RSS 1.0Attention Deficit Disorder
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Identifying digital markers of attention-deficit/hyperactivity disorder (ADHD) in a remote monitoring setting: Prospective observational studyBACKGROUND: The symptoms and associated characteristics of attention-deficit/hyperactivity disorder (ADHD) are typically assessed in person at a clinic or in a research lab. Mobile health offers a new approach to obtaining additional passively and continuously measured real-world behavioral data. Using our new ADHD remote technology (ART) system, based on the Remote Assessment of Disease and Relapses (RADAR)-base platform, we explore novel digital markers for their potential to identify behavioral patterns associated with ADHD. The RADAR-base Passive App and wearable device collect sensor data in the background, while the Active App involves participants completing clinical symptom questionnaires. OBJECTIVE: The main aim of this study was to investigate whether adults and adolescents with ADHD differ from individuals without ADHD on 10 digital signals that we hypothesize capture lapses in attention, restlessness, or impulsive behaviors. METHODS: We collected data over 10 weeks from 20 individuals with ADHD and 20 comparison participants without ADHD between the ages of 16 and 39 years. We focus on features derived from (1) Active App (mean and SD of questionnaire notification response latency and of the time interval between questionnaires), (2) Passive App (daily mean and SD of response time to social and communication app notifications, the SD in ambient light during phone use, total phone use time, and total number of new apps added), and (3) a wearable device (Fitbit) (daily steps taken while active on the phone). Linear mixed models and t tests were employed to assess the group differences for repeatedly measured and time-aggregated variables, respectively. Effect sizes (d) convey the magnitude of differences. RESULTS: Group differences were significant for 5 of the 10 variables. The participants with ADHD were (1) slower (P=.047, d=1.05) and more variable (P=.01, d=0.84) in their speed of responding to the notifications to complete the questionnaires, (2) had a higher SD in the time interval between questionnaires (P=.04, d=1.13), (3) had higher daily mean response time to social and communication app notifications (P=.03, d=0.7), and (4) had a greater change in ambient (background) light when they were actively using the smartphone (P=.008, d=0.86). Moderate to high effect sizes with nonsignificant P values were additionally observed for the mean of time intervals between questionnaires (P=.06, d=0.82), daily SD in responding to social and communication app notifications (P=.05, d=0.64), and steps taken while active on the phone (P=.09, d=0.61). The groups did not differ in the total phone use time (P=.11, d=0.54) and the number of new apps downloaded (P=.24, d=0.18). CONCLUSIONS: In a novel exploration of digital markers of ADHD, we identified candidate digital signals of restlessness, inconsistent attention, and difficulties completing tasks. Larger future studies are needed to replicate these findings and to assess the potential of such objective digital signals for tracking ADHD severity or predicting outcomes.
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An item-level systematic review of the presentation of ADHD in femalesPrevious studies examining sex differences in attention deficit hyperactivity disorder (ADHD) have primarily examined total or subscale scores. This systematic review aimed to examine which symptoms contribute to the female presentation of ADHD at an item-level. Six research literature databases were searched for studies comparing ADHD symptoms and their impact at an item-level in females with ADHD compared with: 1) males with ADHD and 2) females without ADHD. Thirteen studies were included. In childhood, females were more likely to display the symptoms 'fails to sustain attention in tasks' and 'often easily distracted', whereas males were more likely to display the symptoms 'often fidgets', 'difficulty remaining seated when required', 'runs/climbs in situations when inappropriate', 'always on the go', 'often noisy in playing', 'difficulty waiting turn', 'often blurts out answers' and 'often interrupts others'. In adulthood, females were more likely to endorse the symptoms 'easily distracted', 'difficulty organising tasks', 'blurts out answers' and 'talks excessively', as well as to report mind wandering and adverse home impacts. Females with ADHD differ in their symptom profile to males with ADHD, highlighting the need for future research to identify and characterise symptoms typical of female ADHD.
