Attention-deficit/Hyperactivity Disorder in Children: Clinical Profile and Co-morbidity

Comparison of brief group behavioural parent training with individual parent training for preschool children with attention deficit hyperactivity disorder: A randomized feasibility study

BACKGROUND

Behaviour parent training (BPT) is first-line treatment for preschool attention deficit hyperactivity disorder (ADHD). BPT in a group format can be a cost- and time-effective alternative in low and middle-income countries (LMIC) settings with limited resources. We conducted a randomized controlled trial to compare the feasibility and efficacy of group BPT with individual BPT in improving ADHD severity in the preschool age group over 12 weeks.

METHODS

After approval by the ethical committee, the study was conducted in the child guidance clinic, JIPMER. Fifty-six children aged 2.5 to 6 years diagnosed with ADHD according to DSM5 were recruited. Children with autism spectrum disorder and a social quotient less than 50 were excluded. Block randomization parallel design was done. Group interventions were delivered with 4-8 parents per group, focusing on psychoeducation, structuring of routine, attention enhancing tasks, behavioural parenting techniques, and TAU. ADHD severity was assessed using Conner's abbreviated behaviour rating scale at baseline, 4, 8, and 12 weeks. Parental stress was estimated by FISC-MR adapted for ADHD. Statistical analysis included repeated measures ANOVA.

RESULTS

Significant improvement was noticed for both groups (F = 20.261, p < .001, ES (η2 ) = 0.539). Group intervention was not inferior to individual BPT in reducing ADHD severity (F = 0.860, p = .468, ES (η2 ) = 0.047). There was a statistically significant difference from baseline to 12 weeks of intervention in the reduction of parental stress (F = 20.80, p < .001, ES (η2 ) = 0.278) and enhancement of the coping strategies (F = 64.4, (p < .001), ES (η2 ) = 0.78). The intervention had high attendance and fidelity rates.

CONCLUSION

Group BPT was promising in treating ADHD in low-resource settings.

Attention Deficit Hyperactivity Disorder in Preschool Children: A Cross-Sectional Study of Clinical Profile and Co-morbidity

Background:

Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) in preschool children is challenging and complicated owing to the presence of developmentally appropriate overactivity and a dynamic developmental/learning phase shaping their behaviour. We aimed to study the clinical profile and co-morbidity of ADHD in preschool children.

Methods:

Fifty consecutively presenting preschool children with ADHD were enrolled from our child guidance clinic (CGC) between January 2017 and December 2018. The diagnosis and assessment of comorbidities were based on the DSM-5 criteria and Vanderbilt teacher and parent rating scales. Relevant clinical and sociodemographic profiles were assessed and analyzed for association with ADHD subtypes and comorbidity.

Results:

Preschool children with ADHD constituted 8% of all patients visiting the CGC and one-fifth of all children with ADHD. Male:female ratio was 11.5:1. Hyperactive-impulsive was the commonest type, and oppositional defiant disorder (ODD) was the commonest comorbidity. Most children belonged to the lower-middle socioeconomic group. Language delay was observed in 20%. Median social quotient measured using the Vineland Social Maturity Scale was 83.

Conclusions:

Preschool children predominantly have the hyperactive impulsive type of ADHD. Isolated language delay was the predominant comorbid developmental disorder, and ODD was the predominant comorbid behavioural disorder. Addressing these issues would help in the appropriate management of these children.

Effects of Iron Supplementation on Attention Deficit Hyperactivity Disorder in Children Treated with Methylphenidate

Objective

To evaluate the effect of iron on the attention deficit hyperactivity disorder, treated with methylphenidate.

Methods

This double-blind, randomized placebo-controlled clinical trial was performed on 50 children with attention deficit hyperactivity disorder under the treatment of methylphenidate, with ferritin levels below 30 ng/ml and absence of anemia. They were randomly assigned into two groups of ferrous sulfate and placebo, for 12 weeks. Conners' Parent Rating Scale (CPRS) was used to assess the outcome in the first, sixth, and twelfth weeks.

