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Background Parents often recognize problems in their child's development earlier than health professionals do and there is new emphasis on the importance of involving parents in the diagnostic process. In Gothenburg, Sweden, over 100 children were identified as having an autism spectrum disorder (ASD) in 2009–11 through a general population language and autism screening of 2.5 year olds at the city's child healthcare centres. Aims To increase understanding of parents’ lived experience of the neuropsychiatric diagnostic process, i.e. the period from the initial screening at age 2.5 years to the 2-year follow-up of the ASD diagnosis. Methods & Procedures A qualitative design, a phenomenological hermeneutic method, was used. Interviews were conducted with parents of 11 children who were diagnosed with ASD 2 years prior. The parents were interviewed about their experiences of the neuropsychiatric diagnostic process, i.e. the time before the screening, the time during the neuropsychiatric multidisciplinary evaluation and the time after diagnosis. The interviews lasted for 45–130 min, and an interview guide with set questions was used. Most of the interviews were conducted at the parents’ homes. Outcomes & Results The essence that emerged from the data was negotiating knowledge, and the three themes capturing the parents’ experiences of going through the process of having their child diagnosed with ASD were seeking knowledge, trusting and challenging experts, and empowered but alone. Conclusions & Implications The parents expected intervention to start directly after diagnosis but felt they had to fight to obtain the resources their child needed. After the process, they described that they felt empowered but still alone, i.e. although they received useful and important information about their child, they were left to manage the situation by themselves. As for clinical implications, the study points to the necessity of developing routines to support the parents during and after the diagnostic process. Recommended measures include developing a checklist outlining relevant contacts and agencies, establishing a coordinator responsible for each child, dividing the summary meeting at the clinic into two parts, making more than one visit to the preschool, and providing a parental training programme.

Lambek, R., Trillingsgaard, A., Kadesjo, B., Damm, D. & Thomsen, P. H. (2010). Gender differences on the Five to Fifteen questionnaire in a non-referred sample with inattention and hyperactivity-impulsivity and a clinic-referred sample with hyperkinetic disorder. Scandinavian Journal of Psychology 51, 540–447. The aim of the present study was to examine gender differences in children with inattention, hyperactivity, and impulsivity on the Five to Fifteen (FTF) parent questionnaire. First, non-referred girls (n = 43) and boys (n = 51) with problems of attention and hyperactivity-impulsivity and then clinic-referred girls (n = 35) and boys (n = 66) with hyperkinetic disorder (HKD) were compared on the FTF. Results suggested that non-referred boys were more hyperactive-impulsive than non-referred girls, whereas clinic-referred boys and girl with HKD were more similar than dissimilar on the FTF questionnaire. Secondly, it was examined whether the application of gender mixed norms versus gender specific norms would result in varying proportions of clinic-referred children with HKD being identified as impaired on the subdomains of the FTF questionnaire. Based on results it was concluded that the use of a gender mixed normative sample may lead to overestimation of impairment in boys with HKD, but the type of sample applied to define impairment on the FTF should depend on the purpose for applying the questionnaire.

International audience; This 10-week study assessed the efficacy of atomoxetine in combination with psychoeducation compared to placebo and psychoeducation in the improvement of Quality of Life in Swedish stimulant-naive children and adolescents with attention deficit/hyperactivity disorder. A total of 99 patients were treated with atomoxetine (49 patients) or placebo (50 patients) for 10 weeks and assessed regarding broader areas of functioning using the Quality of Life measures Child Health and Illness Profile-Child Edition (CHIP-CE), Family Strain Index [FSI; equivalent to the Family Burden of Illness Module used in the study], Appraisal of Stress in Child-Rearing (ASCR), Five to fifteen (FTF), “I think I am” (“Jag tycker jag är”), and Children's Depression Rating Scale-Revised (CDRS-R) before and after the active treatment phase. Simultaneously, the patients' parents participated in a 4-session psychoeducation program. A statistically significant difference in favor of atomoxetine was seen in the improvement from baseline to study endpoint for the CHIP-CE domains “Achievement” and “Risk avoidance”, for the FSI total score, for the ASCR section (I) domain “Child as a burden”, for all FTF domains except for “Language and Speech”, and for the CDRS-R total score. No difference between treatment groups was observed in the patient-assessed evaluation of self-esteem using the “I think I am” scale. Atomoxetine combined with psychoeducation had a positive effect on various everyday coping abilities of the patients as well as their families during 10 weeks of treatment, whereas the patients' self-image and the parents' image of the climate in the family were not significantly improved.