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Research review: Mechanisms of change and between-family differences in parenting interventions for children with ADHD - an individual participant data meta-analysisBACKGROUND: Understanding the mechanisms of change and between-family differences in behavioural parenting interventions for children with attention-deficit/hyperactivity disorder (ADHD) may help personalise interventions. Therefore, we examined whether improvements in parenting are associated with changes in child behaviour and functional outcomes, and how these associations vary based on parents' baseline parenting levels. METHODS: We collected individual participant data including 19 randomised controlled trials focusing on children with ADHD (n = 1,720). Immediate post-intervention measures of child ADHD and oppositional behaviour severity, reported by parents and functional impairment reported by either the parent or probably masked clinicians, were treated as outcomes. We estimated pathways from intervention (vs. control) to child outcomes, via immediate post-intervention parent reports of constructive parenting (e.g. praise), non-constructive parenting (e.g. physical punishment) and parent-child affection (e.g. warmth), while controlling for baseline values of both child outcomes and parenting levels. Baseline values of each parenting variable were used as moderators of the mediated pathways. RESULTS: Improvements in parenting behaviours and parent-child affection immediately following the intervention jointly explained concurrent improvements in children's ADHD severity, oppositional behaviour and functional impairment. Furthermore, when reversing the direction of the pathways, improvements in all child outcomes jointly explained improvements in each aspect of parenting. Improvements in non-constructive parenting and parent-child affection uniquely accounted for intervention effects on functional impairment, especially for families with higher baseline levels of non-constructive parenting. CONCLUSIONS: Our findings might indicate that improvements in both the behavioural and affective aspects of parenting are associated with concurrent reductions in child behaviour problems and functional impairment. However, more research is necessary to explore the potential causal directionality between parenting and child outcomes. Nonetheless, supporting families with poorer parenting skills may be especially important, as reductions in non-constructive parenting in these families are linked to stronger treatment effects on child functional impairment.
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Oculomotor function in children and adolescents with autism, ADHD or co-occurring autism and ADHDOculomotor characteristics, including accuracy, timing, and sensorimotor processing, are considered sensitive intermediate phenotypes for understanding the etiology of neurodevelopmental conditions, such as autism and ADHD. Oculomotor characteristics have predominantly been studied separately in autism and ADHD. Despite the high rates of co-occurrence between these conditions, only one study has investigated oculomotor processes among those with co-occurring autism + ADHD. Four hundred and five (n = 405; 226 males) Australian children and adolescents aged 4 to 18 years (M = 9.64 years; SD = 3.20 years) with ADHD (n = 64), autism (n = 66), autism + ADHD (n = 146), or neurotypical individuals (n = 129) were compared across four different oculomotor tasks: visually guided saccade, anti-saccade, sinusoidal pursuit and step-ramp pursuit. Confirmatory analyses were conducted using separate datasets acquired from the University of Nottingham UK (n = 17 autism, n = 22 ADHD, n = 32 autism + ADHD, n = 30 neurotypical) and University of Kansas USA (n = 29 autism, n = 41 neurotypical). Linear mixed effect models controlling for sex, age and family revealed that children and adolescents with autism + ADHD exhibited increased variability in the accuracy of the final saccadic eye position compared to neurotypical children and adolescents. Autistic children and adolescents demonstrated a greater number of catch-up saccades during step-ramp pursuit compared to neurotypical children and adolescents. These findings suggest that select differences in saccadic precision are unique to autistic individuals with co-occurring ADHD, indicating that measuring basic sensorimotor processes may be useful for parsing neurodevelopment and clinical heterogeneity in autism.
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The impact of motivation on sustained attention in very preterm and term-born children: An ERP studyOBJECTIVE: To compare the effect of motivational features on sustained attention in children born very preterm and at term. METHOD: EEG was recorded while 34 8-to-11-year-old children born very preterm and 34 term-born peers completed two variants of a cued continuous performance task (CPT-AX); a standard CPT-AX with basic shape stimuli, and structurally similar motivating variant, with a storyline, familiar characters, and feedback. RESULTS: Higher hit rates, quicker response times and larger event-related potential (ERP) amplitudes were observed during the motivating, compared with the standard, task. Although groups did not differ in task performance, between-task differences in ERPs associated with orienting were larger in term-born than very preterm children. CONCLUSION: The findings add to previous evidence of disruption to the brain networks that support salience detection and selective attention in children born preterm. Manipulations that increase intrinsic motivation can promote sustained attention in both term-born and very preterm children.
