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ATTENTION 2.0 PROFESSIONAL
EDITION WINTER 2011
Childhood Attention-Deficit/Hyperactivity Disorder
and Future Substance Use Disorders: Comparative Meta-Analyses. Charach,
Alice; Yeung, Emanuela; Climans, Troy; Lillie, Erin. Journal of the
American Academy of Child & Adolescent Psychiatry, January
2011, v50 n1, pp. 9-21.
OBJECTIVE: In recent years cohort studies have examined
childhood attention-deficit/hyperactivity disorder (ADHD) as a risk
factor for substance use disorders (SUDs) in adolescence and young
adulthood. The long-term risk is estimated for development of alcohol,
cannabis, combined alcohol and psychoactive SUDs, combined SUDs
(nonalcohol), and nicotine use disorders in children with ADHD.
METHOD: MEDLINE, CINHAL, PsycINFO, and EMBASE were
searched through October 2009; reference lists of included studies were
hand-searched. Prospective cohort studies were included if they compared
children with ADHD to children without, identified cases using
standardized criteria by mean age of 12 years, followed participants
until adolescence (nicotine use) or young adulthood (psychoactive
substance use disorder, with and without alcohol, alcohol use disorder,
cannabis use disorder), and reported SUD outcomes. Two independent
reviewers examined articles and extracted and cross-checked data.
Effects were summarized as pooled odds ratios (ORs) in a random effects
RESULTS: Thirteen studies were included. Only two of
five meta-analyses, for alcohol use disorder (N = 3,184) and for
nicotine use (N = 2,067), estimated ORs showing stability when evaluated
by sensitivity analyses. Childhood ADHD was associated with alcohol use
disorder by young adulthood (OR = 1.35, 95% confidence interval =
1.11-1.64) and with nicotine use by middle adolescence (OR = 2.36, 95%
confidence interval = 1.71-3.27). The association with drug use
disorder, nonalcohol (N = 593), was highly influenced by a single
CONCLUSIONS: Childhood ADHD is associated with alcohol
and drug use disorders in adulthood and with nicotine use in
Service Utilization for Lifetime Mental
Disorders in U.S. Adolescents: Results of the National Comorbidity
Survey-Adolescent Supplement (NCS-A). Merikangas, Kathleen Ries; He,
Jian-ping; Burstein, Marcy; Swendsen, Joel; et al. Journal of the
American Academy of Child & Adolescent Psychiatry, January
2011, v50 n1, pp. 32-45.
OBJECTIVE: Mental health policy for youth has been
constrained by a paucity of nationally representative data concerning
patterns and correlates of mental health service utilization in this
segment of the population. The objectives of this investigation were to
examine the rates and sociodemographic correlates of lifetime mental
health service use by severity, type, and number of DSM-IV disorders in
the National Comorbidity Survey-Adolescent Supplement.
METHOD: Face-to-face survey of mental disorders from
2002 to 2004 using a modified version of the fully structured World
Health Organization Composite International Diagnostic Interview in a
nationally representative sample of 6,483 adolescents 13 to 18 years old
for whom information on service use was available from an adolescent and
a parent report. Total and sector-specific mental health service use was
RESULTS: Approximately one third of adolescents with
mental disorders received services for their illness (36.2%). Although
disorder severity was significantly associated with an increased
likelihood of receiving treatment, half of adolescents with severely
impairing mental disorders had never received mental health treatment
for their symptoms. Service rates were highest in those with
attention-deficit/hyperactivity disorder (59.8%) and behavior disorders
(45.4%), but fewer than one in five affected adolescents received
services for anxiety, eating, or substance use disorders. Comorbidity
and severe impairment were strongly associated with service utilization,
particularly in youth with behavior disorders. Hispanic and non-Hispanic
Black adolescents were less likely than their White counterparts to
receive services for mood and anxiety disorders, even when such
disorders were associated with severe impairment.
