability. Future research would benefit from optimization of the CR index through careful selection of brain variables for a pediatric sample.

Family Functioning in Children With ADHD and Subthreshold ADHD: A 3-Year Longitudinal Study

OBJECTIVE

To compare family functioning over time for elementary school children with Attention-Deficit/Hyperactivity Disorder (ADHD; N = 179) and subthreshold ADHD (ST-ADHD; N = 86), to children without ADHD (Control; N = 212).

METHOD

ADHD was assessed using the Conners 3 ADHD Index and Diagnostic Interview Schedule for Children IV. At baseline, 18-month follow-up and 36-month follow-up, parents completed measures assessing a range of family functioning domains.

RESULTS

At baseline, the ADHD group reported higher psychological distress, less parenting self-efficacy, less parenting consistency, and more stressful life events; and both groups reported poorer family quality of life (QoL) and greater parenting anger. Trajectories were largely similar to controls (i.e., stable over time), but unlike controls, ADHD and ST-ADHD groups showed lessening parent-partner support and parenting warmth, respectively; and both groups showed worsening aspects of family QoL.

CONCLUSION

Families of children with ADHD and ST-ADHD report persistently poor or worsening family functioning; highlighting a need for tailored psycho-social supports.

Age at diagnosis and diagnostic delay across attention-deficit hyperactivity and autism spectrums

BACKGROUND

Despite the known benefits of accurate and timely diagnosis for children with attention-deficit hyperactivity disorder and autism spectrum disorders (autism), for some children this goal is not always achieved. Existing research has explored diagnostic delay for autism and attention-deficit hyperactivity disorder only, and when attention-deficit hyperactivity disorder and autism co-occur, autism has been the focus. No study has directly compared age at diagnosis and diagnostic delay for males and females across attention-deficit hyperactivity disorder, autism and specifically, attention-deficit hyperactivity disorder + autism.

METHODS

Australian caregivers (N = 677) of children with attention-deficit hyperactivity disorder, autism or attention-deficit hyperactivity disorder + autism were recruited via social media (n = 594) and the Monash Autism and ADHD Genetics and Neurodevelopment Project (n = 83). Caregivers reported on their child's diagnostic process. Diagnostic delay was the mean difference between general initial developmental concerns and the child's attention-deficit hyperactivity disorder and autism diagnosis.

RESULTS

Children with autism were significantly younger at autism diagnosis than the attention-deficit hyperactivity disorder + autism group (ηp2 = 0.06), whereas children with attention-deficit hyperactivity disorder were significantly older at attention-deficit hyperactivity disorder diagnosis than the attention-deficit hyperactivity disorder + autism group (ηp2 = 0.01). Delay to attention-deficit hyperactivity disorder and autism diagnosis was significantly longer in the attention-deficit hyperactivity disorder + autism group compared to attention-deficit hyperactivity disorder (ηp2 = 0.02) and autism (η2 = 0.04) only. Delay to autism diagnosis for females with autism (η2 = 0.06) and attention-deficit hyperactivity disorder + autism (η2 = 0.04) was longer compared to males.

CONCLUSIONS

Having attention-deficit hyperactivity disorder + autism and being female were associated with longer delays to diagnosis. The reasons for these delays and possible adverse effects on outcomes require further study.

Association between relative age at school and persistence of ADHD in prospective studies: an individual participant data meta-analysis

BACKGROUND

The youngest children in a school class are more likely than the oldest to be diagnosed with ADHD, but this relative age effect is less frequent in older than in younger school-grade children. However, no study has explored the association between relative age and the persistence of ADHD diagnosis at older ages. We aimed to quantify the association between relative age and persistence of ADHD at older ages.

METHODS

For this meta-analysis, we searched MEDLINE, Embase, CINAHL, PsycINFO, and PubPsych up to April 1, 2022, with terms related to "cohort" and "ADHD" with no date, publication type, or language restrictions. We gathered individual participant data from prospective cohorts that included at least ten children identified with ADHD before age 10 years. ADHD was defined by either a clinical diagnosis or symptoms exceeding clinical cutoffs. Relative age was recorded as the month of birth in relation to the school-entry cutoff date. Study authors were invited to share raw data or to apply a script to analyse data locally and generate anonymised results. Our outcome was ADHD status at a diagnostic reassessment, conducted at least 4 years after the initial assessment and after age 10 years. No information on sex, gender, or ethnicity was collected. We did a two-stage random-effects individual participant data meta-analysis to assess the association of relative age with persistence of ADHD at follow-up. This study was registered with PROSPERO, CRD42020212650.

FINDINGS

Of 33 119 studies generated by our search, we identified 130 eligible unique studies and were able to gather individual participant data from 57 prospective studies following up 6504 children with ADHD. After exclusion of 16 studies in regions with a flexible school entry system that did not allow confident linkage of birthdate to relative age, the primary analysis included 41 studies in 15 countries following up 4708 children for a period of 4 to 33 years. We found that younger relative age was not statistically significantly associated with ADHD persistence at follow-up (odds ratio 1·02, 95% CI 0·99-1·06; p=0·19). We observed statistically significant heterogeneity in our model (Q=75·82, p=0·0011, I2=45%). Participant-level sensitivity analyses showed similar results in cohorts with a robust relative age effect at baseline and when restricting to cohorts involving children with a clinical diagnosis of ADHD or with a follow-up duration of more than 10 years.

INTERPRETATION

The diagnosis of ADHD in younger children in a class is no more likely to be disconfirmed over time than that of older children in the class. One interpretation is that the relative age effect decreases the likelihood of children of older relative age receiving a diagnosis of ADHD, and another is that assigning a diagnostic label of ADHD leads to unexplored carryover effects of the initial diagnosis that persist over time. Future studies should be conducted to explore these interpretations further.

FUNDING

None.

Longitudinal Trajectories of White Matter Development in Attention-Deficit/Hyperactivity Disorder

BACKGROUND

Few longitudinal studies have investigated whether white matter development reflects differential outcomes for children with and without attention-deficit/hyperactivity disorder (ADHD). To examine whether deviations from typical trajectories of white matter development were associated with the persistence or remission of ADHD symptoms, this study examined microstructural and morphological properties of 71 white matter tracts from 390 high angular diffusion scans acquired prospectively for 62 children with persistent ADHD, 37 children remitted from ADHD, and 85 children without ADHD.

METHODS

Participants (mean age at wave 1 = 10.39 years, scan interval = 18 months) underwent up to 3 magnetic resonance imaging assessments. White matter tracts were reconstructed using TractSeg, a semiautomated method. For each tract, we derived measures of fiber density (microstructure) and fiber bundle cross-section (morphology) using fixel-based analysis. Linear mixed models were used to compare trajectories of fiber development between the persistent ADHD, remitted ADHD, and non-ADHD groups.

RESULTS

Compared with the non-ADHD group, the remitted and persistent ADHD groups showed accelerated fiber development in thalamic pathways, striatal pathways, and the superior longitudinal fasciculus. In the remitted ADHD group, accelerated fiber development in corticospinal, frontopontine, striatal-premotor, and thalamo-premotor pathways was associated with greater reductions in ADHD symptom severity. The persistent ADHD group showed ongoing white matter alterations along sensorimotor pathways.