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Commentary: Using QbTest for monitoring pharmacological treatment response in ADHD - are we there yet?Individuals with attention-deficit/hyperactivity disorder (ADHD) exhibit varied responses to pharmacological treatments (e.g. stimulants and non-stimulants). Accurately and promptly detecting treatment-related improvements, response failure, or deterioration poses significant challenges, as current monitoring primarily relies on subjective ratings. In this commentary, we critically evaluate the evidence supporting the use of QbTest for objectively monitoring ADHD treatment response in clinical practice. We also offer recommendations for future research, advocating for rigorous clinical trials and longitudinal studies to further explore the potential utilisation of QbTest and other tools for monitoring treatment responses in individuals with ADHD.
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A national evaluation of QbTest to support ADHD assessment: A real-world, mixed methods approachBACKGROUND: QbTest is a commercially available, computerised test of attention, impulsivity, and activity designed to assist with the diagnosis of attention deficit hyperactivity disorder (ADHD). Health Innovation East Midlands (formerly East Midlands AHSN), led the implementation of the QbTest on behalf of the 15 Health Innovation Networks across Child and Adolescent Mental Health services (CAMHS) and Paediatric sites in England between April 2020 and March 2023. We evaluate the impact of this programme on diagnostic assessment at participating sites. METHODS: A mixed-methods approach was used including: case-note data collected on 10-30 cases per site pre and post QbTest implementation; interviews with healthcare staff working with QbTest; and surveys to explore perspectives of healthcare staff and patients/carers. Case-note data was descriptively analysed to compare time to diagnosis (number of appointments and days) pre/post QbTest implementation. Survey data was analysed descriptively. Qualitative interview data was explored using thematic analysis. RESULTS: Case-note data was provided by 20 sites across England. Comparison of mean values pre- and post-QbTest implementation identified a decrease of 0.37 (11.5%) in number of appointments to reach a diagnostic decision, a 55-day (12.5%) increase in days from initial referral to diagnosis, and a 12-day (10.3%) increase in days to reach a diagnostic decision. Exploratory analyses indicated greater benefit for Paediatric services over CAMHS, in terms of a decrease in days from referral to diagnosis and number of appointments to diagnosis. Interviews with healthcare staff (n=21) revealed that the QbTest was perceived to support a faster, more efficient diagnostic process. Survey data (n=65 healthcare staff, n=22 patients/carers) identified that the QbTest helped patients understand their symptoms and the diagnostic decision. Although some logistical issues (e.g., room requirements) and patient issues (e.g., sensory sensitivity) were identified, healthcare staff considered that QbTest was easily incorporated into the ADHD assessment pathway. CONCLUSION: The national implementation of QbTest in ADHD clinics resulted in a small reduction in the number of clinical appointments needed to reach a diagnostic decision, with greatest benefit demonstrated in Paediatric sites. Data were impacted by COVID-19 therefore, further evaluation is warranted.
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Sex differences in ADHD diagnosis and clinical care: A national study of population healthcare records in Wales [in press]Background: Population-based studies have observed sex biases in the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD). Females are less likely to be diagnosed or prescribed ADHD medication. This study uses national healthcare records, to investigate sex differences in diagnosis and clinical care in young people with ADHD, particularly regarding recognition and treatment of other mental health conditions. Method(s): The cohort included individuals diagnosed with ADHD, born between 1989 and 2013 and living in Wales between 2000 and 2019. Routine primary and secondary healthcare record data were used to derive diagnoses of ADHD and other neurodevelopmental and mental health conditions, as well as ADHD and antidepressant medications. Demographic variables included ethnicity, socioeconomic deprivation, and contact with social services. Result(s): There were 16,458 individuals diagnosed with ADHD (20.3% females, ages 3-30 years), with a male-to-female ratio of 3.9:1. Higher ratios (4.8:1) were seen in individuals diagnosed younger (<12 years), with the lowest ratio (1.9:1) in those diagnosed as adults (>18). Males were younger at first recorded ADHD diagnosis (mean=10.9 vs 12.6 years), more likely to be prescribed ADHD medication, and younger at diagnosis of co-occurring neurodevelopmental conditions. In contrast, females were more likely to receive a diagnosis of anxiety, depression, or another mental health condition and to be prescribed antidepressant medications, prior to ADHD diagnosis. These sex differences were largely stable across demographic groups. Conclusion(s): This study adds to the evidence base that females with ADHD are experiencing later recognition and treatment of ADHD. The results indicate that this may be partly because of diagnostic over-shadowing from other mental health conditions, such as anxiety and depression, or initial misdiagnosis. Further research and dissemination of findings to the public are needed to improve awareness, timely diagnosis, and treatment of ADHD in females. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license.