Objective: The aim of the study was to assess omega 3/6 fatty acids (eye q) in attention deficit hyperactivity disorder (ADHD). Method: The study included a randomized, 3-month, omega 3/6 placebo-controlled, one-way crossover trial with 75 children and adolescents (8—18 years), followed by 3 months with omega 3/6 for all. Investigator-rated ADHD Rating Scale—IV and Clinical Global Impression (CGI) scale were outcome measures. Results: A majority did not respond to omega 3/6 treatment. However, a subgroup of 26% responded with more than 25% reduction of ADHD symptoms and a drop of CGI scores to the near-normal range. After 6 months, 47% of all showed such improvement. Responders tended to have ADHD inattentive subtype and comorbid neurodevelopmental disorders. Conclusion: A subgroup of children and adolescents with ADHD, characterized by inattention and associated neurodevelopmental disorders, treated with omega 3/6 fatty acids for 6 months responded with meaningful reduction of ADHD symptoms. (J. of Att. Dis. 2009; 12(5) 394-401)

The primary objective of this study was to assess the impact of atomoxetine in combination with psychoeducation, compared with placebo and psychoeducation, on health-related quality of life (HRQL) in Swedish stimulant-naïve pediatric patients with attention deficit/hyperactivity disorder (ADHD). HRQL results will be presented elsewhere. Here, psychoeducation as well as efficacy and safety of the treatment are described.A total of 99 pediatric ADHD patients were randomized to a 10-week double-blind treatment with atomoxetine (49 patients) or placebo (50 patients). Parents of all patients received four sessions of psychoeducation. Atomoxetine was dosed up to approximately 1.2 mg/kg day (or = 70 kg) or 80 mg/day (70 kg). Improvement of ADHD symptoms was evaluated using the ADHD rating scale (ADHD-RS) and clinical global impression (CGI) rating scales. Safety was assessed based on adverse events (AEs).The study population was predominantly male (80.8%) and diagnosed with the combined ADHD subtype (77.8%). The least square mean (lsmean) change from baseline to endpoint in total ADHD-RS score was -19.0 for atomoxetine patients and -6.3 for placebo patients, resulting in an effect size (ES) of 1.3 at endpoint. Treatment response (reduction in ADHD-RS score ofor = 25 oror = 40%) was achieved in 71.4 or 63.3% of atomoxetine patients and 28.6 or 14.3% of placebo patients. The lsmean change from baseline to endpoint in CGI-Severity was -1.8 in the atomoxetine group compared with -0.3 in the placebo group. The difference between treatments in CGI-Improvement at endpoint was -1.4 in favor of atomoxetine. No serious AEs occurred. The safety profile of atomoxetine was in line with the current label.Atomoxetine combined with psychoeducation was superior to placebo and psychoeducation in ADHD core symptoms improvement. The large ES might be a result of including stimulant-naïve patients only, but also may indicate a positive interaction between atomoxetine treatment and psychoeducation, possibly by increased compliance.

A population study of 409 seven-year-old children in a middle-sized Swedish town was performed. All children were examined by the same doctor and evaluated by means of parent interview, motor examinations, and teacher reports on behaviour in the classroom. Follow-up was carried out 8 months later. The rate of severe problems in the fields of attention deficit-hyperactivity disorder (ADHD), developmental coordination disorder (DCD), and deficits in attention, motor control, and perception (DAMP) (the combination of ADHD and DCD) was 6.1%, with boys being affected more frequently than girls. There was considerable overlap between ADHD and DCD, with about half of each diagnostic group also meeting criteria for the other diagnosis. Attention deficits at diagnosis strongly predicted attention deficits at follow-up. If parents had noted attention deficits in the home setting, then teachers almost always independently agreed that there were similar problems in the classroom. However, the reverse did not always apply. Clumsiness also showed striking stability over time. The diagnosis of DAMP, particularly severe DAMP, had a stronger association with classroom dysfunction and with high Conners scores than did diagnoses of ADHD or DCD. It is concluded that DAMP may be a clinically valid diagnostic construct.

