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Objective. A new once-a-day methylphenidate (MPH) formulation, Concerta (methylphenidate HCl) extended-release tablets (OROS MPH), has been developed. This study was conducted to determine the safety and efficacy of OROS MPH in a multicenter, randomized, clinical trial. Methods. Children with attention-deficit/hyperactivity disorder (ADHD; n = 282), all subtypes, ages 6 to 12 years, were randomized to placebo (n = 90), immediate-release methylphenidate (IR MPH) 3 times a day (tid; dosed every 4 hours; n = 97), or OROS MPH once a day (qd; n = 95) in a double-blind, 28-day trial. Outcomes in multiple domains were assessed, and data were analyzed using analysis of variance and Kaplan Meier product limit estimates for time to study cessation. The primary time point for analysis was the last available patient visit using last observation carried forward. Results. Children in the OROS and IR MPH groups showed significantly greater reductions in core ADHD symptoms than did children on placebo. This was true both at the end of week 1 and at the end of treatment on the basis of mean teacher and parent IOWA Conners ratings. IR MPH tid and OROS MPH qd did not differ significantly on any direct comparisons. Forty-eight percent of the placebo group discontinued early compared with 14% and 16% in the IR MPH and OROS MPH groups, respectively. Conclusions. For the treatment of core ADHD symptoms, OROS MPH dosed qd and IR MPH dosed tid were superior to placebo and were not significantly different from each other. [ABSTRACT FROM AUTHOR]

Objective: To examine the effects of sugar on the behavior or cognition of children by using meta-analytic techniques on reported studies.Data Sources: Studies were identified through a literature search of the MEDLINE and PsychINFO databases and the authors' files using sugar, sucrose, and attention deficit disorder as the search terms.Study Selection: Studies were required to (1) intervene by having the subjects consume a known quantity of sugar, (2) use a placebo (artificial sweetener) condition (3) blind the subjects, parents, and research staff to the conditions; and (4) report statistics that could be used to compute the dependent measures effect sizes.Data Extraction: Variables included publication year, study setting, subject type and number, gender, age, sugar and placebo type and dose, prior dietary condition, measurement construct, means and SDs for the sugar and placebo conditions, and direction of effect.Data Synthesis: Sixteen reports met the inclusion criteria for a total of 23 within-subject design studies. The weighted mean effect size and related statistics for each of the 14 measurement constructs revealed that although the range for these means was from -0.14 for direct observations and up to +0.30 for academic tests, the 95% confidence interval for all 14 mean effect sizes included 0.Conclusion: The meta-analytic synthesis of the studies to date found that sugar does not affect the behavior or cognitive performance of children. The strong belief of parents may be due to expectancy and common association. However, a small effect of sugar or effects on subsets of children cannot be ruled out. [ABSTRACT FROM AUTHOR]