CONCLUSIONS

These results suggest that variations in white matter development are associated with different clinical trajectories in ADHD. The findings advance our understanding of the neurobiological mechanisms underpinning ADHD symptom progression and provide novel evidence in support of developmental models of ADHD.

Adolescents with ADHD and co-occurring motor difficulties show a distinct pattern of maturation within the corticospinal tract from those without: A longitudinal fixel-based study

It is well documented that attention-deficit hyperactivity disorder (ADHD) often presents with co-occurring motor difficulties. However, little is known about the biological mechanisms that explain compromised motor skills in approximately half of those with ADHD. To provide insight into the neurobiological basis of poor motor outcomes in ADHD, this study profiled the development of white matter organization within the cortico-spinal tract (CST) in adolescents with ADHD with and without co-occurring motor problems, as well as non-ADHD control children with and without motor problems. Participants were 60 children aged 9-14 years, 27 with a history of ADHD and 33 controls. All underwent high-angular resolution diffusion MRI data at up to three time points (115 in scans total). We screened for motor impairment in all participants at the third time point (≈14 years) using the Developmental Coordination Disorder Questionnaire (DCD-Q). Following pre-processing of diffusion MRI scans, fixel-based analysis was performed, and the bilateral CST was delineated using TractSeg. Mean fiber density (FD) and fiber cross-section (FC) were extracted for each tract at each time-point. To investigate longitudinal trajectories of fiber development, linear mixed models were performed separately for the left and right CST, controlling for nuisance variables. To examine possible variations in fiber development between groups, we tested whether the inclusion of group and the interaction between age and group improved model fit. At ≈10 years, those with ADHD presented with lower FD within the bilateral CST relative to controls, irrespective of their prospective motor status. While these microstructural abnormalities persisted into adolescence for individuals with ADHD and co-occurring motor problems, they resolved for those with ADHD alone. Divergent maturational pathways of motor networks (i.e., the CST) may, at least partly, explain motor problems individuals with ADHD.

Categorical and dimensional approaches to the developmental relationship between ADHD and irritability

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) and irritability commonly co-occur, and follow similar developmental trajectories from childhood to adolescence. Understanding of the developmental relationship between these co-occurrences is limited. This study provides a longitudinal assessment of how ADHD diagnostic status and symptom patterns predict change in irritability.

METHODS

A community sample of 337 participants (45.2% ADHD), recruited for the Childhood Attention Project, completed the Affective Reactivity Index (ARI) to measure irritability at baseline (mean age 10.5 years) and follow-up after 18-months. Latent change score models were used to assess how (a) baseline ADHD vs. control group status, (b) baseline symptom domain (inattention, hyperactivity-impulsivity) and (c) longitudinal change in ADHD symptom severity predicted change in irritability.

RESULTS

Irritability was significantly higher among the ADHD group than controls; however, change in irritability over time did not differ between groups. When assessed across the entire cohort, change in irritability was predicted by higher symptom count in the hyperactive-impulsive domain, but not the inattentive domain. Greater declines in ADHD symptoms over time significantly predicted greater declines in irritability. Baseline ADHD symptom severity was found to significantly predict change in irritability; however, baseline irritability did not significantly predict change in ADHD symptoms.

CONCLUSIONS

ADHD symptoms-particularly hyperactive-impulsive symptoms-predict the degree and trajectory of irritability during childhood and adolescence, even when symptoms are below diagnostic thresholds. The use of longitudinal, dimensional and symptom domain-specific measures provides additional insight into this relationship.

Fronto-parietal white matter microstructure associated with working memory performance in children with ADHD

INTRODUCTION

Attention Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with many functional impairments thought to be underpinned by difficulties in executive function domains such as working memory. The superior longitudinal fasciculus (SLF) plays an integral role in the development of working memory in neurotypical children. Neuroimaging research suggests reduced white matter organization of the SLF may contribute to working memory difficulties commonly seen in ADHD. This study aimed to examine the relationship between white matter organization of the SLF and working memory in children with ADHD.

METHODS

We examined the association of tract volume and apparent fibre density (AFD) of the SLF with working memory in children with ADHD (n = 64) and controls (n = 58) aged 9-11years. Children completed a computerized spatial n-back task and underwent diffusion magnetic resonance imaging (dMRI). Constrained spherical deconvolution-based tractography was used to construct the three branches of the SLF bilaterally and examine volume and AFD of the SLF.

RESULTS

Regression analyses revealed children with ADHD exhibited poorer working memory, and lower volume and AFD of the left SLF-II compared to healthy controls. There was also an association between reaction time and variability (RT and RT-V) and the left SLF-II. Further analyses revealed volume of the left SLF-II mediated the relationship between ADHD and working memory performance (RT and RT-V).

DISCUSSION

These findings add to the current body of ADHD literature, revealing the potential role of frontoparietal white matter in working memory difficulties in ADHD.

Cortical structural and functional coupling during development and implications for attention deficit hyperactivity disorder

Functional connectivity is scaffolded by the structural connections of the brain. Disruptions of either structural or functional connectivity can lead to deficits in cognitive functions and increase the risk for neurodevelopmental disorders such as attention deficit hyperactivity disorder (ADHD). To date, very little research has examined the association between structural and functional connectivity in typical development, while no studies have attempted to understand the development of structure-function coupling in children with ADHD. 175 individuals (84 typically developing children and 91 children with ADHD) participated in a longitudinal neuroimaging study with up to three waves. In total, we collected 278 observations between the ages 9 and 14 (139 each in typically developing controls and ADHD). Regional measures of structure-function coupling were calculated at each timepoint using Spearman's rank correlation and mixed effect models were used to determine group differences and longitudinal changes in coupling over time. In typically developing children, we observed increases in structure-function coupling strength across multiple higher-order cognitive and sensory regions. Overall, weaker coupling was observed in children with ADHD, mainly in the prefrontal cortex, superior temporal gyrus, and inferior parietal cortex. Further, children with ADHD showed an increased rate of coupling strength predominantly in the inferior frontal gyrus, superior parietal cortex, precuneus, mid-cingulate, and visual cortex, compared to no corresponding change over time in typically developing controls. This study provides evidence of the joint maturation of structural and functional brain connections in typical development across late childhood to mid-adolescence, particularly in regions that support cognitive maturation. Findings also suggest that children with ADHD exhibit different patterns of structure-function coupling, suggesting atypical patterns of coordinated white matter and functional connectivity development predominantly in the regions overlapping with the default mode network, salience network, and dorsal attention network during late childhood to mid-adolescence.

Longitudinal Changes of Resting-State Networks in Children With Attention-Deficit/Hyperactivity Disorder and Typically Developing Children

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent childhood neurodevelopmental disorder. Given the profound brain changes that occur across childhood and adolescence, it is important to identify functional networks that exhibit differential developmental patterns in children with ADHD. This study sought to examine whether children with ADHD exhibit differential developmental trajectories in functional connectivity compared with typically developing children using a network-based approach.

METHODS

This longitudinal neuroimaging study included 175 participants (91 children with ADHD and 84 control children without ADHD) between ages 9 and 14 and up to 3 waves (173 total resting-state scans in children with ADHD and 197 scans in control children). We adopted network-based statistics to identify connected components with trajectories of development that differed between groups.