A community-representative sample of screened and clinically examined children with language delay at 2.5 years of age was followed up at school age when their language development was again examined and the occurrence of neuropsychiatric/neurodevelopmental disorder (attention deficit/hyperactivity disorder (ADHD) and/or autism spectrum disorder (ASD)) was documented.(1) To determine whether these 7-8-year-old children with a history of language delay have deficits in narrative skills compared with the age norms of standardized tests; and (2) to analyse if there is a relationship between narrative outcome, cognitive profile, and neuropsychiatric diagnosis.Twenty-one children recruited from a community sample and with a history of language delay underwent an in-depth multidisciplinary examination at 7-8 years of age. Their narrative and cognitive skills were examined using the Bus Story Test, the Narrative Memory Subtest from the Developmental Neuropsychological Assessment (NEPSY), and The Wechsler Intelligence Scale for Children III (WISC-III).The three measures of the Bus Story Test (information, sentence length, and subordinate clauses) were below age norms for all 21 children, of whom 13 also had a neuropsychiatric diagnosis, i.e. ADHD and/or ASD. Half of the children with language delay had problems on Bus Story Test Information and on the Narrative Memory subtest independently of co-occurrence of neuropsychiatric disorder. The only difference across the children with language delay pure and those who had language delay plus ADHD or language delay plus ASD was on Freedom from Distractibility, where children with ADHD and ASD scored low. In addition, children with ASD had a much lower overall cognitive level (FSIQ) and poorer results on Processing Speed.Swedish children with late developing language at 2.5 years of age have persisting difficulties with oral narrative skills at age 7-8 years. However, almost none of the children with language delay had problems when responding to story-related questions--irrespective of whether or not they had an additional diagnosis of ADHD or ASD. Thus, asking story-related questions may be a good intervention strategy when working with these children. Because narrative difficulties are a reflection of linguistic, cognitive and/or pragmatic/social difficulties, it is important for clinicians of different specialties to work in close collaboration in order to establish a reliable measure that can be used in clinical assessment. Poor results on the WISC-III Kaufman Freedom from Distractibility factor had a strong relationship with a neuropsychiatric diagnosis (not just ADHD), whereas poor results on Bus Story Test Information or NEPSY Narrative Memory (measured as Free Recall) did not. Narrative problems were present among the language delay children even in the presence of adequate speech and verbal comprehension. Thus, narrative assessment may be a useful tool for identifying children with more persistent subtle language and pragmatic problems who are at risk for academic failure.

Objective: We assess the diagnostic accuracy of the QbTest, which measures the cardinal symptoms of ADHD. Method: The study group comprised 182 children (mean age about 10 years), of whom 124 had ADHD and 58 had other clinical diagnosis of which 81% had ASD. Results: Only QbTest parameters for inattention and hyperactivity differentiated between ADHD and other clinical diagnoses at the p ≤ .01 level, not for measures of impulsivity. Sensitivity ranged from 47% to 67% and specificity from 72% to 84%. Positive predictive value ranged from 41% to 86%, and negative predictive value from 43% to 86%. Area under the curve varied from .70 to .80. Conclusion: The ability of the individual QbTest parameters to identify ADHD was moderate. The test’s ability to discriminate between ADHD subtypes was unsatisfactory.

This paper describes the development of a new parent questionnaire ("Five to Fifteen", or the FTF) for elicitation of symptoms and problems typical of ADHD and its comorbidities. The FTF comprises 181 statements related to behavioural or developmental problems that can be endorsed as either "does not apply" (0), applies sometimes or to some extent" (1), "definitely applies" (2), plus a number of open-ended questions including some about the child's strengths. The items are arranged into eight different domains (memory, learning, language, executive functions, motor skills, perception, social skills, and emotional/behavioural problems), most of which can be subdivided into subdomains. For each domain, a mean score ranging from 0-2 can be calculated. A representative sample (n=1350) of the total population of 6-15-year-old children was targeted. Parents of 63% of these completed a questionnaire and returned it to the researchers. Boys showed significantly more problems than did girls across domains and age. Younger children had more problems than pre-adolescents and adolescents (except in the domains of social skills and emotional/behavioural problems). Executive dysfunction was common, and 5.3% of all children in the population had clear problems suggesting a diagnosis of ADHD according to parent report. The paper provides means, medians, and 90(th) and 95(th) centiles for individual items as well as for the eight domains. The Discussion centres on whether or not the FTF can (or should) be used in school-aged children for the identification of children at risk for ADHD or other early childhood onset neuropsychiatric disorder.