Results

Almost all CPRS subscales improved in the ferrous sulfate group from the baseline to the endpoint, although only the changes in conduct subscale scores were significant (p = 0.003). There was no significant difference in score changes between two groups in intergroup comparison. Also, the score of learning problems (p = 0.007) in the first six weeks, and conduct (p = 0.023) and psychosomatic (p = 0.018) subscales in the second six weeks were improved in the ferrous sulfate group compared with the placebo group.

Conclusion

Our study showed promising effects of iron supplementation in the improvement of subscales of the CPRS.

Pre-school attention deficit hyperactivity disorder: 12 weeks prospective study

INTRODUCTION

Extant literature lack studies on behavioural training or pharmacotherapy in Indian preschool children. With adverse long term outcomes, effective, safe and affordable early interventions for ADHD are a priority. Aim of this prospective study is to report on short term outcome of preschool ADHD with specific focus on safety and tolerability of medications.

METHODS

Children with ADHD aged 2.5-6 years were assessed for severity and adverse events at baseline and follow-up using Conner's abbreviated rating scale and Clinical Global Impression-Severity scale. Children with Autism spectrum disorder and those with social quotient less than 50 were excluded. Statistical Analysis included descriptive statistics and Repeated measures ANOVA.

RESULTS

Of 56 children recruited, 33.93 %(N = 19) were on behavioural interventions alone, 66.07 %(N = 37) were on a combination of medication and behavioural intervention. All children received treatment according to standard care. The most prescribed drug was clonidine (44.64%), then risperidone (28.7%), methylphenidate (10.7%) and atomoxetine (10.7%). Medication choice was determined by affordability, availability and comorbidity profile. Sedation occurred in 24 % of children on clonidine. Atomoxetine was not well tolerated in 2 children. Methylphenidate was well tolerated. Irrespective of medication choice, all children showed significant improvement at 12 weeks (p < 0.001).

CONCLUSIONS

Choice of interventions is largely determined by availability and affordability. There is a need for structured parent behavioural training program deliverable in low resource setting. Anti-ADHD medications should be made available under the NMHP, RBSK program and all government settings in India, to address over-prescription of antipsychotics in preschool ADHD.

Prevalence and correlates of Attention Deficit Hyperactive Disorder (ADHD) risk factors among school children in a rural area of North India

BACKGROUND

Attention-deficit hyperactive disorder (ADHD) is one of the most common neurodevelopmental disorders of childhood and has the potential for continuity into adolescence and adulthood. Its presence increases difficulties in academic performance and social interactions besides leading to low self-esteem. The present study aimed to determine the prevalence of ADHD among children of age 6-12 years in Government schools of a rural area in Jammu district of J and K.

METHODS

The present study was conducted in R.S. Pura block of Jammu district. Miran Sahib zone of R.S Pura block was chosen randomly and all the government primary schools in this zone were included in the survey. The presence of ADHD was assessed using Vanderbilt ADHD diagnostic teacher rating scale. The children positive for ADHD were visited at their residential places and a personal information questionnaire (PIQ) was administered to their parents-preferably the mother. The data thus collected was presented as proportions.

RESULTS

ADHD prevalence was found to be 6.34% (13/205). Majority (69.3%) of the ADHD-positive children were living in a joint family and belonged to lower/lower middle class. Family history of ADHD was absent in all the ADHD-positive children.

CONCLUSION

The current study conducted in a rural area among 6- to 12-year-old children of Government schools has shown a reasonably high ADHD prevalence of 6.34%.

Child and adolescent mental health problems in Nepal: a scoping review

Introduction

Globally, 10–20% of children and adolescents suffer from mental disorders, with half of all them starting by the age of 14 and three-quarters before the age of 25. In Nepal, 40% of the population is younger than 18 years of age, and as such there is a large proportion of the population that is at risk of developing a mental disorder. There has been a recent recognition of child and adolescent mental health problems in Nepal, although prior to this it had remained almost invisible on the health agenda. In response to growing concern, there is a need to conduct a review on children and adolescent mental health problems in Nepal.