RESULTS

Children with ADHD exhibited differential developmental trajectories compared with typically developing control children in networks connecting cortical and limbic regions as well as between visual and higher-order cognitive regions. A pattern of reduction in functional connectivity between corticolimbic networks was seen across development in the control group that was not present in the ADHD group. Conversely, the ADHD group showed a significant decrease in connectivity between predominantly visual and higher-order cognitive networks that was not displayed in the control group.

CONCLUSIONS

Our findings show that the developmental trajectories in children with ADHD are characterized by a subnetwork involving different trajectories predominantly between corticolimbic regions and between visual and higher-order cognitive network connections. These findings highlight the importance of examining the longitudinal maturational course to understand the development of functional connectivity networks in children with ADHD.

White matter and sustained attention in children with attention/deficit-hyperactivity disorder: A longitudinal fixel-based analysis

Sustained attention is a cognitive function with known links to academic success and mental health disorders such as attention/deficit-hyperactivity disorder (ADHD). Several functional networks are critical to sustained attention, however the association between white matter maturation in tracts linking functional nodes and sustained attention in typical and atypical development is unknown. 309 diffusion-weighted imaging scans were acquired from 161 children and adolescents (80 ADHD, 81 control) at up to three timepoints over ages 9-14. A fixel-based analysis approach was used to calculate mean fiber density and fiber-bundle cross section in tracts of interest. Sustained attention was measured using omission errors and response time variability on the out-of-scanner sustained attention to response task. Linear mixed effects models examined associations of age, group and white matter metrics with sustained attention. Greater fiber density in the bilateral superior longitudinal fasciculus (SLF) I and right SLF II was associated with fewer attention errors in the control group only. In ADHD and control groups, greater fiber density in the left ILF and right thalamo-premotor pathway, as well as greater fiber cross-section in the left SLF I and II and right SLF III, was associated with better sustained attention. Relationships were consistent across the age span. Results suggest that greater axon diameter or number in the dorsal and middle SLF may facilitate sustained attention in neurotypical children but does not assist those with ADHD potentially due to disorder-related alterations in this region. Greater capacity for information transfer across the SLF was associated with attention maintenance in 9-14-year-olds regardless of diagnostic status, suggesting white matter macrostructure may also be important for attention maintenance. White matter and sustained attention associations were consistent across the longitudinal study, according with the stability of structural organization over this time. Future studies can investigate modifiability of white matter properties through ADHD medications.

Longitudinal maturation of resting state networks: Relevance to sustained attention and attention deficit/hyperactivity disorder

The transition from childhood to adolescence involves important neural function, cognition, and behavior changes. However, the links between maturing brain function and sustained attention over this period could be better understood. This study examined typical changes in network functional connectivity over childhood to adolescence, developmental differences in attention deficit/hyperactivity disorder (ADHD), and how functional connectivity might underpin variability in sustained attention development in a longitudinal sample. A total of 398 resting state scans were collected from 173 children and adolescents (88 ADHD, 85 control) at up to three timepoints across ages 9-14 years. The effects of age, sex, and diagnostic group on changes in network functional connectivity were assessed, followed by relationships between functional connectivity and sustained attention development using linear mixed effects modelling. The ADHD group displayed greater decreases in functional connectivity between salience and visual networks compared with controls. Lower childhood functional connectivity between the frontoparietal and several brain networks was associated with more rapid sustained attention development, whereas frontoparietal to dorsal attention network connectivity related to attention trajectories in children with ADHD alone. Brain network segregation may increase into adolescence as predicted by key developmental theories; however, participants with ADHD demonstrated altered developmental trajectories between salience and visual networks. The segregation of the frontoparietal network from other brain networks may be a mechanism supporting sustained attention development. Frontoparietal to dorsal attention connectivity can be a focus for further work in ADHD.

Examining the Educational Gap for Children with ADHD and Subthreshold ADHD

OBJECTIVE

The present study examined the impact of Attention Deficit Hyperactivity Disorder (ADHD) on core educational outcomes in two large community cohorts of Australian school children.

METHOD

Academic (reading and numeracy) and non-academic (school engagement, attendance, peer victimization, and parental expectations) outcomes were compared between children with ADHD, subthreshold ADHD, and controls when children were in grade 5 (M age = 10.5). Data were drawn from the Longitudinal Study of Australian Children birth cohort (LSAC; N = 3,540) and the Children's Attention Project (CAP; N = 356).

RESULTS

Both subthreshold ADHD and ADHD groups had poorer outcomes on all measures, with medium effects sizes. Differences were not evident between subthreshold ADHD and ADHD groups.

CONCLUSIONS

Educational outcomes examined in this study highlight the educational risk for upperprimary school children with ADHD or subthreshold ADHD, in comparison to their peers. Monitoring these outcomes is necessary to inform policy, practice, and intervention.

Neural correlates of irritability in a community sample of children

Irritability has been associated with aberrant patterns of neural activation, yet little is known about structural brain correlates of irritability. As such, we aimed to investigate associations between irritability and gray matter volume (GMV) in a community sample of children enriched for irritability. The sample comprised children (n=162) aged 9-11 years with and without Attention-Deficit/Hyperactivity Disorder (ADHD), participating in a cohort study with magnetic resonance imaging data available. Mixed effects linear regression analyses tested the associations between irritability symptoms and regional GMV (extracted using Freesurfer). Irritability was associated with smaller gray matter volume across multiple brain regions implicated in executive functioning, and emotion and reward processing including frontal regions and the cingulate.

Head Motion During MRI Predicted by out-of-Scanner Sustained Attention Performance in Attention-Deficit/Hyperactivity Disorder

Objective: To characterize head movements in children with ADHD using an ex-Gaussian distribution and examine associations with out-of-scanner sustained attention. Method: Fifty-six children with ADHD and 61 controls aged 9 to 11 years completed the Sustained Attention to Response Task (SART) and resting-state functional magnetic resonance imaging (fMRI). In-scanner head motion was calculated using ex-Gaussian estimates for mu, sigma, and tau in delta variation signal and framewise displacement. Sustained attention was evaluated through omission errors and tau in response time on the SART. Results: Mediation analysis revealed that out-of-scanner attention lapses (omissions during the SART) mediated the relationship between ADHD diagnosis and in-scanner head motion (tau in delta variation signal), indirect effect: B = 1.29, 95% confidence interval (CI) = [0.07, 3.15], accounting for 29% of the association. Conclusion: Findings suggest a critical link between trait-level sustained attention and infrequent large head movements during scanning (tau in head motion) and highlight fundamental challenges in measuring the neural basis of sustained attention.

