Determinants of inter-practice variation in ADHD diagnosis and stimulant prescribing: cross-sectional database study of a national surveillance network

Mapping neurodevelopmental diversity in executive function

Executive function, an umbrella term used to describe the goal-directed regulation of thoughts, actions, and emotions, is an important dimension implicated in neurodiversity and established malleable predictor of multiple adult outcomes. Neurodevelopmental differences have been linked to both executive function strengths and weaknesses, but evidence for associations between specific profiles of executive function and specific neurodevelopmental conditions is mixed. In this exploratory study, we adopt an unsupervised machine learning approach (self-organising maps), combined with k-means clustering to identify data-driven profiles of executive function in a transdiagnostic sample of 566 neurodivergent children aged 8-18 years old. We include measures designed to capture two distinct aspects of executive function: performance-based tasks designed to tap the state-like efficiency of cognitive skills under optimal conditions, and behaviour ratings suited to capturing the trait-like application of cognitive control in everyday contexts. Three profiles of executive function were identified: one had consistent difficulties across both types of assessments, while the other two had inconsistent profiles of predominantly rating- or predominantly task-based difficulties. Girls and children without a formal diagnosis were more likely to have an inconsistent profile of primarily task-based difficulties. Children with these different profiles had differences in academic achievement and mental health outcomes and could further be differentiated from a comparison group of children on both shared and profile-unique patterns of neural white matter organisation. Importantly, children's executive function profiles were not directly related to diagnostic categories or to dimensions of neurodiversity associated with specific diagnoses (e.g., hyperactivity, inattention, social communication). These findings support the idea that the two types of executive function assessments provide non-redundant information related to children's neurodevelopmental differences and that they should not be used interchangeably. The findings advance our understanding of executive function profiles and their relationship to behavioural outcomes and neural variation in neurodivergent populations.

Adult ADHD Positive Screening and Sibship, Birth Order and Academic Achievement: Implications for Epidemiologists and Physicians in the Kingdom of Saudi Arabia

Background

Attention deficit hyperactivity disorder (ADHD) among the youth and university students differs internationally. This study aims to assess the prevalence of ADHD positivity from a validated screening test among medical students across the Kingdom of Saudi Arabia (KSA) and its associated sociodemographic and family-related factors and the impact of ADHD on students' academic performance. Also, to highlight the implications of the current findings on epidemiologists and family physicians in the region.

Methods

This cross-sectional study utilised the Adult ADHD Self-Report Scale (ASRS) symptom checklist along with several questions on sociodemographic, siblings and personal academic achievement. Multivariable logistic regression models were performed to obtain the Odds Ratios (ORs) of risk of ADHD screening positivity and their 95% confidence intervals (CIs) against potential predictors.

Results

The overall prevalence of positively screened medical students was 38.86%. After adjustment, a statistically significant increased risk of ADHD positivity was observed for students who had one sibling (OR = 1.70, 95% CI = 1.09-2.64). Also, upon examination of birth order, a significant increased risk was observed for students who were firstborn (OR = 1.22, 95% CI = 1.02-1.47). With regard to academic achievement, both before and after adjustment, students who screened positive had a 14% increased risk of obtaining an F GPA (OR = 1.14, 95% CI = 0.99-1.30).

Conclusion

A considerable number of medical students are potentially positive for ADHD. Albeit not diagnostically confirmed - this indicates that a substantial number of people have displayed symptoms akin to ADHD, but were not clinically diagnosed. Research into ADHD in the region is still in its infancy, and epidemiologists would benefit from high-quality databases to address this condition. Also, primary care physicians should develop skills in detecting and managing ADHD in children at an earlier age to improve symptoms in adulthood.

Geographic variation and sociodemographic correlates of prescription psychotropic drug use among children and youth in Ontario, Canada: a population-based study

BACKGROUND

Population-based research examining geographic variability in psychotropic medication dispensing to children and youth and the sociodemographic correlates of such variation is lacking. Variation in psychotropic use could reflect disparities in access to non-pharmacologic interventions and identify potentially concerning use patterns.

METHODS

We conducted a population-based study of all Ontario residents aged 0 to 24 years who were dispensed a benzodiazepine, stimulant, antipsychotic or antidepressant between January 1, 2018, and December 31, 2018. We conducted small-area variation analyses and identified determinants of dispensing using negative binomial generalized estimating equation models.