CONCLUSIONS: Despite advances in public awareness of
mental disorders in youth, a substantial proportion of young people with
severe mental disorders have never received specialty mental health
care. Marked racial disparities in lifetime rates of mental health
treatment highlight the urgent need to identify and combat barriers to
the recognition and treatment of these conditions.
Intrauterine Effects of Maternal
Prepregnancy Overweight on Child Cognition and Behavior in 2 Cohorts.
Brion, Marie-Jo; Zeegers, Mijke; Jaddoe, Vincent; Verhulst, Frank; et
al. Pediatrics, December 27, 2010, Online Early.
OBJECTIVE: Greater maternal prepregnancy adiposity has
been associated with behavioral problems, such as
attention-deficit/hyperactivity disorder, and lower intellectual
function in offspring. However, few studies of humans have explored
this, and it is unclear if intrauterine mechanisms or confounding
factors drive these associations.
PATIENTS AND METHODS: Parental adiposity and offspring
verbal skills, nonverbal skills, and behavioral problems were assessed
in the British Avon Longitudinal Study of Parents and Children (N =
~5000) and Dutch Generation R (N = ~2500) cohorts. We aimed to determine
the plausibility of intrauterine effects by (1) adjusting for multiple
confounders, (2) comparing associations between maternal and paternal
overweight with offspring cognition/behaviors, and (3) searching for
RESULTS: Maternal prepregnancy overweight was
associated with reduced child verbal skills (unadjusted). However, after
adjusting for confounders, this result was not consistently observed in
both cohorts. Maternal overweight was also associated with child total
behavior problems and externalizing problems even after adjusting for
confounders. However, this was observed in Generation R only and was not
replicated in the British Avon Longitudinal Study of Parents and
Children. No associations of maternal overweight with child attention
problems, emotional/internalizing problems, or nonverbal skills were
observed in either cohort. Paternal overweight was not associated with
any of the child outcomes but was also less strongly related to
potential confounding factors than was maternal overweight.
CONCLUSIONS: Overall, we found little consistent
evidence of intrauterine effects of maternal prepregnancy overweight on
child cognition and behavior. Some associations initially observed were
not consistently replicated across cohorts or robust to adjustment for
confounding factors and, thus, are likely to reflect confounding by
socioeconomic or postnatal factors.
Association of Parental ADHD and
Depression With Externalizing and Internalizing Dimensions of Child
Humphreys, Kathryn L.; Mehta, Natasha; Lee, Steve S. Journal of
Attention Disorders, December 20, 2010, Online Early.
OBJECTIVE: To study the independent association of
parental depression and ADHD on three dimensions of child
psychopathology among 178 children aged 5 to 10 years.
METHOD: Self-reported measures of parental depression
and ADHD as well as rating scales and structure diagnostic interviews of
child internalizing, ADHD, and externalizing problems were obtained.
RESULTS: Structural equation modeling indicated that
parental ADHD was positively associated with a broad child problems
factor after a second-order factor of child problems best accounted for
the high intercorrelations among the internalizing, ADHD, and
externalizing child psychopathology factors. Parental depression did not
significantly predict the second-order child problems factor, but it
specifically predicted the child internalizing factor.
CONCLUSION: These results suggest that parental ADHD
may be a nonspecific risk factor for child psychopathology broadly,
whereas parental depression may function as a specific risk factor for
child internalizing problems.
Comorbidity of Migraine With ADHD. Fasmer,
Ole Bernt; Riise, Trond; Lund, Anders; Dilsaver, Steven C.; Hundal,
Oivind; Oedegaard, Ketil J. Journal of Attention Disorders,
December 20, 2010, Online Early.
OBJECTIVE: The purpose of this study was to investigate
how often drugs used to treat migraine and ADHD are prescribed to the
same patients to assess, indirectly, the comorbidity of these
METHOD: We used data from the Norwegian prescription
database for 2006, including the total Norwegian population (N =
4,640,219). RESULTS: Antimigraine drugs were prescribed to 81,225
persons (1.75% of the total population), anti-ADHD drugs to 18,481
persons (0.40%), and 284 persons were prescribed both types of drugs.