Inter-individual performance differences in the stop-signal task are associated with fibre-specific microstructure of the fronto-basal-ganglia circuit in healthy children

Previous Diffusion Tensor Imaging (DTI) studies in children suggest that developmental improvements in inhibitory control is largely mediated by the degree of white matter organisation within a right-lateralised network of fronto-basal-ganglia regions. Recent advances in diffusion imaging analysis now permit greater biological specificity, both in identifying specific fibre populations within a voxel, as well as in the underlying microstructural properties of that white matter. In the present work, employing a novel fixel-based analysis (FBA) framework, we aimed to comprehensively investigate microstructure within the fronto-basal-ganglia circuit in childhood, and its contribution to inhibition performance. Diffusion MRI data were obtained from 43 healthy children and adolescents aged 9-11 years (10.42 ± .41 years, 18 females). Response inhibition for each participant was assessed using the Stop-signal Task (SST) and quantified as a Stop-Signal Reaction Time (SSRT). All steps relevant to FBA were implemented in MRtrix3Tissue, a fork of the MRtrix3 software library. The fronto-basal-ganglia circuit were delineated using probabilistic tractography to identify the tracts connecting the subthalamic nucleus, pre-supplementary motor area and the inferior frontal gyrus. Connectivity-based fixel enhancement (CFE) was then used to assess the association between fibre density (FD) and fibre cross-section (FC) with inhibitory ability. Significant negative associations were identified for FD in both the right and left fronto-basal-ganglia circuit whereby greater FD was associated with better inhibition performance (e.g., reduced SSRTs). This effect was specifically localised to clusters of fixels within white matter proximal to the right subthalamic nucleus. We did not report any meaningful associations between SSRT and FC. Whilst findings are broadly consistent with prior DTI evidence, current results suggest that SSRT is predominantly facilitated by subcortical microstructure of the connections projecting from the subthalamic nucleus to the cortical regions of the network. Our findings extend current understanding of the role of white matter in childhood response inhibition.

The Association Between Autism Symptoms and Child Functioning in a Sample With ADHD Recruited From the Community

Objective: Although autism spectrum disorder (ASD) symptoms are associated with poorer functioning in children with attention-deficit/hyperactivity disorder (ADHD), it is unclear which ASD symptom domains are most impairing. This study investigated whether specific ASD symptom domains were associated with child functioning in children with ADHD. Method: Parents of 164 children with ADHD completed a diagnostic interview to assess ADHD and comorbidities. Parents reported on ASD symptoms (Social Communication Questionnaire) and child quality of life (Pediatric Quality of Life Inventory 4.0). Parents and teachers completed the Strengths and Difficulties Questionnaire (emotional, conduct, and peer problems). Results: Repetitive and stereotyped behaviors were independently associated with emotional (p = .02) and conduct (p = .03) problems, and poorer quality of life (p = .004). Reciprocal social interaction deficits were independently associated with peer problems (p = .03). Conclusion: Reciprocal social interaction deficits and repetitive and stereotyped behaviors are important areas that should be focused on in ADHD assessment and treatment.

Reduced fine motor competence in children with ADHD is associated with atypical microstructural organization within the superior longitudinal fasciculus

Recent work in healthy adults suggests that white matter organization within the superior longitudinal fasciculus (SLF) may, at least partly, explain individual differences in fine motor skills. The SLF is also often implicated in the neurobiology underlying attention deficit hyperactivity disorder (ADHD) as part of the attention network connecting frontal and parietal regions. While ADHD is primarily characterized by inattention, impulsivity and/or hyperactivity, atypical fine motor control is a common comorbid feature. This study aimed to investigate the association between reduced fine motor skills in ADHD and microstructural properties within the SLF. Participants were 55 right-handed children with ADHD and 61 controls aged 9-11 years. Fine motor control was assessed using the Grooved Pegboard task. Children underwent high angular resolution diffusion MRI. Following pre-processing, constrained spherical deconvolution tractography was performed to delineate the three SLF branches bilaterally. Children with ADHD showed significantly poorer fine motor performance relative to controls in the non-dominant hand, indicated by significantly slower left handed Grooved Pegboard task performance. This slower response time for the non-dominant (left) hand was significantly associated with reduced apparent fibre density within the right SLF I, and reduced right SLF I, II and III volume. This finding was independent of spatial attention performance. These data support previous reports indicating that children with ADHD have poorer fine motor performance than controls in their non-dominant hand, and indicates that the neurobiological basis for impaired fine motor control may involve white matter properties within the contralateral SLF. This suggests that white matter properties in fronto-parietal areas may have broader implications than attention.

Understanding motor difficulties in children with ADHD: A fixel-based analysis of the corticospinal tract

AIMS

Children with attention deficit hyperactivity disorder (ADHD) often present with deficits in fine motor control. The cortico-spinal tract (CST) is critical for voluntary motor control. Although neuroimaging work has identified anomalous microstructural properties in the CST in ADHD, no study to date has attempted to investigate the link between deficits in fine motor performance and microstructural properties of the CST in children with ADHD. This study aimed to address this gap using a novel fixel-based analysis (FBA).

METHODS

Participants were 50 right-handed medication naïve children with a history of ADHD and 56 non-ADHD controls aged 9-11 years. Fine motor control was assessed using the Grooved Pegboard task. Children underwent high angular resolution diffusion MRI. Following pre-processing, FBA was performed and the semi-automated deep-learning TractSeg was used to delineate the CST bilaterally. Fibre density (FD), fibre cross-section (FC-log), and fibre density/cross-section (FDC) were extracted for each tract.

RESULTS

Children with ADHD performed significantly worse than non-ADHD children on the Grooved Pegboard task when using their non-dominant hand. They also demonstrated widespread significantly lower diffusion metrics in both CSTs compared to non-ADHD controls. However, no correlations were observed between Grooved Pegboard performance and diffusion metrics for the CST in either hemisphere.

CONCLUSIONS

While we failed to detect a significant relationship between fine motor skill and FBA metrics in either group, this paper extends previous work by showing that children with ADHD and reduced fine motor competence demonstrate atypical microstructure within the CST relative to non-ADHD controls.

White matter tract signatures of fiber density and morphology in ADHD

Previous studies investigating white matter organization in attention deficit hyperactivity disorder (ADHD) have adopted diffusion tensor imaging (DTI). However, attempts to derive pathophysiological models from this research have had limited success, possibly reflecting limitations of the DTI method. This study investigated the organization of white matter tracts in ADHD using fixel based analysis (FBA), a fiber specific analysis framework that is well placed to provide novel insights into the pathophysiology of ADHD. High angular diffusion weighted imaging and clinical data were collected in a large paediatric cohort (N = 144; 76 with ADHD; age range 9-11 years). White matter tractography and FBA were performed across 14 white matter tracts. Permutation based inference testing (using FBA derived measures of fiber density and morphology) assessed differences in white matter tract profiles between children with and without ADHD. Analysis further examined the association between white matter properties and ADHD symptom severity. Relative to controls, children with ADHD showed reduced white matter connectivity along association and projection pathways considered critical to behavioral control and motor function. Increased ADHD symptom severity was associated with reduced white matter organization in fronto-pontine fibers projecting to and from the supplementary motor area. Providing novel insight into the neurobiological foundations of ADHD, this is the first research to uncover fiber specific white matter alterations across a comprehensive set of white matter tracts in ADHD using FBA. Findings inform pathophysiological models of ADHD and hold great promise for the consistent identification and systematic replication of brain differences in this disorder.

Mindful Parenting Behaviors and Emotional Self-Regulation in Children With ADHD and Controls

OBJECTIVE

Mindfulness is defined as paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally and these behaviors can be applied to parenting. Thus far, it is not understood whether mindful parenting (MP) differs in parents of children with and without attention-deficit/hyperactivity disorder (ADHD), and how MP relates to other parenting practices and children's self-regulation.