Is methylphenidate effective for preschool children with attention deficit/hyperactivity disorder?METHODSDesign: Crossover randomised controlled trial (titration phase) followed by parallel group randomised controlled trial (efficacy phase).Allocation: Concealed. Blinding: Double blind.Follow-up period: Five weeks for titration phase and 4 weeks for efficacy phase.Setting: Six academic sites, USA; enrolment February 2001 to April 2003.Patients: Titration phase: 165 children aged 3-5.5 years with DSM-IV attention deficit/hyperactivity disorder (ADHD) of the predominantly hyperactive or combined subtypes (Revised Conners Parent and Teacher Rating Scale hyperactive-impulsive subscale T score of 65). Efficacy phase: 114 children completing the titration phase. Exclusions: previous stimulant treatment; intolerance to methylphenidate; Children's Global Assessment Scale impairment score >/= 50; different primary caregiver over past 6 months; Full Scale IQ score equivalent of 4 70 on the Differential Ability Scales; less than 2 days/week in school; adjustment disorder; psychosis; suicidal; other psychiatric disorder requiring medication; other medical condition; parental history of bipolar disorder; or cocaine or stimulant abuse by a relative living in the child's home.Intervention: Titration phase: methylphenidate 1.25, 2.5, 5 or 7.5 mg three times daily and placebo, each for 1 week, in five different sequences. Efficacy phase: best dose methylphenidate (determined for each child in the titration phase) or placebo.Outcomes: Titration phase: best dose of methylphenidate (dose which produced optimal reduction in symptoms on a composite of the Swanson, Kotkin, Atkins M-Flynn and Pelham (SKAMP) and parent and teacher Conners, Loney and Milich (CLAM) rating scales). Efficacy phase: 'excellent' response (based on a combination of parent and teacher Swanson, Nolan and Pelham (SNAP) rating scales).Patient follow-up: 89% completed titration phase; 68% completed efficacy phase (55% with placebo, 85% with methylphenidate); 100% included in intention-to-treat analyses.MAIN RESULTSTitration phase: methylphenidate 2.5 mg, 5 mg, and 7.5 mg improved symptoms of ADHD in preschool children compared with placebo (composite SKAMP/CLAM scores; p<0.001 for each comparison); methylphenidate 1.25 mg did not (p = 0.06). Efficacy phase: no significant difference between best dose methylphenidate (mean best dose 14.2 mg daily) and placebo in the proportion of children achieving an 'excellent' response at 4 weeks (22% with methylphenidate v 13% with placebo; p = 0.3). Appetite loss, sleeping problems, stomach ache, social withdrawal and lethargy were more common with high dose than low dose methylphenidate or placebo (no further data reported). Eight cases of high blood pressure, with at least one measurement showing tachycardia, occurred during titration. There was one possible seizure,. which was the only serious treatment-related adverse event.CONCLUSIONSMethylphenidate may reduce symptoms of ADHD in preschool children in the short term compared with placebo, but it has not been proven to increase the proportion of children achieving an 'excellent' response over 4 weeks. [ABSTRACT FROM AUTHOR]

Does the risk-benefit profile of selective serotonin reuptake inhibitors (SSRIs) in the treatment of depression in children change when unpublished data is added to the meta-analysis?METHODSDesign: Systematic review with meta-analysis.Data sources: EMBASE, MEDLINE, PsycINFO, CINAHL, and the Cochrane Library searched from inception to April 2003, plus hand searches of key journals, previous systematic reviews and meta-analyses, and contact with experts. Unpublished data extracted from a Committee on Safety of Medicines report on the use of SSRls in children with depression.Study selection and analysis: Inclusion criteria: English language RCTs published in peer reviewed journals, or reviewed in the Committee on Safety of Medicines report comparing SSRIs with placebo for depression in young people (aged 5-18 years). The quality of each RCT was assessed. Trials not clearly described as randomised were excluded. Tests for heterogeneity were carried out. Risk-benefit profiles were calculated for each SSRI based on relative and absolute statistics.Outcomes: Remission (Children's Depression Rating Scale-revised (CDRS-R) score<29; Hamilton Depression Rating Scale <8); response to treatment (50% reduction in CDRS-R score); changes in mean depression level (CDRS-R); serious adverse events; suicidal behaviour and attempts; number of participants discontinuing treatment.MAIN RESULTSSee http://www.ebmentalhealth.com/supplemental for table for RR of SSRIs versus placebo.Fluoxetine: two published RCTs (n = 315) plus unpublished data (n = 458) met inclusion criteria. Fluoxetine significantly increased remission and improved treatment response compared with placebo. Fewer children reported serious adverse effects (SAEs) with fluoxetine compared with placebo. Data on suicidal behaviour were not reported in published trials; unpublished data showed no increased risk with fluoxetine.Paroxetine: one published RCT (n = 180) plus two unpublished trials (n = 478) met inclusion criteria. Paroxetine increased remission compared with placebo but there were no significant differences in response or reduction in depressive symptoms between groups. Paroxetine increased SAEs compared with placebo. In the unpublished trials, paroxetine did not significantly improve outcomes compared with placebo. Combining data revealed no significant differences between groups, except for SAEs, which were significantly more likely with paroxetine.Sertraline: two published RCTs (n = 376) plus unpublished data from these trials met inclusion criteria. Sertraline improved response compared with placebo but there were no significant differences in reduction in depressive symptoms between groups.Citalopram: Only data from two unpublished trials (n = 422) met inclusion criteria. Citalopram did not significantly improve depressive symptoms compared with placebo. Citalopram was associated with a small increase in SAEs compared with placebo.Venlafaxine: one RCT (n = 40) plus two unpublished trials (n = 334) met inclusion criteria. Published data indicated that venlafaxine did not significantly improve depressive symptoms; no SAEs were reported. With unpublished data, venlafaxine was associated with an increased risk of suicide related behaviour and an increased risk of discontinuing treatment due to adverse effects.CONCLUSIONSFluoxetine is likely to be beneficial for depression in young people, and has a favourable risk-benefit profile compared with other SSRIs. Citalopram and venlafaxine are unlikely to be beneficial. For paroxetine, sertraline, and venlafaxine, published data alone indicate that benefits may outweigh the risks; however, combining published and unpublished data suggests that the risks outweigh the benefits. Non-publication of trials and data can lead to false assumptions regarding efficacy of treatments. [ABSTRACT FROM AUTHOR]