There was a positive and significant association between prescription of
antimigraine and anti-ADHD drugs for all age groups between 20 and 50
for both genders, with odds ratios ranging from 1.76 to 2.81.
CONCLUSION: The prescription patterns for these drugs
in adult patients indicate a comorbidity between migraine and ADHD.
Contrasting Parents' and Pediatricians'
Perspectives on Shared Decision-Making in ADHD. Fiks, Alexander G.;
Hughes, Cayce C.; Gafen, Angela; Guevara, James P.; Barg, Frances K.
Pediatrics, December 20, 2010, Online Early.
OBJECTIVE: The goal was to compare how parents and
clinicians understand shared decision-making (SDM) in
attention-deficit/hyperactivity disorder (ADHD), a prototype for SDM in
METHODS: We conducted semi-structured interviews with
60 parents of children 6 to 12 years of age with ADHD (50% black and 43%
college educated) and 30 primary care clinicians with varying
experience. Open-ended interviews explored how pediatric clinicians and
parents understood SDM in ADHD. Interviews were taped, transcribed, and
then coded. Data were analyzed by using a modified grounded theory
RESULTS: Parents and clinicians both viewed SDM
favorably. However, parents described SDM as a partnership between
equals, with physicians providing medical expertise and the family
contributing in-depth knowledge of the child. In contrast, clinicians
understood SDM as a means to encourage families to accept clinicians'
preferred treatment. These findings affected care because parents
mistrusted clinicians whose presentation they perceived as biased. Both
groups discussed how real-world barriers limit the consideration of
evidence-based options, and they emphasized the importance of engaging
professionals, family members, and/or friends in SDM. Although primary
themes did not differ according to race, white parents more commonly
received support from medical professionals in their social
CONCLUSIONS: Despite national guidelines prioritizing
SDM in ADHD, challenges to implementing the process persist. Results
suggest that, to support SDM in ADHD, modifications are needed at the
practice and policy levels, including clinician training, incorporation
of decision aids and improved strategies to facilitate communication,
and efforts to ensure that evidence-based treatment is accessible.
Behavioural symptoms of attention
deficit/hyperactivity disorder in preterm and term children born small
and appropriate for gestational age: A longitudinal study. Heinonen,
Kati; Raikkonen, Katri; Pesonen, Anu-Katriina; Andersson, Sture; et al.
BMC Pediatrics, December 15, 2010, 10:91.
BACKGROUND: It remains unclear whether it is
more detrimental to be born too early or too small in relation to
symptoms of attention deficit/hyperactivity disorder (ADHD). Thus, we
tested whether preterm birth and small body size at birth adjusted for
gestational age are independently associated with symptoms of ADHD in
METHODS: A longitudinal regional birth cohort study
comprising 1535 live-born infants between 03/15/1985 and 03/14/1986
admitted to the neonatal wards and 658 randomly recruited non-admitted
infants, in Finland. The present study sample comprised 828 children
followed up to 56 months. The association between birth status and
parent-rated ADHD symptoms of the child was analyzed with multiple
linear and logistic regression analyses.
RESULTS: Neither prematurity (birth<37 weeks of
gestation) nor lower gestational age was associated with ADHD symptoms.
However, small for gestational age (SGA<-2 standard deviations [SD]
below the mean for weight at birth) status and lower birth weight SD
score were significantly, and independently of gestational age,
associated with higher ADHD symptoms. Those born SGA, relative to those
born AGA, were also 3.60-times more likely to have ADHD symptoms scores
above the clinical cut-off. The associations were not confounded by
factors implicated as risks for pregnancy and/or ADHD.
CONCLUSIONS: Intrauterine growth restriction, reflected in SGA status
and lower birth weight, rather than prematurity or lower gestational age
per se, may increase risk for symptoms of ADHD in young children.