METHODS

This study examined the relationships between MP, parenting behaviors and children's self-regulation in 120 families with child ADHD (85% male; mean age = 11.93) and 105 control families (62% male; mean age = 11.98). Parents completed measures of MP (Interpersonal Mindfulness in Parenting Scale), parenting behaviors (parenting warmth, consistency, and anger assessed with the Longitudinal Study of Australian Children measures), psychological distress (Kessler 6), and children's self-regulation (Social Skills Improvement System-self-control subscale).

RESULTS

When compared with controls, parents of children with ADHD reported significantly lower MP. Higher MP was associated with lower levels of parent psychological distress, higher levels of parenting warmth and consistency, lower levels of parenting anger, and higher child emotion self-regulation in both groups. In mediation analyses, MP was indirectly associated with child emotion self-regulation through lower parenting anger, with the model accounting for 55% of the variance in child self-regulation.

CONCLUSIONS

MP is a useful construct for understanding parent behaviors, and children's emotion self-regulation.

Peer Victimization in Children With ADHD: A Community-Based Longitudinal Study

Objectives: To investigate (a) whether children with ADHD experience higher levels of overt and relational peer victimization (PV) than children without ADHD and (b) child, family, and school predictors of PV in children with ADHD. Method: 173 children with ADHD and 199 non-ADHD controls were recruited through 43 Melbourne schools at mean age 7.3 years. Parent- and teacher-reported PV (Social Experience Questionnaire) data were collected at mean age 8.9 years. Potential child, family, and school predictors of PV were measured at baseline. Results: Children with ADHD experienced higher levels of PV than children without ADHD by both parent- and teacher-report. Child predictors accounted for the greatest variance in PV, and the strongest predictors of PV were teacher-reported conduct problems, and medication use. Conclusion: Children with ADHD are at higher risk of PV compared with non-ADHD controls. Recognizing and addressing PV is important to reduce additional impairment in children with ADHD.

Persistence of disruptive mood dysregulation disorder in children with attention-deficit/hyperactivity disorder

Disruptive mood dysregulation disorder (DMDD) is common in children with ADHD yet it is not known how persistent DMDD is in this population. As such we aimed to investigate the persistence of disruptive mood dysregulation disorder (DMDD) in a community sample of children with ADHD. The sample comprised children (n = 136) participating in a cohort study with data available at age 7 and age 10. DMDD status was ascertained using proxy items from the Diagnostic Interview Schedule for Children, Version IV. Of those with DMDD at age 7 (n = 30), eight (21.1%) had DMDD that persisted at age 10. In the first study investigating the longitudinal course of DMDD in ADHD one in five children with ADHD+DMDD at age 7 continued to meet diagnostic criteria for DMDD three years later.

Manual dexterity in late childhood is associated with maturation of the corticospinal tract

PURPOSE

Despite the important role of manual dexterity in child development, the neurobiological mechanisms associated with manual dexterity in childhood remain unclear. We leveraged fixel-based analysis (FBA) to examine the longitudinal association between manual dexterity and the development of white matter structural properties in the corticospinal tract (CST).

METHODS

High angular diffusion weighted imaging (HARDI) data were acquired for 44 right-handed typically developing children (22 female) aged 9-13 across two timepoints (timepoint 1: mean age 10.5 years ± 0.5 years, timepoint 2: 11.8 ± 0.5 years). Manual dexterity was assessed using the Grooved Pegboard Test, a widely used measure of manual dexterity. FBA-derived measures of fiber density and morphology were generated for the CST at each timepoint. Connectivity-based fixel enhancement and mixed linear modelling were used to examine the longitudinal association between manual dexterity and white matter structural properties of the CST.

RESULTS

Longitudinal mixed effects models showed that greater manual dexterity of the dominant hand was associated with increased fiber cross-section in the contralateral CST. Analyses further demonstrated that the rate of improvement in manual dexterity was associated with the rate of increase in fiber cross-section in the contralateral CST between the two timepoints.

CONCLUSION

Our longitudinal data suggest that the development of manual dexterity in late childhood is associated with maturation of the CST. These findings significantly enhance our understanding of the neurobiological systems that subserve fine motor development and provide an important step toward mapping normative trajectories of fine motor function against microstructural and morphological development in childhood.

ADHD at Age 7 and Functional Impairments at Age 10

BACKGROUND AND OBJECTIVES

Attention-deficit/hyperactivity disorder (ADHD) cohort studies have typically involved clinical samples and have usually recruited children across wide age ranges, limiting generalizability across complexity and developmental stage. We compared academic, emotional-behavioral and social functioning at age 10, and predictors of outcomes, in a nonreferred cohort of children recruited at age 7, between those with full-syndrome (FS) ADHD and controls with no ADHD.

METHODS

This was a prospective cohort study with a 3-year follow-up period. Children were recruited from 43 socioeconomically diverse schools in Melbourne, Australia. Multi-informant outcomes at age 10 were academic functioning (Wide Range Achievement Test 4; Social Skills Improvement System), emotional-behavioral functioning (Strengths and Difficulties Questionnaire total), and social functioning (Strengths and Difficulties Questionnaire peer problems). Outcomes were compared across the groups by using adjusted random-effects linear regression analyses.

RESULTS

In total, 477 children (62% male) were recruited at a mean (SD) age of 7.3 years (0.4). There were 179 participants with FS ADHD, 86 with ST ADHD, and 212 controls. Sample retention was 78.2% at 3-year follow-up. Both the FS and ST groups were functioning worse than controls on almost all outcome measures. The best predictors of outcome for children with ADHD were working memory (academic outcome, P < .001), ADHD symptom severity (emotional-behavioral outcome, parent: P < .001; teacher: P < .01), and autism spectrum disorder symptoms (emotional-behavioral outcome, parent P = .003; social outcome, parent P = .001).

CONCLUSIONS

Children with FS and ST ADHD at age 7 experience persisting functional impairments across domains at age 10. The predictors identified at age 7 present potential targets for intervention to ameliorate impairments.

Associations Between Limbic System White Matter Structure and Socio-Emotional Functioning in Children with ADHD + ASD

Children with attention deficit/hyperactivity disorder (ADHD) combined with autism spectrum disorder (ASD) symptoms (ADHD + ASD) have poorer social and emotional functioning than those with ADHD alone. However, no studies have specifically examined the associations between ASD symptoms, measures of social and emotional functioning and limbic system white matter microstructure. Tractography on the cingulum, uncinate fasciculus and fornix were performed for 151 children with (N = 78) and without (N = 73) ADHD. Participants in the ADHD group who scored 11 or above on the Social Communication Questionnaire were classified as the ADHD + ASD group (N = 16). Significant differences in mean cingulum FA were present between the control group and the ADHD (all) group, however, no significant differences were seen between the ADHD and ADHD + ASD groups. Despite this, significant associations were seen between mean FA of the left cingulum and emotional problems for the ADHD + ASD group. Results give greater insights into the specific biological basis of emotional problems in the ADHD + ASD group, indicating that the cingulum may play a role.