Introduction: Approximately 7.2% of children in the world suffer from attention-deficit/hyperactivity disorder (ADHD). Due to the availability of the osmotic-release oral-system methylphenidate, ADHD currently has a remission rate of up to 30.72%. Nevertheless, it has been reported that patients with ADHD tend to exhibit vitamin A and vitamin D deficiency, which may aggravate the symptoms of ADHD. This study aims to determine the effect of vitamin A and vitamin D supplementation as adjunctive therapy to methylphenidate on the symptoms of ADHD., Methods and Analysis: This is a parallel, prospective, interventional multicentric study. Patients will be enrolled from the southern, central and northern parts of China. A target of 504 patients will be followed for 8 weeks. They will be allocated into three groups (vitamin AD, vitamin D and placebo) and administered the interventions accordingly. Data on changes in the symptoms of ADHD as well as changes in the serum concentrations of vitamin A and vitamin D will be recorded. Both responders and nonresponders based on the sociodemographic and clinical data will also be described to mitigate selection bias., Ethics and Dissemination: This study is performed in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Children's Hospital of Chongqing Medical University, China (approval number: (2019) IRB (STUDY) number 262). The results of the trial will be reported in peer-reviewed scientific journals and academic conferences regardless of the outcomes., Trial Registration Number: NCT04284059., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This study evaluates the impact of a 6-month care management intervention for 206 children diagnosed with comorbid attention deficit hyperactivity disorder (ADHD) from a sample of 321 five- to 12-year-old children recruited for treatment of behavior problems in 8 pediatric primary care offices. Practices were cluster-randomized to Doctor Office Collaboration Care (DOCC) or Enhanced Usual Care (EUC). Chart reviews documented higher rates of service delivery, prescription of medication for ADHD, and titration in DOCC (vs EUC). Based on complex conditional models, DOCC showed greater acute improvement in individualized ADHD treatment goals and follow-up improvements in quality of life and ADHD and oppositional defiant disorder goals. Medication use had a significant effect on acute and follow-up ADHD symptom reduction and quality of life. Medication continuity was associated with some long-term gains. A collaborative care intervention for behavior problems that incorporated treatment guidelines for ADHD in primary care was more effective than psychoeducation and facilitated referral to community treatment.

Objective: Investigate the prevalence and impact of psychiatric comorbidities in community-based samples of schoolchildren with/without ADHD. Method: Teachers and parents screened children in South Carolina (SC; n = 4,604) and Oklahoma (OK; n = 12,626) for ADHD. Parents of high-screen and selected low-screen children received diagnostic interviews (SC: n = 479; OK: n = 577). Results: Psychiatric disorders were increased among children with ADHD and were associated with low academic performance. Conduct disorder/oppositional defiant disorder (CD/ODD) were associated with grade retention (ODD/CD + ADHD: odds ratio [OR] = 3.0; confidence interval [CI] = [1.5, 5.9]; ODD/CD without ADHD: OR = 4.0; CI = [1.7, 9.7]). School discipline/police involvement was associated with ADHD alone (OR = 3.2; CI = [1.5, 6.8]), ADHD + CD/ODD (OR = 14.1, CI = [7.3, 27.1]), ADHD + anxiety/depression (OR = 4.8, CI = [1.6, 14.8]), and CD/ODD alone (OR = 2.8, CI = [1.2, 6.4]). Children with ADHD + anxiety/depression had tenfold risk for poor academic performance (OR = 10.8; CI = [2.4, 49.1]) compared to children with ADHD alone. This should be interpreted with caution due to the wide confidence interval. Conclusion: Most children with ADHD have psychiatric comorbidities, which worsens functional outcomes. The pattern of outcomes varies by type of comorbidity.

Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral condition and the second most common chronic illness in children. The observance of specific behaviors in multiple settings have remained the most successful method for diagnosing the condition, and although there are differences in specific areas of the brain, and a high heritability estimate (∼76%), they are not diagnostically specific. Medications, and particularly stimulant medication, have undergone rigorous studies to document their efficacy dating back to the 1970s. Likewise, behavioral interventions in the form of parent training and classroom programs have demonstrated robust efficacy during the same time period. Both medication and behavioral interventions are symptomatic treatments. The availability of only symptomatic treatments places ADHD in the same category as other chronic conditions such as diabetes and asthma. Successful treatment of most individuals requires ongoing adherence to the therapy. Improved communication between patients and their families, primary and mental health providers, and school personnel is necessary for effective ADHD treatment. Further enhancement of electronic systems to facilitate family, school, and provider communication can improve monitoring of ADHD symptoms and functional performance. The American Academy of Pediatrics ADHD guidelines were initially developed to help primary care clinicians address the needs of their patients with ADHD and were further refined with the second revision in 2019., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Chan has a potential conflict of interest, in that she is a coinventor of the TriVox Health health information technology referenced in this article. In the future, it is possible that this technology will be sold commercially. If this were to occur, Dr Chan and Boston Children’s Hospital might receive financial benefits in the form of compensation. As in all research studies, the hospital has taken steps designed to ensure that this potential for financial gain does not endanger research subjects or undercut the validity and integrity of the information learned by this research; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Attention-deficit/hyperactivity disorder (ADHD) is 1 of the most common neurobehavioral disorders of childhood and can profoundly affect children's academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for evaluation and diagnosis of pediatric ADHD in 2000; recommendations for treatment followed in 2001. The guidelines were revised in 2011 and published with an accompanying process of care algorithm (PoCA) providing discrete and manageable steps by which clinicians could fulfill the clinical guideline's recommendations. Since the release of the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders has been revised to the fifth edition, and new ADHD-related research has been published. These publications do not support dramatic changes to the previous recommendations. Therefore, only incremental updates have been made in this guideline revision, including the addition of a key action statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying process of care algorithm has also been updated to assist in implementing the guideline recommendations. Throughout the process of revising the guideline and algorithm, numerous systemic barriers were identified that restrict and/or hamper pediatric clinicians' ability to adopt their recommendations. Therefore, the subcommittee created a companion article (available in the Supplemental Information) on systemic barriers to the care of children and adolescents with ADHD, which identifies the major systemic-level barriers and presents recommendations to address those barriers; in this article, we support the recommendations of the clinical practice guideline and accompanying process of care algorithm., Competing Interests: POTENTIAL CONFLICT OF INTEREST: All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the American Academy of Pediatrics board of directors. Dr Allan reports a relationship with ADDitude Magazine; Dr Chan reports relationships with TriVox Health and Wolters Kluwer; Dr Lehmann reports relationships with International Medical Informatics Association, Springer Publishing, and Thieme Publishing Group; Dr Wolraich reports a Continuing Medical Education trainings relationship with the Resource for Advancing Children’s Health Institute; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Objective: Assessing race/ethnicity and socioeconomic status (SES) relationships with Attention-Deficit/Hyperactivity Disorder (ADHD) diagnosis, treatment, and access to care has yielded inconsistent results often based only on parent-report. In contrast, this study used broader ADHD diagnostic determination including case-definition to examine these relationships in a multisite elementary-school-based sample., Method: Secondary analysis of children with and without ADHD per parent and teacher-reported Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria evaluated SES, race/ethnicity, and other variables through simple bivariate/multivariable models within and across: parent-reported diagnosis, medication treatment, and meeting ADHD study case-definition., Results: The total sample included 51.9% male, 51.3% White, and 53.1% with private insurance; 10% had parent-reported ADHD diagnoses while 8.3% met ADHD study case-definition. In multivariable models, White children had higher odds of parent-reported diagnoses than Black, Hispanic, and Other Race/Ethnicity children (p < 0.05), but only Hispanic children had lower odds of being case-positive (<0.05); males and children in single-parent households had higher odds of parent-reported diagnoses and being case-positive (p < 0.05); and children who were White, male, and had health insurance had higher odds of taking medication (p < 0.05). Among children who were case-positive, those with Medicaid, White, and 2-parent statuses had higher odds of parent-reported diagnoses (p < 0.05)., Conclusion: Children with underlying ADHD appear more likely to have assessment/medication treatment access if they are White, male, have health insurance (particularly Medicaid), and live in 2-parent households. While boys and children raised by single parents may have higher rates of ADHD diagnoses, false-positive diagnostic risk also appeared higher, inviting further investigation.