RESULTS

The age- and sex-standardized rate of psychotropic dispensing to children and youth was 76.8 (range 41.7 to 144.4) prescriptions per 1000 population, with large variation in psychotropic dispensing across Ontario's census divisions. Males had higher antipsychotic [rate ratio (RR) 1.40; 95% confidence interval (CI) 1.36 to 1.44) and stimulant (RR 1.75; 95% CI 1.70 to 1.80) dispensing rates relative to females, with less use of benzodiazepines (RR 0.85; 95% CI 0.83 to 0.88) and antidepressants (RR 0.81; 95% CI 0.80 to 0.82). Lower antipsychotic dispensing was observed in the highest income neighbourhoods (RR 0.72; 95% CI 0.70 to 0.75) relative to the lowest. Benzodiazepine (RR 1.12; 95% CI 1.01 to 1.24) and stimulant (RR 1.11; 95% CI 1.01 to 1.23) dispensing increased with the density of mental health services in census divisions, whereas antipsychotic use decreased (RR 0.82; 95% CI 0.73 to 0.91). The regional density of child and adolescent psychiatrists and developmental pediatricians (RR 1.00; 95% CI 0.99 to 1.01) was not associated with psychotropic dispensing.

CONCLUSION

We found significant variation in psychotropic dispensing among young Ontarians. Targeted investment in regions with long wait times for publicly-funded non-pharmacological interventions and novel collaborative service models may minimize variability and promote best practices in using psychotropics among children and youth.

Age-related clinical characteristics of children and adolescents with ADHD

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) has been associated with difficulties in regulating aversion states, high functional impairment, and a high risk of psychopathology across the lifespan. ADHD is clinically heterogeneous, with a wide spectrum of severity and associated symptoms. Clinical characteristics need to be carefully defined in different periods of life as ADHD course, symptoms, and comorbidities may fluctuate and change over time. Adolescence usually represents the transition from primary to secondary education, with a qualitative and quantitative change in environmental and functional demands, thus driving symptoms' change.

METHODS

In order to characterize age-related clinical features of children (<11 years) and adolescents (≥11 years) with ADHD, we conducted a naturalistic study on 750 children and adolescents assessed for ADHD at our Neuropsychiatry Unit over the course of 3 years (2018-2020).

RESULTS

We found that ADHD symptoms were significantly higher in children than adolescents. More importantly, we found worse global functioning, lower adaptive skills, higher levels of anxiety and depressive symptoms, somatic complaints, emotional dysregulation, social problems, and aggression in adolescents, despite a lower severity of ADHD-specific symptoms.

CONCLUSION

These results should be confirmed in longitudinal observational studies of adequate sample size in order to reliably describe a potential course characterized by worsening of functioning, reduction in ADHD-specific symptoms and increase in general psychopathology during the transition from childhood to adolescence.

Effect of short-term methylphenidate on social impairment in children with attention deficit/hyperactivity disorder: systematic review

Attention Deficit/Hyperactivity disorder (ADHD) is one of the most common disorders in school-age children. In addition to learning difficulties associated with the disorder's core symptoms of inattention and hyperactivity, children with ADHD display substantial social impairments. Methylphenidate (MPH) in formulations such as Ritalin or Concerta mitigates inattention and hyperactivity, but the effects of the therapy on social behavior in children with ADHD are not clear. This review aims to determine the effectiveness of short term (up to 6 months) MPH treatment on three domains of social skills in children aged 6-14 with ADHD: (i) Recognition of nonverbal emotional expressions, which are a marker of inherent (unlearned) social understanding, (ii) theory of mind (ToM) components that relate to learned cognition and social communication, and (iii) social competence in everyday environments. 15 relevant studies were identified based on inclusion/exclusion criteria. The results show mixed effects: the overall social performance as evaluated by parents, teachers or peers, and some components of ToM, were found to improve following a weeks-long course of MPH treatment. However, the effects of the medication are less clear when evaluating momentary/nonverbal social responses such as reactions to emotional facial expressions. While the findings of this review indicate that an MPH medication regime of order weeks to months could improve, to a degree, social impairment in children with ADHD, more studies are required to identify the medications' mechanism and confirm such a conclusion.