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Exploring the unmet needs of teachers of young children with ADHD symptoms: A qualitative studyBACKGROUND/OBJECTIVES: Children with Attention and Hyperactivity Deficit Disorder (ADHD) and those at risk of ADHD typically exhibit challenging behaviours that may disrupt the classroom environment and be frustrating for teachers. This study aimed to explore teachers' experiences and emotions regarding teaching children with high levels of ADHD symptoms and their perceptions of what might help to meet their unmet support needs. METHODS: Semi-structured interviews were conducted with 17 primary educational practitioners for children aged between four and eight years in the UK. Interview scripts were analysed using reflexive thematic analysis. Six main themes and 8 subthemes were developed. These included: (1) ADHD behaviours can disrupt the learning environment; (2) teachers face practical demands on their expertise and particular skills; (3) managing ADHD behaviours can be overwhelming for teachers; (4) teachers and children may treat children with ADHD negatively, which can impact on children's emotions and lead to labelling; (5) existing support for teachers is limited; and (6) teachers need more specific training about ADHD. RESULTS: The analysis revealed that teachers working with children with externalising behaviours such as ADHD can feel overwhelmed. CONCLUSIONS: The findings from this study suggest that teachers require more training in managing externalising behaviour in the classroom.
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A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of Well Parent Japan in routine care in Japan: The training and nurturing support for mothers (TRANSFORM) studyBACKGROUND: Well Parent Japan (WPJ) is a new hybrid group parent training programme combining sessions to improve mothers' psychological well-being with a culturally adapted version of the New Forest Parenting Programme (NFPP). This study investigates the effectiveness and cost-effectiveness of WPJ against treatment as usual (TAU) within Japanese child mental health services. METHODS: TRANSFORM was a pragmatic multi-site randomised controlled trial (RCT) with two parallel arms. Altogether 124 mothers of 6-12-year-old children with DSM-5 ADHD were randomised to WPJ (n = 65) or TAU (n = 59). Participants were assessed at baseline, post-treatment and three-month follow-up. The primary outcome was parent-domain stress following intervention. Secondary outcomes included maternal reports of child-domain stress, parenting practices, parenting efficacy, mood, family strain, child behaviour and impairment. Objective measures of the parent-child relationship were collected at baseline and post-treatment. Data analysis was intention to treat (ITT) with treatment effects quantified through analysis of covariance (ANCOVA) via multilevel modelling. An incremental cost-effectiveness ratio (ICER) assessed WPJ's cost-effectiveness. RESULTS: WPJ was superior to TAU in reducing parent-domain stress post-treatment (adjusted mean difference = 5.05, 95% CI 0.33 to 9.81, p = .036) and at follow-up (adjusted mean difference 4.82, 95% CI 0.09 to 9.55, p = .046). Significant WPJ intervention effects were also observed for parenting practices, parenting efficacy and family strain. WPJ and TAU were not significantly different post-intervention or at follow-up for the other secondary outcomes. The incremental cost of WPJ was 34,202 JPY (315.81 USD). The probability that WPJ is cost-effective is 74% at 10,000 JPY (USD 108.30) per one-point improvement in parenting stress, 92% at 20,000 JPY (216.60 USD). The programme was delivered with high fidelity and excellent retention. CONCLUSIONS: WPJ can be delivered in routine clinical care at modest cost with positive effects on self-reported well-being of the mothers, parenting practices and family coping. WPJ is a promising addition to psychosocial interventions for ADHD in Japan.