Cortical Development in Typically
Developing Children With Symptoms of Hyperactivity and Impulsivity:
Support for a Dimensional View of Attention Deficit Hyperactivity
Disorder. Shaw, Philip; Gilliam, Mary; Liverpool, Maria; Weddle,
Catherine; et al. American Journal of Psychiatry, December 15,
2010, Online Early.
OBJECTIVE: There is considerable epidemiological and
neuropsychological evidence that attention deficit hyperactivity
disorder (ADHD) is best considered dimensionally, lying at the extreme
end of a continuous distribution of symptoms and underlying cognitive
impairments. The authors investigated whether cortical brain development
in typically developing children with symptoms of hyperactivity and
impulsivity resembles that found in the syndrome of ADHD. Specifically,
they examined whether a slower rate of cortical thinning during late
childhood and adolescence, which they previously found in ADHD, is also
linked to the severity of symptoms of hyperactivity and impulsivity in
typically developing children.
METHOD: In a longitudinal analysis, a total of 193
typically developing children with 389 neuroanatomic magnetic resonance
images and varying levels of symptoms of hyperactivity and impulsivity
(measured with the Conners' Parent Rating Scale) were contrasted with
197 children with ADHD with 337 imaging scans. The relationship between
the rates of regional cortical thinning and severity of symptoms of
hyperactivity/impulsivity was determined.
RESULTS: Youth with higher levels of
hyperactivity/impulsivity had a slower rate of cortical thinning,
predominantly in prefrontal cortical regions, bilaterally in the middle
frontal/premotor gyri, extending down the medial prefrontal wall to the
anterior cingulate; the orbitofrontal cortex; and the right inferior
frontal gyrus. For each increase of one point in the
hyperactivity/impulsivity score, there was a decrease in the rate of
regional cortical thinning of 0.0054 mm/year (SE=0.0019 mm/year).
Children with ADHD had the slowest rate of cortical thinning.
CONCLUSIONS: Slower cortical thinning during
adolescence characterizes the presence of both the symptoms and syndrome
of ADHD, providing neurobiological evidence for dimensionality of the
Economic burden and comorbidities of
attention-deficit/hyperactivity disorder among pediatric patients
hospitalized in the United States. Meyers, Juliana L.; Classi, Peter M.;
Wietecha, Linda A.; Candrilli, Sean D. Child and Adolescent
Psychiatry and Mental Health, December 14, 2010, 4:31.
BACKGROUND: This retrospective database analysis used
data from the Healthcare Cost and Utilization Project's Nationwide
Inpatient Sample (NIS) to examine common primary diagnoses among
children and adolescents hospitalized with a secondary diagnosis of
attention- deficit/hyperactivity disorder (ADHD) and assessed the burden
METHODS: Hospitalized children (aged 6-11 years) and
adolescents (aged 12-17 years) with a secondary diagnosis of ADHD were
identified. The 10 most common primary diagnoses (using the first 3
digits of the ICD-9-CM code) were reported for each age group. Patients
with 1 of these conditions were selected to analyze demographics, length
of stay (LOS), and costs. Control patients were selected if they had 1
of the 10 primary diagnoses and no secondary ADHD diagnosis. Patient and
hospital characteristics were reported by cohort (i.e., patients with
ADHD vs. controls), and LOS and costs were reported by primary
diagnosis. Multivariable linear regression analyses were undertaken to
adjust LOS and costs based on patient and hospital characteristics.
RESULTS: A total of 126,056 children and 204,176
adolescents were identified as having a secondary diagnosis of ADHD.
Among children and adolescents with ADHD, the most common diagnoses
tended to be mental health related (i.e., affective psychoses, emotional
disturbances, conduct disturbances, depressive disorder, or adjustment
reaction). Other common diagnoses included general symptoms, asthma (in
children only), and acute appendicitis. Among patients with ADHD, a
higher percentage were male, white, and covered by Medicaid. LOS and
costs were higher among children with ADHD and a primary diagnosis of
affective psychoses (by 0.61 days and $51), adjustment reaction (by 1.71
days and $940), or depressive disorder (by 0.41 days and $124) versus
controls. LOS and costs were higher among adolescents with ADHD and a
primary diagnosis of affective psychoses (by 1.04 days and $353),
depressive disorder (by 0.94 days and $517), conduct disturbances (by
0.86 days and $1,330), emotional disturbances (by 1.45 days and $1,626),
adjustment reaction (by 1.25 days and $702), and neurotic disorders (by
1.60 days and $541) versus controls.