Developmental coordination disorder (DCD) is a common motor problem affecting—even in rather severe form—several percent of school age children. In the past, DCD has usually been called ‘clumsy child syndrome’ or ‘non-cerebralpalsy motor-perception dysfunction’. This disorder is more common in boys than in girls and is very often associated with psychopathology, particularly with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorders/ autistic-type problems. Conversely, children with ADHD and autism spectrum problems, particularly those given a diagnosis of Asperger syndrome, have a very high rate of comorbid DCD. Psychiatrists appear to be unaware of this type of comorbidity in their young patients. Neurologists, on the other hand, usually pay little attention to the striking behavioral and emotional problems shown by so many of their ‘clumsy’ patients. A need exists for a much clearer focus on DCD—in child psychiatry and in child neurology—both in research and in clinical practice.

Objective To study characteristics of attention-deficit/hyperactivity disorder (ADHD) in a representative group of clinically impaired young children in Sweden with the disorder. Method One hundred thirty-one children with ADHD (aged 3–7 years) were examined, and their parents were interviewed. Independent parent questionnaire data (Child Behavior Checklist, ADHD Rating Scale-IV, Conners) were collected. For comparison 131 children without ADHD were matched for age, gender, parents’ marital status, child's adoption status, and social class. Results Children with ADHD had extremely high ADHD symptom levels—on average four to eight times higher than the comparison group. Sociodemographic correlates of ADHD symptoms were more pronounced in parent questionnaire data than in parent interview data, underscoring the importance of diagnostic interview when dealing with clinical issues. Very few of the children with ADHD (6%) appeared “normal” with regard to attention/activity level at clinical examination. Conclusions Clinic children with a diagnosis of DSM-IV ADHD have typical and impairing symptoms already before starting school. The variance of ADHD in this age group appears to be accounted for by primary psychosocial factors only to a limited degree. It would seem reasonable to establish supportive and treatment measures for these young children so that the psychosocial and academic problems shown by so many individuals with ADHD later in their development might be reduced.

This study examined patterns of comorbid/associated diagnoses and associated problems in a population sample of children with and without DSM-III-R attention-deficit hyperactivity disorder (ADHD). Half (N = 409) of a mainstream school population of Swedish 7-year-olds were clinically examined, and parents and teachers were interviewed and completed questionnaires. The children were followed up 2-4 years later. Eighty-seven per cent of children meeting full criteria for ADHD (N = 15) had one or more and 67% at least two--comorbid diagnoses. The most common comorbidities were oppositional defiant disorder and developmental coordination disorder. Children with subthreshold ADHD (N = 42) also had very high rates of comorbid diagnoses (71% and 36%), whereas those without ADHD (N = 352) had much lower rates (17% and 3%). The rate of associated school adjustment, learning, and behaviour problems at follow-up was very high in the ADHD groups. We concluded that pure ADHD is rare even in a general population sample. Thus, studies reporting on ADHD cases without comorbidity probably refer to highly atypical samples. By and large, such studies cannot inform rational clinical decisions.

Objective To estimate the prevalence, comorbidity, and outcome in developmental coordination disorder (DCD). Method In this population study of 7-year-olds undergoing individual examination plus teacher and parent interviews, children were followed up at ages 8, 9, and 10 years. Results Severe DCD occurred in 4.9% and moderate DCD in another 8.6%. Boy-girl ratios ranged from 4:1 to 7:1. Children with severe and moderate DCD did not differ from each other on any measure, but both groups were clearly separated from children without DCD with respect to associated attention deficit symptoms, Asperger's disorder symptoms, school dysfunction scores, and outcome. Approximately half of all children with DCD had moderate to severe symptoms of attention-deficit/hyperactivity disorder (ADHD). Conclusions DCD is a common problem, and it is strongly associated with ADHD symptoms. A diagnosis of DCD at age 7 years predicts DCD at age 8 years and restricted reading comprehension at age 10 years. Clinicians need to acquaint themselves with DCD and its comorbidity so that they can provide better services to affected children.