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Sex differences in attention-deficit hyperactivity disorder diagnosis and clinical care: A national study of population healthcare records in WalesBACKGROUND: Population-based studies have observed sex biases in the diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD). Females are less likely to be diagnosed or prescribed ADHD medication. This study uses national healthcare records, to investigate sex differences in diagnosis and clinical care in young people with ADHD, particularly regarding recognition and treatment of other mental health conditions. METHODS: The cohort included individuals diagnosed with ADHD, born between 1989 and 2013 and living in Wales between 2000 and 2019. Routine primary and secondary healthcare record data were used to derive diagnoses of ADHD and other neurodevelopmental and mental health conditions, as well as ADHD and antidepressant medications. Demographic variables included ethnicity, socioeconomic deprivation and contact with social services. RESULTS: There were 16,458 individuals diagnosed with ADHD (20.3% females, ages 3-30 years), with a male-to-female ratio of 3.9:1. Higher ratios (4.8:1) were seen in individuals diagnosed younger (<12 years), with the lowest ratio (1.9:1) in those diagnosed as adults (>18). Males were younger at first recorded ADHD diagnosis (mean = 10.9 vs. 12.6 years), more likely to be prescribed ADHD medication and younger at diagnosis of co-occurring neurodevelopmental conditions. In contrast, females were more likely to receive a diagnosis of anxiety, depression or another mental health condition and to be prescribed antidepressant medications, prior to ADHD diagnosis. These sex differences were largely stable across demographic groups. CONCLUSIONS: This study adds to the evidence base that females with ADHD are experiencing later recognition and treatment of ADHD. The results indicate that this may be partly because of diagnostic overshadowing from other mental health conditions, such as anxiety and depression, or initial misdiagnosis. Further research and dissemination of findings to the public are needed to improve awareness, timely diagnosis and treatment of ADHD in females.
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Experience of CBT in adults with ADHD: A mixed methods studyINTRODUCTION: The National Institute for Health and Care Excellence (NICE) recommends Cognitive-Behavioural therapy (CBT) as the psychotherapeutic treatment of choice for adults with Attention Deficit Hyperactivity Disorder (ADHD) in the UK. However, the literature often refers to adapted CBT programs tailored for ADHD and provides limited insight into how adults with ADHD experience and perceive this form of treatment in routine clinical practice. METHODS: This mixed-methods study aims to explore ADHD individuals' experience and perception of CBT delivered in routine clinical practice, to gain a better understanding of this treatment's helpfulness and perceived effectiveness. RESULTS: A survey (n=46) and semi-structured in-depth interviews (n=10) were conducted to explore the experience of CBT and its perceived effectiveness in managing ADHD. The interviews were analysed using thematic analysis and the survey was synthesised using descriptive narratives. The thematic analysis highlighted three key themes: difficulties with the CBT framework, difficulties with CBT therapists, and consequences of CBT. The survey highlighted similar findings. Participants described the CBT framework as, generic, rigid, and too short, and described the CBT therapist as unspecialised, unempathetic, and not sufficiently adapting CBT to ADHD-related difficulties. DISCUSSIONS: Overall, participants found non-adapted, generic CBT in the UK to be unhelpful, overwhelming, and at times harmful to their mental well-being. Therefore, it is necessary for clinical bodies in the UK, while following the indicated NICE guidelines, to be mindful of adapting CBT delivery of CBT, to be most effective for people with ADHD and to mitigate potential harm.
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The impacts associated with having ADHD: An umbrella reviewIntroduction Attention Deficit Hyperactivity Disorder (ADHD) affects up to 5% of the population and is characterised by symptoms of impulsivity, hyperactivity and inattention. These symptoms are significantly impairing and carry additional risks for children and adults with ADHD, including negative mental health (e.g. depression), physical health (e.g. obesity) and societal outcomes (e.g. imprisonment, divorce). Very few studies have attempted to synthesise these risks in one publication due to the breadth of evidence published on the adverse outcomes of ADHD. Methods An umbrella review was performed to identify reviews (systematic, meta-analysis and narrative) that investigate the risks arising from having ADHD. We conducted a narrative synthesis of the findings and conducted a quality review of the included publications. Results Upon searching five databases, 16,675 records were identified. Of these, 125 reviews met the criteria for inclusion. A narrative synthesis of these findings highlighted three key domains of risks associated with ADHD: mental health, physical health, social and lifestyle. Most reviews were of good and moderate quality. Discussion This review highlights the many risks associated with having ADHD, beyond its three key symptom domains and the impact of the condition on daily functioning. Registration International Prospective Register of Systematic Reviews (PROSPERO CRD42023404073).