CONCLUSION: Clinicians and health care decision makers
should be aware of the potential impact of ADHD on hospitalized children
Differences between children and
adolescents in treatment response to atomoxetine and the correlation
between health-related quality of life and Attention
Deficit/Hyperactivity Disorder core symptoms: Meta-analysis of five
atomoxetine trials. Wehmeier, Peter M.; Schacht, Alexander; Escobar,
Rodrigo; Savill, Nicola; Harpin, Val. Child and Adolescent
Psychiatry and Mental Health, December 6, 2010,
OBJECTIVES: To explore the influence of age on
treatment responses to atomoxetine and to assess the relationship
between core symptoms of attention deficit/hyperactivity disorder (ADHD)
and health-related quality of life (HR-QoL) outcomes.
DATA SOURCES: Data from five similar clinical trials of
atomoxetine in the treatment of children and adolescents with ADHD were
included in this meta-analysis.
STUDY SELECTION: Atomoxetine studies that used the ADHD
Rating Scale (ADHD-RS) and the Child Health and Illness Profile Child
Edition (CHIP-CE) as outcome measures were selected.
INTERVENTIONS: Treatment with atomoxetine. MAIN OUTCOME
MEASURES: Treatment group differences (atomoxetine vs placebo) in terms
of total score, domains, and subdomains of the CHIP-CE were compared
across age groups, and correlations between ADHD-RS scores and CHIP-CE
scores were calculated by age.
RESULTS: Data of 794 subjects (611 children, 183
adolescents) were pooled. At baseline, adolescents showed significantly
(p<0.05) greater impairment compared with children in the Family
Involvement, Satisfaction with Self, and Academic Performance subdomains
of the CHIP-CE. Treatment effect of atomoxetine was significant in both
age groups for the Risk Avoidance domain and its subdomains. There was a
significant age-treatment interaction with greater efficacy seen in
adolescents in both the Risk Avoidance domain and the Threats to
Achievement subdomain. Correlations between ADHD-RS and CHIP-CE scores
were generally low at baseline and moderate in change from baseline and
were overall similar in adolescents and children.
CONCLUSIONS: Atomoxetine was effective in improving
some aspects of HR-QoL in both age groups. Correlations between core
symptoms of ADHD and HR-QoL were low to moderate.
Dietary Sensitivities and ADHD Symptoms:
Thirty-five Years of Research. Stevens, Laura J.; Kuczek, Thomas;
Burgess, John R.; Hurt, Elizabeth; Arnold, L. Eugene. Clinical
Pediatrics, December 2, 2010, Online Early.
Artificial food colors (AFCs) have not been established
as the main cause of attention-deficit hyperactivity disorder (ADHD),
but accumulated evidence suggests that a subgroup shows significant
symptom improvement when consuming an AFC-free diet and reacts with
ADHD-type symptoms on challenge with AFCs. Of children with suspected
sensitivities, 65% to 89% reacted when challenged with at least 100 mg
of AFC. Oligoantigenic diet studies suggested that some children in
addition to being sensitive to AFCs are also sensitive to common
nonsalicylate foods (milk, chocolate, soy, eggs, wheat, corn, legumes)
as well as salicylate-containing grapes, tomatoes, and orange. Some
studies found "cosensitivity" to be more the rule than the exception.
Recently, 2 large studies demonstrated behavioral sensitivity to AFCs
and benzoate in children both with and without ADHD. A trial elimination
diet is appropriate for children who have not responded satisfactorily
to conventional treatment or whose parents wish to pursue a dietary
Quality of care for childhood
attention-deficit/hyperactivity disorder in a managed care medicaid
program. Zima, Bonnie T.; Bussing, Regina; Tang, Lingqi; Zhang, Lily; et
al. Journal of the American Academy of Child & Adolescent
Psychiatry, December 2010, v49 n12, pp. 1225-1237.e11.