Longitudinal patterns of white matter fibre density and morphology in children are associated with age and pubertal stage

The pubertal period involves dynamic white matter development. This period also corresponds with rapid gains in higher cognitive functions including attention, as well as increased risk of developing mental health difficulties. This longitudinal study comprised children aged 9-13 years (n = 130). Diffusion magnetic resonance imaging (dMRI) data were acquired (b = 2800s/mm2, 60 directions) at two time-points. We derived measures of fibre density and morphology using the fixel-based analysis framework and performed a tract-based mixed-effects modelling analysis to understand patterns of white matter development with respect to age, sex, pubertal stage, and the change in pubertal stage. We observed significant increases in apparent fibre density across a large number of white matter pathways, including major association and commissural pathways. We observed a linear relationship between pubertal stage and fibre density and morphology in the right superior longitudinal fasciculus, and fibre morphology in the right inferior longitudinal fasciculus. Finally, we report a significant interaction between the change in pubertal stage and age in the development of fibre density, for left-lateralised association tracts. Overall, white matter development across ages 9-13 years involves the expansion of major white matter fibre pathways, with key association pathways linked with pubertal stage.

Longitudinal Trajectories of Sustained Attention Development in Children and Adolescents with ADHD

The present study characterizes changes in sustained attention ability over ages 9-14, and whether longitudinal trajectories of attention development differ between persistent ADHD, remitted ADHD and control groups. The Sustained Attention to Response Task (SART) was administered to 120 children with ADHD and 123 controls on three occasions between ages 9 and 14. Trajectories of sustained attention development, indicated by changes in SART performance (standard deviation of response time [SDRT], omission errors, and ex-Gaussian parameters sigma and tau), were examined using generalized additive mixed models. For all measures there was a significant main effect of age; response time variability and number of omission errors improved linearly as children aged. However, children with ADHD had significantly greater SDRT, tau and omission errors than controls across waves. There were no significant group differences in sigma, indicating that the greater overall response time variability (SDRT) observed in ADHD was likely driven by more intermittent long responses (larger tau). Trajectories of sustained attention performance did not differ between children with persistent ADHD or ADHD in remission. Longitudinal trajectories of sustained attention development are comparable between ADHD and controls, however children with ADHD (regardless of remission status) display a performance deficit equivalent to typical controls 1-3 years younger. Findings highlight the need for continued clinical support for children in remission from ADHD and provide support for tau as an endophenotype of ADHD.

Can a teacher-led mindfulness intervention for new school entrants improve child outcomes? Protocol for a school cluster randomised controlled trial

INTRODUCTION

The first years of school are critical in establishing a foundation for positive long-term academic, social and well-being outcomes. Mindfulness-based interventions may help students transition well into school, but few robust studies have been conducted in this age group. We aim to determine whether compared with controls, children who receive a mindfulness intervention within the first years of primary school have better: (1) immediate attention/short-term memory at 18 months post-randomisation (primary outcome); (2) inhibition, working memory and cognitive flexibility at 18 months post-randomisation; (3) socio-emotional well-being, emotion-regulation and mental health-related behaviours at 6 and 18 months post-randomisation; (4) sustained changes in teacher practice and classroom interactions at 18 months post-randomisation. Furthermore, we aim to determine whether the implementation predicts the efficacy of the intervention, and the cost effectiveness relative to outcomes.

METHODS AND ANALYSIS

This cluster randomised controlled trial will be conducted in 22 primary schools in disadvantaged areas of Melbourne, Australia. 826 students in the first year of primary school will be recruited to detect between groups differences of Cohen's d=0.25 at the 18-month follow-up. Parent, teacher and child-assessment measures of child attention, emotion-regulation, executive functioning, socio-emotional well-being, mental health-related behaviour and learning, parent mental well-being, teacher well-being will be collected 6 and 18 months post-randomisation. Implementation factors will be measured throughout the study. Intention-to-treat analyses, accounting for clustering within schools and classes, will adopt a two-level random effects linear regression model to examine outcomes for the intervention versus control students. Unadjusted and analyses adjusted for baseline scores, baseline age, gender and family socioeconomic status will be conducted.

ETHICS AND DISSEMINATION

Ethics approval has been received by the Human Research Ethics Committee at the University of Melbourne. Findings will be reported in peer-review publications, national and international conference presentations and research snapshots directly provided to participating schools and families.

PRE-RESULTS TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12619000326190).

Factors Associated With Educational Support in Young Adolescents With ADHD

Objective: This study aimed to examine patterns of use and factors associated with education support use in students with ADHD during early adolescence. Method: Participants were 130 adolescents (M = 13.7 years, SD = 1.1) with ADHD. Educational support use and the factors associated with use were collected by parent and teacher questionnaires and standardized academic tests during the 2014-2015 school years. Support rates and categories are described. Logistic regression models examine individual, family, and school variables associated with support versus no support. Results: About two thirds of students with ADHD (60%) had accessed education support in the current school year, which included social support (36%), Individualized Educational Plans (IEPs; 22%), Student Support Groups (SSGs; 18%), counseling (17%), mentoring (15%), and homework support (9%). Academic risk (adjusted odds ratio [OR] = 2.30, 95% confidence interval [CI] = [1.03, 5.14], p = .04), behavioral problems (adjusted OR = 1.47, 95% CI = [1.01, 2.14], p = .047), and attending a Catholic school (adjusted OR = 5.10, 95% CI = [1.59, 16.42], p = .006) were associated with receiving support independent of adolescent age, gender, ADHD medication use, and socioeconomic status. Conclusions: Future research needs to determine whether education support makes a difference to long-term outcomes for students with ADHD and to determine why some students at academic risk receive no support.

Associations Between Family and Community Protective Factors and Attention-Deficit/Hyperactivity Disorder Outcomes Among US Children

BACKGROUND

Evidence has established the association between risk factors and attention-deficit/hyperactivity disorder (ADHD) severity, but less is known about factors that may have protective effects on clinical, academic, and social outcomes among children with ADHD.

OBJECTIVE

To examine associations between family cohesion, caregiver social support, community support, and (1) ADHD severity, (2) school engagement, and (3) difficulty making or keeping friends.

METHODS

Cross-sectional study of school-aged and adolescent children with ADHD using data from the 2016 National Survey of Children's Health. Our outcomes were (1) parent-rated ADHD severity, (2) school engagement, and (3) difficulty making or keeping friends. Our independent variables were (1) family cohesion, (2) caregiver social support, and (3) community support. We used logistic regression models to examine associations between our independent variables and each of our outcome variables, adjusting for child and parent sociodemographic characteristics.

RESULTS

In our sample (N = 4,122, weighted N = 4,734,322), children exposed to family cohesion and community support had lower odds of moderate to severe ADHD [adjusted OR (aOR): 0.73 (0.55-0.97); aOR: 0.73 (0.56-0.95), respectively], higher odds of school engagement [aOR: 1.72, (1.25-2.37); aOR: 1.38, (1.04-1.84), respectively], and lower odds of difficulty making or keeping friends [aOR: 0.64, (0.48-0.85); aOR: 0.52, (0.40-0.67), respectively].

CONCLUSION

Among children with ADHD, family cohesion and community support show protective effects in clinical, academic, and social outcomes. Systematically identifying family- and community-level strengths may be important components of multimodal treatment strategies in children with ADHD.