Time of onset and/or diagnosis of ADHD in European children: a systematic review

BACKGROUND

Attention-Deficit/ Hyperactivity Disorder (ADHD) is one of the most common childhood neurobehavioral conditions. Symptoms related to this disorder cause a significant impairment in school tasks and in the activities of children's daily lives; an early diagnosis and appropriate treatment could almost certainly help improve their outcomes. The current study, part of the Models Of Child Health Appraised (MOCHA) project, aims to explore the age at which children experience the onset or diagnosis of ADHD in European countries.

METHODS

A systematic review was done examining the studies reporting the age of onset/diagnosis (AO/AD) of ADHD in European countries (28 European Member States plus 2 European Economic Area countries), published between January 1, 2010 and December 31, 2019. Of the 2276 identified studies, 44 met all the predefined criteria and were included in the review.

RESULTS

The lowest mean AO in the children diagnosed with ADHD alone was 2.25 years and the highest was 7.5 years. It was 15.3 years in the children with ADHD and disruptive behaviour disorder. The mean AD ranges between 6.2 and 18.1 years.

CONCLUSIONS

Our findings indicate that there is a wide variability in both the AO and AD of ADHD, and a too large distance between AO and AD. Since studies in the literature suggest that an early identification of ADHD symptoms may facilitate early referral and treatment, it would be important to understand the underlying reasons behind the wide variability found.

TRIAL REGISTRATION

PROSPERO registration: CRD42017070631 .

Attention Deficit Hyperactivity Disorder (ADHD) among elementary students in rural China: Prevalence, correlates, and consequences

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a widely recognized mental health problem in developed countries but remains under-investigated in developing settings. This study examines the prevalence, correlates, and consequences of ADHD symptoms among elementary school students in rural China.

METHODS

Cross-sectional data were collected from 6,719 students across 120 rural primary schools in China on ADHD symptoms, demographic characteristics, and academic performance in reading and math. ADHD symptoms were evaluated using the caregiver-reported ADHD Rating Scale-IV.

RESULTS

The prevalence of ADHD symptoms was 7.5% in our sample. Male students, students in lower grade levels, and students with lower cognitive ability showed a significantly higher prevalence of ADHD symptoms (ORs = 2.56, 2.06, and 1.84, respectively; p<0.05). Left-behind children showed a significantly lower prevalence of ADHD symptoms than did children who were living with their parents (OR = 0.74, p < 0.05). Adjusted regressions show that students with ADHD symptoms scored 0.12 standardized deviations lower in reading (p < 0.05) and 0.19 standardized deviations lower in math (p < 0.01).

LIMITATIONS

The ADHD Rating Scale-IV is a screening scale rather than a diagnostic test. Caregiver self-report measures also may underestimate ADHD symptoms for our sample.

CONCLUSIONS

ADHD is a common disorder among rural students in China and appears to be contributing to poor academic outcomes. The higher prevalence of ADHD among students with low cognitive ability also suggests that many rural children in China face multifactorial learning challenges. Taken together, the findings indicate a need for educators and policymakers in rural China to develop programs to reduce risk and support students with ADHD symptoms.

Excess mortality in the first COVID pandemic peak: cross-sectional analyses of the impact of age, sex, ethnicity, household size, and long-term conditions in people of known SARS-CoV-2 status in England

Background

The SARS-CoV-2 pandemic has passed its first peak in Europe.

Aim

To describe the mortality in England and its association with SARS-CoV-2 status and other demographic and risk factors.

Design and setting

Cross-sectional analyses of people with known SARS-CoV-2 status in the Oxford RCGP Research and Surveillance Centre (RSC) sentinel network.

Method

Pseudonymised, coded clinical data were uploaded from volunteer general practice members of this nationally representative network (n = 4 413 734). All-cause mortality was compared with national rates for 2019, using a relative survival model, reporting relative hazard ratios (RHR), and 95% confidence intervals (CI). A multivariable adjusted odds ratios (OR) analysis was conducted for those with known SARS-CoV-2 status (n = 56 628, 1.3%) including multiple imputation and inverse probability analysis, and a complete cases sensitivity analysis.