Background: Factors surrounding pediatricians' parenting advice and training on parenting during residency have not been well studied. The Resident Parenting Questionnaire (RPQ) was developed to assess (a) the relationship between pediatric residents' upbringing and their parenting advice style and (b) factors associated with confidence and resource use when delivering parenting advice. Methods: Three hundred and one pediatric residents from 15 United States residency programs completed the RPQ with upbringing and advice responses categorized using Baumrind's parenting model (authoritative, authoritarian, permissive). Chi-square/Fisher's exact tests, Bowker's test of symmetry, and regression analyses assessed associations between residents' upbringing, parenting advice style/content, and confidence in providing parenting advice. Results: Most participants indicated being raised authoritatively (68%) and giving authoritative parenting advice (83%), but advice differed based on how they perceived their upbringing ( p < 0.001). Residents noting authoritative upbringing were more likely to give authoritative advice (85%) while others tended to give advice differing from upbringing (e.g., those perceiving authoritarian upbringing were more likely to give authoritative/permissive). Analyses suggest resident race, acculturation, future plans, and resident level are associated with parenting advice type. Confidence in giving parenting advice decreased significantly as patient age increased and increased with resident level advancement. Residents reported consulting attending physicians for parenting advice guidance more than any other evidence-based resources. Conclusion: Most pediatric residents appear to be aware of appropriate authoritative parenting advice regardless of upbringing, especially as they advance through residency. Residents may benefit from opportunities to reflect upon their upbringing, particularly if raised in authoritarian or permissive styles. Targeted training of residents on evidence-based parenting strategies, particularly for older pediatric patients, appears warranted.

Objective: To describe the use of stimulants and alpha-2 agonists (A2As) for the treatment of preschool-aged children with attention-deficit hyperactivity disorder (ADHD) at 2 Developmental-Behavioral Pediatrics Research Network sites., Methods: Demographic information, diagnoses, and medications prescribed by developmental-behavioral pediatricians (DBPs) were extracted from the electronic health record for all outpatient visits from January 1, 2010, to December 31, 2011. The subset of visits for children aged 2 to 5 years who had a diagnosis of ADHD was included in this analysis. Multivariable models were constructed to identify factors associated with prescribing stimulants and A2As., Results: Over the 2-year period, 984 children with a diagnosis of ADHD were seen at 1779 visits. Of the 984 children, 342 (34.8%) were prescribed a stimulant, and 243 (24.7%) were prescribed an A2A. Both medications were prescribed at the same visit at least once during the 2-year period for 97 children (9.9%). Alpha-2 agonists were prescribed more often at site 2 than site 1 (OR [odds ratio] = 1.62, p = 0.015). Stimulants were more likely to be prescribed for older preschool-aged children (OR = 1.66, p < 0.001), and A2As were more likely to be prescribed for younger children (OR = 0.82, p = 0.02). Both stimulants and A2As were more likely to be prescribed to children with ADHD and comorbid conditions., Conclusion: Alpha-2 agonists are commonly used by some DBPs for preschool ADHD. Variation in the use of A2As across sites may indicate a lack of consensus on when to use these medications and suggests a need for comparative effectiveness research to better define the relative benefits and side effects of A2As and stimulants for the treatment of preschool ADHD.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.