Objective

To review the existing studies on child and adolescent mental health problems in Nepal.

Methodology

A scoping review approach was used to identify studies on child and adolescent mental problems in Nepal. A search of Medline and PubMed databases for articles published from the database inception to August 2018 was conducted.

Results

Ten papers were identified, and they all together included 7876 participants. Two studies reported on Post traumatic Stress Symptoms (PTSS) and described a prevalence of 10.7% to 51% of earthquake-affected children and adolescents in the Kathmandu district of Nepal. Another study reported that 53.2% of former child soldiers met the cut-off score for PTSS. Two school surveys found that the prevalence of emotional and behavioural problems in school children ranged between 12.9 and 17.03%, whereas a study on emotional and behavioural disorders in homeless children reported a prevalence of 28.6%. The prevalence of Autism Spectrum Disorder (ASD) was estimated to be as high as three in every 1000 persons in Nepal by one study. The clinical prevalence of anxiety disorders was reported ranging from 18.8% to 24.4% while that of Attention Deficit Hyperactivity Disorder (ADHD) was 10–11.7% in various clinical samples of children and adolescents.

Conclusion

Only a few studies on the prevalence of child and adolescent mental health in Nepal have been conducted. Clearly, there is a need for better study design and larger studies to understand more fully the prevalence of child and adolescent mental health disorders in Nepal, in order to adequately plan public health services accordingly.

Electronic supplementary material

The online version of this article (10.1186/s13033-019-0310-y) contains supplementary material, which is available to authorized users.

Genetic variants of the folate metabolic system and mild hyperhomocysteinemia may affect ADHD associated behavioral problems

An etiologically complex disorder, Attention Deficit Hyperactivity Disorder (ADHD), is often associated with various levels of cognitive deficit. Folate/vitamin B₉ is crucial for numerous biochemical pathways including neural stem cell proliferation and differentiation, regulation of gene expression, neurotransmitter synthesis, myelin synthesis and repair, etc. and a scarcity has often been linked to cognitive deficit. Our pilot study in the field revealed significant association of few genetic variants with ADHD. Mild hyperhomocysteinemia and vitamin B₁₂ deficiency was also noticed in the probands. In the present study additional genetic variants, folate and vitamin B₆, which may affect folate-homocysteine metabolic pathway, were investigated in 866 individuals including nuclear families with ADHD probands (N=221) and ethnically matched controls (N=286) to find out whether ADHD associated traits are affected by these factors. Population based analysis revealed significant over representation of MTRR rs1801394 "G" allele and "GG" genotype in all as well as male probands. Stratified analysis showed significantly higher frequency of RFC1 rs1051266 and BHMT rs3733890 "AG" genotypes in full term and prematurely delivered ADHD probands respectively. Probands with rs1801394 "GG" genotype and BHMT rs3733890 "G" allele showed association with hyperhomocysteinemia. MTHFR rs1801131, MTR rs1805087 and BHMT rs3733890 also showed association with ADHD index. While rs1051266, rs1801131, and rs1805087 showed association with behavioral problems, rs3733890 was associated with ODD score. Conduct problem exhibited association with RFC1 rs1051266, MTHFR rs1801133 and MTRR rs1801394. Gene-gene interaction analysis revealed positive synergistic interactions between rs1051266, rs1801131 and rs1801394 in the probands as compared to the controls. It can be inferred from the data obtained that folate system genetic variants and mild hyperhomocysteimenia may affect ADHD associated traits by attenuating folate metabolism.

ADHD research in India: A narrative review

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with no clear etiopathogenesis. Owing to unique socio cultural milieu of India, it is worthwhile reviewing research on ADHD from India and comparing findings with global research. Thereby, we attempted to provide a comprehensive overview of research on ADHD from India.