Characterisation of depressive symptoms in young children with and without attention deficit hyperactivity disorder

Depressive symptoms and attention deficit hyperactivity disorder (ADHD) are prevalent and commonly co-occur in childhood. To assist with early identification of depression in children with ADHD, we aimed to: (1) use factor analysis to determine whether the construct of depression is measured consistently in those with and without ADHD; and (2) determine whether overall depressive symptoms and specific depressive symptoms were elevated in children with ADHD relative to controls. Participants comprised a community-based sample of 179 children with ADHD (51% Combined presentation, 35% Inattentive presentation) and 212 non-ADHD controls aged 6-8 years. Participants were screened for ADHD and underwent a structured diagnostic interview which confirmed ADHD status and assessed depressive symptoms. The factor structure of depressive symptoms was similar, enabling comparisons between the two groups to be made. Eighteen children with ADHD (10%) and three control participants (1%) experienced either MDD or subthreshold MDD. Children with ADHD experienced more depressive symptoms than controls (Cohen's d =1.19, p < 0.001), with the following symptoms elevated in children with ADHD relative to controls: sadness (32% vs. 14%, p < 0.001), irritability (52% vs. 19%, p < 0.001), insomnia (56% vs. 22%, p < 0.001), psychomotor agitation (53% vs. 9%, p < 0.001), feeling bad about oneself (50% vs. 24%, p < 0.001), difficulty concentrating (75% vs. 14%, p < 0.001) and making decisions (56% vs. 17%, p < 0.001). This study provides support for the occurrence of depressive symptoms in children with ADHD as young as six and highlights the importance of early assessment for depressive symptoms in children with ADHD.

Association Between Parenting Style and Socio-Emotional and Academic Functioning in Children With and Without ADHD: A Community-Based Study

OBJECTIVE

In a community-based study, we examined parenting style and its relationship to functioning in 6- to 8-year-old children ( n = 391; 66.2% male) with ADHD ( n = 179), compared with non-ADHD controls ( n = 212).

METHOD

Parenting style was assessed using parent-reported (93.5% female) measures of warmth, consistency, and anger. Child socio-emotional and academic functioning was measured via parent- and teacher-reported scales, and direct academic assessment.

RESULTS

Parents reported less consistency and more anger in the ADHD group compared with non-ADHD controls, with no differences in warmth. Parenting warmth, consistency, and anger were associated with parent-reported aspects of socio-emotional functioning for children with ADHD and non-ADHD controls, after adjusting for socio-demographic variables, externalizing comorbidities, and ADHD symptom severity. Parenting style was no longer related to academic functioning and most teacher-reported outcomes after adjustment.

CONCLUSION

Generic parenting interventions that promote warm, consistent, and calm parenting may help alleviate socio-emotional impairments in children with ADHD.

Examining the Relationship Between Children's ADHD Symptomatology and Inadequate Parenting: The Role of Household Chaos

OBJECTIVE

This study examines the interrelations of parenting practices, emotional climate, and household chaos in families with children with and without ADHD. In particular, indirect pathways from children's ADHD symptomatology to inadequate parenting and negative emotional climate via household chaos were investigated.

METHOD

Parenting, emotional climate, and household chaos were assessed using questionnaires and a speech sample of parents of 31 children with and 53 without ADHD, aged 7 to 13 years.

RESULTS

Group differences were found for certain parenting dimensions, the parent-child relationship, critical comments, and household chaos. While we found significant indirect effects between children's ADHD and certain parenting dimensions through household chaos, no effects were found for any aspect of emotional climate.

CONCLUSION

Children's ADHD symptoms translate into inadequate parenting through household chaos, which underlines the need for interventions to improve household organization skills in parents of children with ADHD.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A network analysis approach to ADHD symptoms: More than the sum of its parts

In interpreting attention-deficit/hyperactivity disorder (ADHD) symptoms, categorical and dimensional approaches are commonly used. Both employ binary symptom counts which give equal weighting, with little attention to the combinations and relative contributions of individual symptoms. Alternatively, symptoms can be viewed as an interacting network, revealing the complex relationship between symptoms. Using a novel network modelling approach, this study explores the relationships between the 18 symptoms in the Diagnostic Statistical Manual (DSM-5) criteria and whether network measures are useful in predicting outcomes. Participants were from a community cohort, the Children’s Attention Project. DSM ADHD symptoms were recorded in a face-to-face structured parent interview for 146 medication naïve children with ADHD and 209 controls (aged 6–8 years). Analyses indicated that not all symptoms are equal. Frequencies of endorsement and configurations of symptoms varied, with certain symptoms playing a more important role within the ADHD symptom network. In total, 116,220 combinations of symptoms within a diagnosis of ADHD were identified, with 92% demonstrating a unique symptom configuration. Symptom association networks highlighted the relative importance of hyperactive/impulsive symptoms in the symptom network. In particular, the ‘motoric’-type symptoms as well as interrupts as a marker of impulsivity in the hyperactive domain, as well as loses things and does not follow instructions in the inattentive domain, had high measures of centrality. Centrality-measure weighted symptom counts showed significant association with clinical but not cognitive outcomes, however the relationships were not significantly stronger than symptom count alone. The finding may help to explain heterogeneity in the ADHD phenotype.

Chronic tic disorders in children with ADHD

OBJECTIVE

To examine in a community-based cohort: (1) the prevalence of chronic tic disorder (CTD) in children with attention-deficit/hyperactivity disorder (ADHD) compared with non-ADHD controls at ages 7 and 10; and (2) the additional psychiatric and functional burden of CTD in children with ADHD.

METHODS

Children aged 6-8 years with ADHD (n=179) and controls (n=212) were recruited through 43 Victorian schools using parent and teacher screening surveys (Conners 3 ADHD Index), followed by case confirmation (Diagnostic Interview Schedule for Children-IV (DISC-IV)). CTD was identified using the DISC-IV categories chronic motor tic disorder, chronic vocal tic disorder or Tourette syndrome at baseline and 36-month follow-up. Internalising and externalising disorders, social functioning, academic performance and quality of life were also measured. Tests of proportions and independent t-tests were used to compare the ADHD+CTD group with sex-matched ADHD alone children.

RESULTS

Compared with controls, children with ADHD were 4.1 (95% CI 1.1 to 14.1) times more likely to have CTD at age 7, and 5.9 (95% CI 1.6 to 17.9) times more likely at age 10. Children with ADHD+CTD experienced higher rates of internalising disorders and peer problems, and poorer quality of life than those with ADHD alone.

CONCLUSIONS

CTD prevalence is higher in children with ADHD compared with controls, and confers substantial additional psychiatric and functional burden. Clinicians need to consider CTD in both the initial assessment and ongoing management of children with ADHD, and address both the symptoms and the associated impairments.

Maternal ADHD symptoms, child ADHD symptoms and broader child outcomes

OBJECTIVE

This study investigated the associations between maternal symptoms of attention deficit hyperactivity disorder (ADHD) and child functional outcomes in a community-based sample of children with and without ADHD.

DESIGN AND SETTING

In this cohort study, children with ADHD and healthy controls were recruited through schools in Melbourne, Australia, using a combined screening (Conners 3 ADHD Index) and case confirmation (Diagnostic Interview Schedule for Children Version IV) procedure.

PATIENTS

117 children with ADHD and 149 control children were included in the analyses.

MAIN OUTCOME MEASURES

Maternal ADHD symptoms (Conners Adult ADHD Rating Scale) and child outcomes (ADHD severity, quality of life (QoL), academic competence, social-emotional functioning) were measured at a mean child age of 8.9 years.