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Systematic review and meta-analysis: relative age in attention-deficit/ hyperactivity disorder and autism spectrum disorderYoungest students in their class, with birthdates just before the school entry cut-off date, are overrepresented among children receiving an Attention-Deficit/Hyperactivity Disorder (ADHD) diagnosis or medication for this. This is known as the relative age effect. This systematic review and meta-analysis summarises the evidence on the influence of relative age on ADHD symptoms, diagnosis and medication prescribing. As no review to date has investigated the association with autism spectrum disorder (ASD) diagnosis, this is also examined. Following prospective registration with PROSPERO, we conducted a systematic review according to the PRISMA guidelines. We searched seven databases: Medline, Embase, PsycInfo, Web of Science Core Collection, ERIC, Psychology and Behavioural Sciences Collection, and Cochrane Library. Additional references were identified from manual search of retrieved reviews. We performed a meta-analysis of quantitative data. Thirty-two studies were included, thirty-one investigated ADHD and two ASD. Younger relative age was associated with ADHD diagnosis and medication, with relative risks of 1.38 (1.36-1.52 95% CI) and 1.28 (1.21-1.36 95% CI) respectively. However, risk estimates exhibited high heterogeneity. A relative age effect was observed for teacher ratings of ADHD symptoms but not for parent ratings. With regard to ASD, the youngest children in their school year were more likely to be diagnosed with ASD. This review confirms a relative age effect for ADHD diagnosis and prescribed ADHD medication and suggests that differences in teacher and parent ratings might contribute to this. Further research is needed on the possible association with ASD.
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A comparison of visual attention to pictures in the Autism Diagnostic Observation Schedule in children and adolescents with ADHD and/or autismBACKGROUND: Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are neurodevelopmental conditions which frequently co-occur. The Autism Diagnostic Observation Schedule (ADOS) is commonly used to aid with diagnostic assessment of ASD but was not originally designed for use in those with comorbid ADHD. Visual attention to social stimuli has been often studied in ASD using eye-tracking, to obtain quantitative indices of how attention is deployed to different parts of a social image/scene. As the ADOS includes tasks that rely on attending to and processing images of social scenes, these measures of visual attention could provide useful additional objective measurement alongside ADOS scores to enhance the characterisation of autistic symptoms in those with ADHD. METHODS: Children with ASD, comorbid ASD and ADHD, ADHD and Neurotypical (NT) controls were recruited (n=84). Visual attention was measured using eye-tracking during free viewing of social scenes selected from the ADOS. The full ADOS was then administered. Stimulant medication was temporarily withdrawn during this assessment. Research diagnoses were based on the Development and Wellbeing Assessment (DAWBA), ADOS, Social Communication Questionnaire (SCQ, a measure of ASD severity) and Conners' Rating Scales (CRS-3, a measure of ADHD severity) following clinical consensus. RESULTS: Using factorial ANOVAs to model ADHD, Autism and their interaction, we found that fixation duration to faces was reduced in those with ASD (ASD and ASD+ADHD) compared to those without ASD (ADHD and NT). Reduced visual attention to faces in the whole sample was associated with Autism symptom severity (SCQ subscale scores) but not ADHD symptom severity (CRS-3 scores). DISCUSSION: Our findings provide preliminary evidence in support of implementing visual attention measurement during assessment of ASD in the context of comorbidity with ADHD. For example, if a child with ADHD was found to reduce attention to faces in ADOS pictures this may suggest additive difficulties on the autism spectrum. Replication across a larger sample would be informative. This work has future potential in the clinic to help with complex cases, including those with co-occurring ADHD and ASD.
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Attention-deficit/hyperactivity disorderAttention-deficit/hyperactivity disorder (ADHD; also known as hyperkinetic disorder) is a common neurodevelopmental condition that affects children and adults worldwide. ADHD has a predominantly genetic aetiology that involves common and rare genetic variants. Some environmental correlates of the disorder have been discovered but causation has been difficult to establish. The heterogeneity of the condition is evident in the diverse presentation of symptoms and levels of impairment, the numerous co-occurring mental and physical conditions, the various domains of neurocognitive impairment, and extensive minor structural and functional brain differences. The diagnosis of ADHD is reliable and valid when evaluated with standard diagnostic criteria. Curative treatments for ADHD do not exist but evidence-based treatments substantially reduce symptoms and/or functional impairment. Medications are effective for core symptoms and are usually well tolerated. Some non-pharmacological treatments are valuable, especially for improving adaptive functioning. Clinical and neurobiological research is ongoing and could lead to the creation of personalized diagnostic and therapeutic approaches for this disorder.