METHODS

A boolean search of articles published in English from September 1966 to January 2017 on electronic search engines Google Scholar, PubMed, IndMED, MedIND, using the search terms "ADHD", "Attention Deficit and Hyperactivity Disorder", "Hyperactivity" ,"Child psychiatry", "Hyperkinetic disorder", "Attention Deficit Disorder", "India"was carried out and peer - reviewed studies conducted among human subjects in India were included for review. Case reports, animal studies, previous reviews were excluded from the current review.

RESULTS

Results of 73 studies found eligible for the review were organized into broad themes such as epidemiology, etiology, course and follow up, clinical profile and comorbidity, assessment /biomarkers, intervention/treatment parameters, pathways to care and knowledge and attitude towards ADHD.

DISCUSSION

There was a gap noted in research from India in the domains of biomarkers, course and follow up and non-pharmacological intervention. The prevalence of ADHD as well as comorbidity of Bipolar Disorder was comparatively lower compared to western studies. The studies found unique to India include comparing the effect of allopathic intervention with Ayurvedic intervention, yoga as a non pharmacological intervention. There is a need for studies from India on biomarkers, studies with prospective research design, larger sample size and with matched controls.

Thyroid and Cortisol hormones in Attention Deficit Hyperactivity Disorder: A case-control study

AIM

There is paucity of research in the putative role of hormonal biomarkers in Attention Deficit Hyperactivity Disorder (ADHD). The current study aimed to analyze the clinical profile, socio-demographic status, co-morbidity, hormonal biomarkers namely Thyroid hormones and Cortisol in children with ADHD and compare them with healthy controls and to explore the association of the hormonal biomarkers with severity of ADHD.

METHODS

Thirty children with DSM-IV TR diagnosis of ADHD were assessed using semi structured proforma, Conners' Parent Rating Scale revised short (CPRS - R: S) , Mini international neuropsychiatric interview for children and adolescents and Childrens' Global Assessment Scale as well as serum levels of total Triiodothyronine (T3) ,total Thyroxine (T4) , Thyroid Stimulating Hormone (TSH) and Cortisol using chemiluminescent immunometric assay and compared with 30 age- and gender -matched controls.

RESULTS

The typical profile of cases of ADHD was of a male with mean age of 9.47 years (S.D=2.43) belonging to Hyperactive subtype of ADHD. Serum T4 was significantly lower in cases compared to controls. No significant difference was found in serum T3, TSH and Cortisol levels. No significant correlation between the CPRS : R-S scores and the hormonal biomarkers.

CONCLUSIONS

There is need for exploration of Serum T4 as putative biomarker for ADHD with replication in future studies. It may also be important to report the negative finding of Cortisol as a biomarker of ADHD in the context of effective utilization of resources for research with special relevance to resource deficit developing countries.

Effect of Poly Unsaturated Fatty Acids Administration on Children with Attention Deficit Hyperactivity Disorder: A Randomized Controlled Trial

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is a common disorder of childhood. Studies have indicated nutritional deficiencies, particularly Poly Unsaturated Fatty Acids (PUFA) deficiency in these children and have suggested supplementation with PUFA for clinical improvement.

AIM

The present study aimed at evaluating the effect of PUFA administration in Indian children with ADHD.

SETTINGS AND DESIGN

The study was conducted in the paediatrics and psychiatry departments of a tertiary care hospital. We conducted a prospective double blind randomized control trial on children aged 4-11 years, diagnosed with ADHD according to DSM-IV TR criterias and Kiddie-Schedule for Affective Disorders and Schizophrenia - Present and lifetime version.

MATERIALS AND METHODS

The study subjects were randomized into study and control groups. The control group was administered Atomoxetine, while the study group received Atomoxetine along with Eicosapentanoic acid (EPA) and Docosahexanoic acid (DHA). Both groups were followed up every 2 weeks over the next 4 months using Conner's Parent Rating Scale - Revised (CPRS-R).