An estimated 10% to 20% of youth in primary care exhibit behavioral symptoms and may go underdetected. Most screeners identify risk base of symptoms alone, irrespective of functional impairment. To address this issue, the Pediatric Symptom Checklist-17 (PSC-17), a widely used symptom screener, was combined with functional impairment and current behavioral services enrollment items to form the Pediatric Behavioral Health Screen (PBHS) and assessed compared to the full Child Behavior Checklist (CBCL). A total of 267 youth between 6 and 16 years of age were administered the screener and the CBCL. Areas under the receiver operating curves approached or exceeded 0.90 in all analyses, reflecting excellent classification accuracy. Almost no false negatives were observed among currently untreated cases with functional impairment. No differential item functioning was found. Performance of the PSC-17 as a pediatric primary care behavioral health screener supported previous research, and additional functional impairment items to form the PBHS appeared useful, particularly for interpreting borderline range scores.

Factors surrounding pediatricians' parenting advice and training on parenting during residency have not been well studied. The primary purpose of this study was to examine pediatric residents' self-reported experiences giving parenting advice and explore the relationship between parenting advice given and types of parenting residents received as children. Thirteen OUHSC pediatric residents were individually interviewed to examine experiences being parented and giving parenting advice. Phenomenological methods were used to explicate themes and secondary analyses explored relationships of findings based upon Baumrind's parenting styles (authoritative, authoritarian, permissive). While childhood experiences were not specifically correlated to the parenting advice style of pediatric residents interviewed, virtually all reported relying upon childhood experiences to generate their advice. Those describing authoritative parents reported giving more authoritative advice while others reported more variable advice. Core interview themes related to residents' parenting advice included anxiety about not being a parent, varying advice based on families' needs, and emphasis of positive interactions and consistency. Themes related to how residents were parented included discipline being a learning process for their parents and recalling that their parents always had expectations, yet always loved them. Pediatric residents interviewed reported giving family centered parenting advice with elements of positive interactions and consistency, but interviews highlighted many areas of apprehension residents have around giving parenting advice. Our study suggests that pediatric residents may benefit from more general educational opportunities to develop the content of their parenting advice, including reflecting on any impact from their own upbringing.

Background: Attention deficit/hyperactivity disorder (ADHD) is associated with adverse outcomes and elevated societal costs. The American Academy of Pediatrics (AAP) 2011 guidelines recommend "behavior therapy" over medication as first-line treatment for children aged 4-5 years with ADHD; these recommendations are consistent with current guidelines from the American Academy of Child and Adolescent Psychiatry for younger children. CDC analyzed claims data to assess national and state-level ADHD treatment patterns among young children., Methods: CDC compared Medicaid and employer-sponsored insurance (ESI) claims for "psychological services" (the procedure code category that includes behavior therapy) and ADHD medication among children aged 2-5 years receiving clinical care for ADHD, using the MarketScan commercial database (2008-2014) and Medicaid (2008-2011) data. Among children with ESI, ADHD indicators were compared during periods preceding and following the 2011 AAP guidelines., Results: In both Medicaid and ESI populations, the percentage of children aged 2-5 years receiving clinical care for ADHD increased over time; however, during 2008-2011, the percentage of Medicaid beneficiaries receiving clinical care was double that of ESI beneficiaries. Although state percentages varied, overall nationally no more than 55% of children with ADHD received psychological services annually, regardless of insurance type, whereas approximately three fourths received medication. Among children with ESI, the percentage receiving psychological services following release of the guidelines decreased significantly by 5%, from 44% in 2011 to 42% in 2014; the change in medication treatment rates (77% in 2011 compared with 76% in 2014) was not significant., Conclusions and Comments: Among insured children aged 2-5 years receiving clinical care for ADHD, medication treatment was more common than receipt of recommended first-line treatment with psychological services. Among children with ADHD who had ESI, receipt of psychological services did not increase after release of the 2011 guidelines. Scaling up evidence-based behavior therapy might lead to increased delivery of effective ADHD management without the side effects of ADHD medications.