The aim of this study was to assess baseline levels and changes in plasma fatty acid profiles in children and adolescents with ADHD, in a placebo-controlled study with Omega 3/6 supplementation, and to compare with treatment response. Seventy-five children and adolescents aged 8–18 years with DSM-IV ADHD were randomized to 3 months of Omega 3/6 (Equazen eye q) or placebo, followed by 3 months of open phase Omega 3/6 for all. n-3, n-6, n-6/n-3 ratio, EPA and DHA in plasma were measured at baseline, 3 and 6 months. Subjects with more than 25 % reduction in ADHD symptoms were classified as responders. At baseline, no significant differences in mean fatty acid levels were seen across active/placebo groups or responder/non-responder groups. The 0–3 month changes in all parameters were significantly greater in the active group (p

Background It is only recently that comorbidity in ADHD has come to the forefront as one of the most important aspects of the disorder. It is agreed that, often, these problems are at least as important as ADHD in contributing to the longer term outcome in the individual child. Objective To provide the reader with basic information about clinics and treatment of comorbidity in ADHD. Method Review of the empirically based literature. Results ADHD exists in a surprisingly high frequency together with a broad range of child neuropsychiatric disorders. This is accompanied with many still unresolved treatment problems. Conclusion It would not be appropriate to develop ADHD–services where clinicians would only have expertise in ADHD as such. Anyone working with children, adolescents and adults with ADHD would need to have training in general neuropsychiatry. Further research in this field is urgently needed. (Less)

Attention-deficit-hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with a high degree of associated behavioural problems. In order to study characteristics of ADHD with and without oppositional defiant disorder (ODD) in a representative group of young children with clinical impairment in Sweden, 131 children (101 males, 30 females) with ADHD (mean age 5 years, SD 1 year 5 months; range 3 to 7 years) were clinically examined, and their parents interviewed. Independent questionnaire data (Child Behavior Checklist, ADHD Rating Scale-IV, ODD Rating Scale-IV, Conners Hyperactivity Index) were collected. For comparison 131 children without ADHD were matched for sex, age, marital status, and socioeconomic status (115 males, 16 females; mean age 4 years 10 months, SD 1 year 5 months; range 3 to 7 years). Sixty percent of those with ADHD met full DSM-IV criteria for ODD. Only 10 of the 131 children with ADHD had no symptoms of ODD at all. The rate of children meeting full diagnostic criteria for ODD was similar across all age cohorts. Males were overrepresented in ODD, as were children of divorced parents and of mothers with low socioeconomic status. ADHD combined subtype was a stable independent factor influencing the diagnosis of ODD, regardless of psychosocial factors. Those with ADHD with ODD consistently showed higher rates of ADHD symptoms than did those with ADHD without ODD. The prevalent comorbidity of ADHD with ODD indicates that all children presenting with ADHD or ODD symptoms need to be assessed with a view to exploring both types of problem behaviours. The link between ODD and some psychosocial variables indicates the need to address these, possibly by measures such as parent training and network support.

Objective To study prevalence and comorbidity of Tourette's disorder in the general population of children and in a clinical setting. Method School-age children in the general population and children attending a county-wide tic disorder clinic were screened and examined by the same doctor. Behavioral-psychometric instruments with demonstrated reliability and validity were used. Results Depending on the sample characteristics, 0.15% to 1.1% of all children had Tourette's disorder. Boys outnumbered girls by 4:1 through 6:1. Attention deficits and empathy/autism spectrum problems (including Asperger's disorder) were very common, each type of comorbidity affecting approximately two thirds of individuals with Tourette's disorder. Overall behavior problem scores were high, and affected children exhibited a marked degree of functional impairment. Conclusions Tourette's disorder is a common disorder with high rates of significant comorbidity. In most cases, attention deficits and empathy problems are likely to cause more suffering than the tics per se.