STATISTICAL ANALYSIS

The data was carefully analysed by SPSS (17^th version) software with the help of a statistician. Confidence interval of 95% was used. The complete data was analysed using appropriate parametric and non parametric tests. Correlation was done between various socio-demographic and illness related parameters. For all analyses, probability of 5% or less was assumed to represent statistical significance.

RESULTS

Fifty children diagnosed with ADHD were randomized to study group (n=25) and control group (n=25). The study group had greater reduction in ADHD scores as compared to the control group, although not statistically significant (p = 0.08). Improvement was more significant in male study subjects with combined type of ADHD.

CONCLUSION

It may be concluded that PUFA supplementation improves the symptoms of ADHD. However, the effect is not clinically significant if supplementation is not given for prolonged duration and in adequate doses.

Potential contribution of monoamine oxidase a gene variants in ADHD and behavioral co-morbidities: scenario in eastern Indian probands

Attention deficit hyperactivity disorder (ADHD) is the most frequently diagnosed behavioral disorder in children with a high frequency of co-morbid conditions like conduct disorder (CD) and oppositional defiant disorder (ODD). These traits are controlled by neurotransmitters like dopamine, serotonin and norepinephrine. Monoamine oxidase A (MAOA), a mitochondrial enzyme involved in the degradation of amines, has been reported to be associated with aggression, impulsivity, depression, and mood changes. We hypothesized that MAOA can have a potential role in ADHD associated CD/ODD and analyzed 24 markers in a group of Indo-Caucasoid subjects. ADHD probands and controls (N = 150 each) matched for ethnicity and gender were recruited following the Diagnostic and Statistical Manual for Mental Disorders-IV. Appropriate scales were used for measuring CD and ODD traits. Markers were genotyped by PCR-based methods and data obtained analyzed using the Cocaphase program under UNPHASED. Only eight markers were found to be polymorphic. rs6323 "G" allele showed higher frequencies in ADHD (P = 0.0023), ADHD + CD (P = 0.03) and ADHD + ODD (P = 0.01) as compared to controls. Haplotype analysis revealed statistically significant difference for three haplotypes in ADHD cases (P < 0.02). Statistically significant differences were also noticed for haplotypes in ADHD + CD and ADHD + ODD cases (P < 0.01). LD analysis showed significant variation in different groups. Multidimensionality reduction analysis showed independent as well as interactive effects of markers. Genotypes showed correlation with behavioral problems in ADHD and ADHD + CD. We interpret that MAOA gene variants may contribute to the etiology of ADHD as well as associated co-morbid CD and ODD in this ethnic group.

Prevalence of epileptiform discharges in children with sensori-neural hearing loss and behavioral problems compared to their normal hearing peers

OBJECTIVE

Overactivity and behavioral problems are common problems in children with prelingually profound sensorineural hearing loss (SNHL). Data on epileptiform electroencephalography (EEG) discharges in deaf children with psychological disorders are so limited. The primary focus of this study was to determine the prevalence of epileptiform discharges (EDs) in children with SNHL and overactivity or behavioral problems.

MATERIALS & METHODS

A total of 262 patients with prelingually profound SNHL who were referred to our cochlear implantation center between 2008 and 2010 were enrolled in this study. Children with SNHL who had diagnosis of overactivity and/or behavioral problems by a pediatric psychiatrist, underwent electroencephalography (EEG). EEG analysis was carried out by a board-certified pediatric neurologist. The control group consisted of 45 cases with overactivity or behavioral problems and normal hearing.

RESULTS

One hundred thirty-eight children with mean age of 3.5±1.23 year were enrolled in the case group, of whom 88 cases (63.7%) were boy. The control group consisted of 45 cases with mean age of 3.2±1.53 years, of whom 30 (66.6%) cases were male. EDs were detected in 28 (20.02%) children of the case group (with SNHL) in comparison with 4 (8.88%) in the control group (without SNHL), which was statistically significantly different.

CONCLUSION

In this study, we obtained higher frequency of EDs in deaf children with overactivity and/or behavioral problem compared to the children without SNHL. Further studies are required to evaluate the possible association of SNHL with EDs in overactive children.