Objectives: To describe the parent-reported prevalence of treatments for attention deficit/hyperactivity disorder (ADHD) among a national sample of children with special health care needs (CSHCN), and assess the alignment of ADHD treatment with current American Academy of Pediatrics guidelines., Study Design: Parent-reported data from the 2009-2010 National Survey of Children with Special Health Care Needs allowed for weighted national and state-based prevalence estimates of medication, behavioral therapy, and dietary supplement use for ADHD treatment among CSHCN aged 4-17 years with current ADHD. National estimates were compared across demographic groups, ADHD severity, and comorbidities. Medication treatment by drug class was described., Results: Of CSHCN with current ADHD, 74.0% had received medication treatment in the past week, 44.0% had received behavioral therapy in the past year, and 10.2% used dietary supplements for ADHD in the past year. Overall, 87.3% had received past week medication treatment or past year behavioral therapy (both, 30.7%; neither, 12.7%). Among preschool-aged CSHCN with ADHD, 25.4% received medication treatment alone, 31.9% received behavioral therapy alone, 21.2% received both treatments, and 21.4% received neither treatment. Central nervous system stimulants were the most common medication class (84.8%) among CSHCN with ADHD, followed by the selective norepinephrine reuptake inhibitor atomoxetine (8.4%)., Conclusion: These estimates provide a benchmark of clinical practice for the period directly preceding issuance of the American Academy of Pediatrics' 2011 ADHD guidelines. Most children with ADHD received medication treatment or behavioral therapy; just under one-third received both. Multimodal treatment was most common for CSHCN with severe ADHD and those with comorbidities. Approximately one-half of preschoolers received behavioral therapy, the recommended first-line treatment for this age group., (Published by Elsevier Inc.)

Objective: To determine the impact of varying attention-deficit/hyperactivity disorder (ADHD) diagnostic criteria, including new DSM-5 criteria, on prevalence estimates., Method: Parent and teacher reports identified high- and low-screen children with ADHD from elementary schools in 2 states that produced a diverse overall sample. The parent interview stage included the Diagnostic Interview Schedule for Children-IV (DISC-IV), and up to 4 additional follow-up interviews. Weighted prevalence estimates, accounting for complex sampling, quantified the impact of varying ADHD criteria using baseline and the final follow-up interview data., Results: At baseline 1,060 caregivers were interviewed; 656 had at least 1 follow-up interview. Teachers and parents reported 6 or more ADHD symptoms for 20.5% (95% CI = 18.1%-23.2%) and 29.8% (CI = 24.5%-35.6%) of children respectively, with criteria for impairment and onset by age 7 years (DSM-IV) reducing these proportions to 16.3% (CI = 14.7%-18.0%) and 17.5% (CI = 13.3%-22.8%); requiring at least 4 teacher-reported symptoms reduced the parent-reported prevalence to 8.9% (CI = 7.4%-10.6%). Revising age of onset to 12 years per DSM-5 increased the 8.9% estimate to 11.3% (CI = 9.5%-13.3%), with a similar increase seen at follow-up: 8.2% with age 7 onset (CI = 5.9%-11.2%) versus 13.0% (CI = 7.6%-21.4%) with onset by age 12. Reducing the number of symptoms required for those aged 17 and older increased the overall estimate to 13.1% (CI = 7.7%-21.5%)., Conclusion: These findings quantify the impact on prevalence estimates of varying case definition criteria for ADHD. Further research of impairment ratings and data from multiple informants is required to better inform clinicians conducting diagnostic assessments. DSM-5 changes in age of onset and number of symptoms required for older adolescents appear to increase prevalence estimates, although the full impact is uncertain due to the age of our sample., (Published by Elsevier Inc.)

Primary care provided in a Medical Home (MH) can improve outcomes for Children with Special Health Care Needs. It is important for residents to experience MH in their training. The Oklahoma Family Support 360 project, a five-year collaborative initiative, established a MH in a pediatric primary care resident continuity clinic at the University of Oklahoma Health Sciences Center. A study of the effects of enhancement of the seven key MH attributes showed a significant decrease in Emergency Service use, a significant increase in Dental Service use, high satisfaction with MH activities, and high ratings for a positive impact on quality of life for the child and family. The project demonstrated that a MH could be established in a pediatric academic program, improved health service use, and had a high level of satisfaction from participating families. This model provides a good example of the MH qualities for residents in training.