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Autonomic nervous system functioning in ADHDIn this chapter, we introduce the autonomic nervous system (ANS), discuss the mechanisms underlying arousal regulation in humans, and present theoretical frameworks suggesting that altered autonomic functioning is likely to contribute to behavioral, cognitive, and emotional difficulties experienced by people with attention deficit/hyperactivity disorder (ADHD). The reviewed evidence in this chapter suggests that autonomic hypofunctioning and difficulties in regulating arousal according to situational demands may cause inattention, restlessness, reduced vigilance and cognitive difficulties (especially during monotonous and unrewarding activities), and emotional dysregulation and irritability in people with ADHD. Although the chapter is specifically focused on ADHD, we also provide the reader with an overview of the literature investigating autonomic dysfunction in psychiatric or psychological conditions that often co-occur with ADHD, including oppositional defiant disorder and conduct disorder, mood disorder, and autism spectrum disorder. We discuss the effects of pharmacological and nonpharmacological interventions for ADHD on autonomic functioning, and we propose that ADHD medication and some nonpharmacological interventions may be effective in reducing inattention and hyperactivity, and improving global functioning in people with ADHD, because they normalize activity of the ANS and improve arousal regulation. The concluding sections include a brief discussion about the possible implications of the findings presented in this chapter for clinical and research practice. Specifically, we stress the importance of clarifying, in future research, the role of altered autonomic functioning in ADHD, which could prove helpful for developing more efficient and valid assessment and intervention tools for people with this neurodevelopmental condition.
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Use of healthcare services before diagnosis of attention-deficit/hyperactivity disorder: A population-based matched case-control studyOBJECTIVE: To compare use of healthcare services and reasons for attendance by children and young people (CYP) with attention-deficit/hyperactivity disorder (ADHD) versus non-ADHD controls. DESIGN: Population-based matched case-control study. SETTING: English primary care electronic health records with linked hospital records from the Clinical Practice Research Datalink, 1998-2015. PARTICIPANTS: 8127 CYP with an ADHD diagnosis aged 4-17 years at the time of diagnosis and 40 136 non-ADHD controls matched by age, sex and general practitioner (GP) practice. MAIN OUTCOME MEASURES: Medical diagnoses, prescriptions, hospital admissions and hospital procedures in the 2 years before diagnosis (or the index date for controls). RESULTS: CYP with ADHD attended healthcare services twice as often as controls (rate ratios: GP: 2.0, 95% CI=2.0, 2.1; hospital 1.8, 95% CI=1.8, 1.9). CYP with ADHD attended their GP, received prescriptions and were admitted to hospital for a wide range of reasons. The strongest association for GP attendances, comparing CYP with versus without ADHD, was for 'mental and behavioural disorders' (OR=25.2, 95% CI=23.3, 27.2). Common reasons for GP attendance included eye, ear, nose, throat, oral (OR=1.5, 95% CI=1.4, 1.5) and conditions such as asthma (OR=1.3, 95% CI=1.3, 1.4) or eczema (OR=1.2, 95% CI=1.0, 1.3). CONCLUSIONS: Two years before diagnosis, CYP with ADHD attended healthcare services twice as often as CYP without. CYP with ADHD had increased rates of physical conditions, such as asthma and eczema. These contacts may be an opportunity for earlier recognition and diagnosis of ADHD.