Results

Mortality peaked in week 16. People living in households of ≥9 had a fivefold increase in relative mortality (RHR = 5.1, 95% CI = 4.87 to 5.31, P<0.0001). The ORs of mortality were 8.9 (95% CI = 6.7 to 11.8, P<0.0001) and 9.7 (95% CI = 7.1 to 13.2, P<0.0001) for virologically and clinically diagnosed cases respectively, using people with negative tests as reference. The adjusted mortality for the virologically confirmed group was 18.1% (95% CI = 17.6 to 18.7). Male sex, population density, black ethnicity (compared to white), and people with long-term conditions, including learning disability (OR = 1.96, 95% CI = 1.22 to 3.18, P = 0.0056) had higher odds of mortality.

Conclusion

The first SARS-CoV-2 peak in England has been associated with excess mortality. Planning for subsequent peaks needs to better manage risk in males, those of black ethnicity, older people, people with learning disabilities, and people who live in multi-occupancy dwellings.

Household presentation of influenza and acute respiratory illnesses to a primary care sentinel network: retrospective database studies (2013-2018)

Background

Direct observation of the household spread of influenza and respiratory infections is limited; much of our understanding comes from mathematical models. The study aims to determine household incidence of influenza-like illness (ILI), lower (LRTI) and upper (URTI) respiratory infections within a primary care routine data and identify factors associated with the diseases’ incidence.

Methods

We conducted two five-year retrospective analyses of influenza-like illness (ILI), lower (LRTI) and upper (URTI) respiratory infections using the England Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care sentinel network database; a cross-sectional study reporting incident rate ratio (IRR) from a negative binomial model and a retrospective cohort study, using a shared gamma frailty survival model, reporting hazard ratios (HR). We reported the following household characteristics: children < 5 years old, each extra household member, gender, ethnicity (reference white), chronic disease, pregnancy, and rurality.

Results

The IRR where there was a child < 5 years were 1·62 (1·38–1·89, p < 0·0001), 2·40 (2.04–2.83, p < 0·0001) and 4·46 (3.79–5.255, p < 0·0001) for ILI, LRTI and URTI respectively. IRR also increased with household size, rurality and presentations and by female gender, compared to male. Household incidence of URTI and LRTI changed little between years whereas influenza did and were greater in years with lower vaccine effectiveness.

The HR where there was a child < 5 years were 2·34 (95%CI 1·88–2·90, p < 0·0001), 2·97 (95%CI 2·76–3·2, p < 0·0001) and 10·32 (95%CI 10.04–10.62, p < 0·0001) for ILI, LRTI and URTI respectively. HR were increased with female gender, rurality, and increasing household size.

Conclusions

Patterns of household incidence can be measured from routine data and may provide insights for the modelling of disease transmission and public health policy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09790-3.

Disparities in the excess risk of mortality in the first wave of COVID-19: Cross sectional study of the English sentinel network

OBJECTIVES

Few studies report contributors to the excess mortality in England during the first wave of coronavirus disease 2019 (COVID-19) infection. We report the absolute excess risk (AER) of mortality and excess mortality rate (EMR) from a nationally representative COVID-19 sentinel surveillance network including known COVID-19 risk factors in people aged 45 years and above.

METHODS

Pseudonymised, coded clinical data were uploaded from contributing primary care providers (N = 1,970,314, ≥45years). We calculated the AER in mortality by comparing mortality for weeks 2 to 20 this year with mortality data from the Office for National Statistics (ONS) from 2018 for the same weeks. We conducted univariate and multivariate analysis including preselected variables. We report AER and EMR, with 95% confidence intervals (95% CI).

RESULTS

The AER of mortality was 197.8/10,000 person years (95%CI:194.30-201.40). The EMR for male gender, compared with female, was 1.4 (95%CI:1.35-1.44, p<0.00); for our oldest age band (≥75 years) 10.09 (95%CI:9.46-10.75, p<0.00) compared to 45-64 year olds; Black ethnicity's EMR was 1.17 (95%CI: 1.03-1.33, p<0.02), reference white; and for dwellings with ≥9 occupants 8.01 (95%CI: 9.46-10.75, p<0.00). Presence of all included comorbidities significantly increased EMR. Ranked from lowest to highest these were: hypertension, chronic kidney disease, chronic respiratory and heart disease, and cancer or immunocompromised.

CONCLUSIONS

The absolute excess mortality was approximately 2 deaths per 100 person years in the first wave of COVID-19. More personalised shielding advice for any second wave should include ethnicity, comorbidity and household size as predictors of risk.