RESULTS

Mothers of children with ADHD had clinically elevated ADHD symptoms compared with mothers of control children (adjusted analysis: 18.0% vs 2.0%, P<0.001). Elevated maternal ADHD symptoms were associated with greater child ADHD symptom severity and lower QoL by maternal report for children with (severity P=0.01; QoL P=0.003) and without (severity P=0.003; QoL P=0.003) ADHD. Elevated maternal ADHD symptoms were additionally associated with increased parent-rated emotional problems, peer problems and total impairment scores in children without ADHD (all P<0.01).

CONCLUSIONS

Maternal ADHD symptoms are associated with increased ADHD symptom severity and reduced QoL by maternal report in offspring with or without ADHD, and have broader negative associations with emotional and social functioning in children without ADHD. In the evaluation of the referred children, maternal ADHD symptoms should be considered and referral made to adult services where indicated.

Trauma exposure in children with and without ADHD: prevalence and functional impairment in a community-based study of 6-8-year-old Australian children

Both ADHD and trauma exposure are common childhood problems, but there are few empirical data regarding the association between the two conditions. The aims of this study were to compare lifetime prevalence of trauma exposure in children with and without ADHD, and to explore the association between trauma exposure and outcomes in children with ADHD. Children aged 6-8 years with ADHD (n = 179) and controls (n = 212) recruited from 43 schools were assessed for ADHD, trauma exposure and comorbid mental health disorders using the Diagnostic Interview Schedule for Children IV. Outcome data were collected by direct child assessment, parent report and teacher-report, and included ADHD symptom severity, internalizing and externalizing problems, quality of life, and academic functioning. Logistic and linear regression models were used to examine differences adjusted for child and family socio-demographics. Children with ADHD were more likely than controls to have ever experienced a traumatic event (27 vs 16%; OR: 1.99; 95% CI 1.21, 3.27). This difference remained significant in the adjusted model (OR: 1.76, 95% CI 1.03, 3.01) accounting for child factors (age and gender) and family socio-demographic factors (parent age, parent high school completion and single parent status). Among those with ADHD, trauma-exposed children had higher parent-reported ADHD severity and more externalizing problems than non-exposed children, however, this effect attenuated in adjusted model. Children with ADHD were more likely to have experienced a traumatic event than controls. The high prevalence of trauma exposure in our sample suggests that clinicians should evaluate for trauma histories in children presenting with ADHD.

Association Between Parenting Style and Social Outcomes in Children with and Without Attention-Deficit/Hyperactivity Disorder: An 18-Month Longitudinal Study

OBJECTIVE

In a community-based sample of children with attention-deficit/hyperactivity disorder (ADHD) (n = 179) and non-ADHD controls (n = 212), this longitudinal study explored changes in parenting style over time; and whether parenting style prospectively predicts child functional outcomes.

METHODS

Attention-deficit/hyperactivity disorder diagnosis was assessed using the Conners ADHD index and Diagnostic Interview Schedule for Children IV. Children (70.3% boys) were assessed at baseline (mean age: 7.3 yr) and after 18 months (mean age: 8.9 yr) using a range of parent- and teacher-reported measures of child socioemotional and academic functioning. Parenting style was assessed through parent-reported measures of warmth, consistency, and anger.

RESULTS

At 18-month follow-up, there was a small significant decline in parenting warmth and parenting anger, and an increase in parenting consistency across groups. In the ADHD group, parenting warmth at baseline was positively related to 18-month prosocial behavior and responsibility by parent report, whereas parenting consistency predicted these child outcomes by teacher report. Parenting anger was positively associated with peer problems and negatively associated with prosocial behavior, self-control, and responsibility by parent report. Associations were similar for non-ADHD controls and all associations held after adjusting for a range of family, child, and parent factors. After additional adjustment of baseline levels of child functioning, parenting warmth and consistency continued to be associated with 18-month child outcomes. Parenting style was unrelated to emotional problems and academic competence over time.

CONCLUSION

Parenting style is independently related to aspects of future social outcomes of children with ADHD. Results hold implications for parenting interventions aimed at managing ADHD-related social impairments over time.

Correlates of Anxiety in 6- to 8-Year-Old Children With ADHD: A Community-Based Study

OBJECTIVE

The aim of this study was to identify the child and parent/family correlates of anxiety in a community-based sample of children with ADHD.

METHOD

Children (6-8 years) with ADHD ( n = 179) and controls ( n = 212) were assessed for ADHD and anxiety using the Diagnostic Interview Schedule for Children IV. Potential child and parent/family correlates were measured through direct assessments, and parent- and teacher-reported questionnaires. Associations were examined using univariate and multivariate logistic regression analyses.

RESULTS

One in four children with ADHD ( n = 44) met criteria for an anxiety disorder, compared with one in 20 controls ( n = 10). Anxiety was common in both boys and girls with ADHD. The strongest correlates of anxiety in multivariate analyses were ADHD subtype, primary caregiver psychosocial distress, and neighborhood socioeconomic disadvantage.

CONCLUSION

Anxiety is common in children with ADHD. This study provides insight into the potential parent/family stressors that may increase risk for anxiety in children with ADHD.

Relationship Between Executive Functioning and Symptoms of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder in 6-8 Year Old Children

This study examined relationships between executive functioning (EF) and ADHD/ASD symptoms in 339 6-8 year-old children to characterise EF profiles associated with ADHD and ADHD + ASD. ADHD status was assessed using screening surveys and diagnostic interviews. ASD symptoms were measured using the Social Communication Questionnaire, and children completed assessments of EF. We found the EF profile of children with ADHD + ASD did not differ from ADHD-alone and that lower-order cognitive skills contributed significantly to EF. Dimensionally, ASD and inattention symptoms were differentially associated with EF, whereas hyperactivity symptoms were unrelated to EF. Differences between categorical and dimensional findings suggest it is important to use both diagnostic and symptom based approaches in clinical settings when assessing these children's functional abilities.

Association between autism symptoms and family functioning in children with attention-deficit/hyperactivity disorder: a community-based study

Autism spectrum disorder (ASD) symptoms are elevated in populations of children with attention-deficit/hyperactivity disorder (ADHD). This study examined cross-sectional associations between ASD symptoms and family functioning in children with and without ADHD. Participants were recruited to a longitudinal cohort study, aged 6-10 years (164 ADHD; 198 controls). ADHD cases were ascertained using community-based screening and diagnostic confirmation from a diagnostic interview. ASD symptoms were measured using the Social Communication Questionnaire. Outcome variables were parent mental health, family quality of life (FQoL), couple conflict and support, and parenting behaviours. After adjustment for a range of child and family factors (including other mental health comorbidities), higher ASD symptoms were associated with poorer FQoL across all three domains; emotional impact (p = 0.008), family impact (p = 0.001) and time impact (p = 0.003). In adjusted analyses by subgroup, parents of children with ADHD+ASD had poorer parent self-efficacy (p = 0.01), poorer FQoL (p ≤ 0.05), with weak evidence of an association for less couple support (p = 0.06), compared to parents of children with ADHD only. Inspection of covariates in the adjusted analyses indicated that the association between ASD symptoms and most family functioning measures was accounted forby child internalising and externalising disorders, ADHD severity, and socioeconomic status; however, ASD symptoms appear to be independently associated with poorer FQoL in children with ADHD. The presence of ASD symptoms in children with ADHD may signal the need for enhanced family support.