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Remote Recruitment Strategy and Structured E-Parenting Support (STEPS) App: Feasibility and Usability StudyBACKGROUND: The Structured E-Parenting Support (STEPS) app provides support for parents of children with elevated hyperactivity, impulsivity, inattention, and conduct problems who are awaiting clinical assessment. STEPS will be evaluated in a randomized controlled trial (RCT) within the Online Parent Training for the Initial Management of ADHD Referrals (OPTIMA) research program in the United Kingdom. Phase 1 of the OPTIMA tested the feasibility of participants' recruitment and the app's usability. OBJECTIVE: This study aimed to adapt a digital routine clinical monitoring system, myHealthE, for research purposes to facilitate waitlist recruitment; test using remote methods to screen and identify participants quickly and systematically; pilot the acceptability of the recruitment and assessment protocol; and explore the usability of STEPS. METHODS: myHealthE was adapted to screen patients' data. Parents' and clinicians' feedback on myHealthE was collected, and information governance reviews were conducted in clinical services planning to host the RCT. Potential participants for the observational feasibility study were identified from new referrals using myHealthE and non-myHealthE methods. Descriptive statistics were used to summarize the demographic and outcome variables. We estimated whether the recruitment rate would meet the planned RCT sample size requirement (n=352). In addition to the feasibility study participants, another group of parents was recruited to assess the STEPS usability. They completed the adapted System Usability Scale and responded to open-ended questions about the app, which were coded using the Enlight quality construct template. RESULTS: Overall, 124 potential participants were identified as eligible: 121 (97.6%) via myHealthE and 3 (2.4%) via non-myHealthE methods. In total, 107 parents were contacted, and 48 (44.9%) consented and were asked if, hypothetically, they would be willing to participate in the OPTIMA RCT. Of the 28 feasibility study participants who provided demographic data, 21 (75%) identified as White. Their children had an average age of 8.4 (SD 1.7) years and 65% (31/48) were male. During the primary recruitment period (June to July 2021) when 45 participants had consented, 38 (84%) participants agreed hypothetically to take part in the RCT (rate of 19/mo, 95% CI 13.5-26.1), meeting the stop-go criterion of 18 participants per month to proceed with the RCT. All parents were satisfied or very satisfied with the study procedures. Parents (n=12) recruited to assess STEPS' usability described it as easy to navigate and use and as having an attractive combination of colors and visual design. They described the content as useful, pitched at the right level, and sensitively presented. Suggested improvements included adding captions to videos or making the recorded reflections editable. CONCLUSIONS: Remote recruitment and study procedures for testing a parenting intervention app are feasible and acceptable for parents. The parents felt that STEPS was a useful and easy-to-use digital parenting support tool. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s40814-021-00959-0.
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Practitioner Review: Clinical utility of the QbTest for the assessment and diagnosis of attention-deficit/hyperactivity disorder - a systematic review and meta-analysisBACKGROUND: Several computerised cognitive tests (e.g. continuous performance test) have been developed to support the clinical assessment of attention-deficit/hyperactivity disorder (ADHD). Here, we appraised the evidence-base underpinning the use of one of these tests - the QbTest - in clinical practice, by conducting a systematic review and meta-analysis investigating its accuracy and clinical utility. METHODS: Based on a preregistered protocol (CRD42022377671), we searched PubMed, Medline, Ovid Embase, APA PsycINFO and Web of Science on 15th August 2022, with no language/type of document restrictions. We included studies reporting accuracy measures (e.g. sensitivity, specificity, or Area under the Receiver Operating Characteristics Curve, AUC) for QbTest in discriminating between people with and without DSM/ICD ADHD diagnosis. Risk of bias was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2). A generic inverse variance meta-analysis was conducted on AUC scores. Pooled sensitivity and specificity were calculated using a random-effects bivariate model in R. RESULTS: We included 15 studies (2,058 participants; 48.6% with ADHD). QbTest Total scores showed acceptable, rather than good, sensitivity (0.78 [95% confidence interval: 0.69; 0.85]) and specificity (0.70 [0.57; 0.81]), while subscales showed low-to-moderate sensitivity (ranging from 0.48 [0.35; 0.61] to 0.65 [0.52; 0.75]) and moderate-to-good specificity (from 0.65 [0.48; 0.78] to 0.83 [0.60; 0.94]). Pooled AUC scores suggested moderate-to-acceptable discriminative ability (Q-Total: 0.72 [0.57; 0.87]; Q-Activity: 0.67 [0.58; 0.77); Q-Inattention: 0.66 [0.59; 0.72]; Q-Impulsivity: 0.59 [0.53; 0.64]). CONCLUSIONS: When used on their own, QbTest scores available to clinicians are not sufficiently accurate in discriminating between ADHD and non-ADHD clinical cases. Therefore, the QbTest should not be used as stand-alone screening or diagnostic tool, or as a triage system for accepting individuals on the waiting-list for clinical services. However, when used as an adjunct to support a full clinical assessment, QbTest can produce efficiencies in the assessment pathway and reduce the time to diagnosis.