OBJECTIVE: To examine whether clinical severity is
greater among children receiving attention-deficit/hyperactivity
disorder (ADHD) care in primary care compared with those in specialty
mental health clinics, and to examine how care processes and clinical
outcomes vary by sector across three 6-month time intervals.
METHOD: This was a longitudinal cohort study of 530
children aged 5 to 11 years receiving ADHD care in primary care or
specialty mental health clinics from November 2004 through September
2006 in a large, countywide managed care Medicaid program.
RESULTS: Clinical severity at study entry did not
differ between children who received ADHD care in solely primary or
specialty mental health care clinics. At three 6-month intervals,
receipt of no care ranged from 34% to 44%, and unmet need for mental
health services ranged from 13% to 20%. In primary care, 80% to 85% of
children had at least one stimulant prescription filled and averaged one
to two follow-up visits per year. Less than one-third of children in
specialty mental health clinics received any stimulant medication, but
all received psychosocial interventions averaging more than five visits
per month. In both sectors, stimulant medication refill prescription
persistence was poor (31%-49%). With few exceptions, ADHD diagnosis,
impairment, academic achievement, parent distress, and parent-reported
treatment satisfaction, perceived benefit, and improved family
functioning did not differ between children who remained in care and
those who received no care.
CONCLUSION: Areas for quality improvement are alignment
of clinical severity with provider type, follow-up visits, stimulant use
in specialty mental health, agency data infrastructure to document
delivery of evidence-based psychosocial treatment, and stimulant
medication refill prescription persistence.
Task-related default mode network
modulation and inhibitory control in ADHD: effects of motivation and
methylphenidate. Liddle, Elizabeth B.; Hollis, Chris; Batty, Martin J.;
Groom, Madeleine J.; et al. Journal of Child Psychology and
Psychiatry, November 12, 2010, Online Early.
BACKGROUND: Deficits characteristic of attention
deficit/hyperactivity disorder (ADHD), including poor attention and
inhibitory control, are at least partially alleviated by factors that
increase engagement of attention, suggesting a hypodopaminergic reward
deficit. Lapses of attention are associated with attenuated deactivation
of the default mode network (DMN), a distributed brain system normally
deactivated during tasks requiring attention to the external world.
Task-related DMN deactivation has been shown to be attenuated in ADHD
relative to controls. We hypothesised that motivational incentives to
balance speed against restraint would increase task engagement during an
inhibitory control task, enhancing DMN deactivation in ADHD. We also
hypothesised that methylphenidate, an indirect dopamine agonist, would
tend to normalise abnormal patterns of DMN deactivation.
METHOD: We obtained functional magnetic resonance
images from 18 methylphenidate-responsive children with ADHD (DSM-IV
combined subtype) and 18 pairwise-matched typically developing
children aged 9-15 years while they performed a paced Go/No-go task. We
manipulated motivational incentive to balance response speed against
inhibitory control, and tested children with ADHD both on and off
RESULTS: When children with ADHD were
off-methylphenidate and task incentive was low, event-related DMN
deactivation was significantly attenuated compared to controls, but the
two groups did not differ under high motivational incentives. The
modulation of DMN deactivation by incentive in the children with ADHD,
off-methylphenidate, was statistically significant, and significantly
greater than in typically developing children. When children with ADHD
were on-methylphenidate, motivational modulation of event-related DMN
deactivation was abolished, and no attenuation relative to their
typically developing peers was apparent in either motivational
CONCLUSIONS: During an inhibitory control task,
children with ADHD exhibit a raised motivational threshold at which
task-relevant stimuli become sufficiently salient to deactivate the DMN.
Treatment with methylphenidate normalises this threshold, rendering
their pattern of task-related DMN deactivation indistinguishable from
that of typically developing children.
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