Objective: To describe the epidemiology of ADHD in communities using a DSM-IVTR case definition., Method: This community-based study used multiple informants to develop and apply a DSM -IVTR-based case definition of ADHD to screening and diagnostic interview data collected for children 5-13 years of age. Teachers screened 10,427 children (66.4%) in four school districts across two states (SC and OK). ADHD ratings by teachers and parent reports of diagnosis and medication treatment were used to stratify children into high and low risk for ADHD. Parents (n = 855) of high risk and gender frequency-matched low risk children completed structured diagnostic interviews. The case definition was applied to generate community prevalence estimates, weighted to reflect the complex sampling design., Results: ADHD prevalence was 8.7% in SC and 10.6% in OK. The prevalence of ADHD medication use was 10.1% (SC) and 7.4% (OK). Of those medicated, 39.5% (SC) and 28.3% (OK) met the case definition. Comparison children taking medication had higher mean symptom counts than other comparison children., Conclusions: Our ADHD estimates are at the upper end of those from previous studies. The identification of a large proportion of comparison children taking ADHD medication suggests that our estimates may be conservative; these children were not included as cases in the case definition, although some might be effectively treated., (© 2012 SAGE Publications.)

Objective: To review what is currently known about service use by youth with attention-deficit/hyperactivity disorder (ADHD) and discuss research and policy implications., Methods: Literature review., Results: The primary care, mental health, and educational service system sectors all play an essential role in caring for youth with ADHD. Recent studies also suggest increasing use of stimulants and other psychoactive medication for youth with ADHD, decreasing mental health visits for ADHD unassociated with medication use, increased use of other psychotropic medications, and a number of barriers to care coordination across primary care, mental health, and schools., Conclusions: Four important services, research, and policy areas that need to be addressed over the next decade include: 1) delving deeper into current service use, 2) paying attention to the context in which service use occurs, 3) operationalizing evidence-based care for real-world settings, and 4) learning what changes clinician and educator behavior.

Despite a large body of evidence for both the validity of the diagnosis of attention deficit hyperactivity disorder (ADHD) and the efficacy of its treatment with medication, there is an equally long history of controversy. This article focuses on presenting safety information for medications approved by the US FDA for the treatment of individuals with ADHD. Stimulant medications are generally safe and effective. The common adverse effects of stimulant medications, including appetite suppression and insomnia, are usually of mild severity and manageable without stopping the medication. The more severe adverse effects such as tics or bizarre behaviours occur with low frequency and usually resolve when the medication is stopped. The possible impact on growth requires careful monitoring. Several rare but potentially severe adverse effects including sudden cardiac death and cancer following long-term treatment have been reported; however, these effects have not been adequately demonstrated to be of significant concern at this time. Atomoxetine also has a mild adverse effect profile in terms of severity and frequency although the numbers of studies and years of clinical experience is considerably less with this drug than for the stimulant medications. When the risks are juxtaposed to the clear efficacy in significantly reducing dysfunctional symptoms of ADHD, benefit-risk analyses support the continued use of these pharmacological treatments for patients with ADHD.

Attention-deficit hyperactivity disorder (ADHD) is a challenging condition to diagnose and treat. For diagnosis, the clinician needs to establish the presence of ADHD on Diagnostic and Statistical Manual of Mental Disorders criteria requiring information from parents and teachers and considering both alternative diagnoses and co-occurring conditions. In the treatment of ADHD as a chronic illness, the clinician needs to educate the family about the condition and partner with them about treatment decisions. The 2 treatments with demonstrated efficacy for ADHD are medications (stimulant medications and a selective norepinephrine reuptake inhibiter) and behavior-modification programs.

This study examines interventions designed to improve communication between individuals who take care of children with ADHD. A teacher rating of 6,171 elementary school children identifies 1,573 children with ADHD or with high risk for ADHD. Parent interviews and information from teachers are collected on 243 children who are randomized into treatment and control conditions and followed for 39 months. The interventions consisted of group workshops and single one-on-one tutorials with parents, teachers, and providers about the evaluation and treatment of ADHD that stressed the need for communication between the three parties. There are few significant effects on communication that are short lived. Results suggest that the interventions are insufficient to cause significant increase in communication. Future attempts to improve parent-teacher-provider coordination should be continuing rather than single-session interventions.

Attention-deficit/hyperactivity disorder (ADHD) is the most common mental disorder in childhood, and primary care clinicians provide a major component of the care for children with ADHD. However, because of limited available evidence, the American Academy of Pediatrics guidelines did not include adolescents and young adults. Contrary to previous beliefs, it has become clear that, in most cases, ADHD does not resolve once children enter puberty. This article reviews the current evidence about the diagnosis and treatment of adolescents and young adults with ADHD and describes how the information informs practice. It describes some of the unique characteristics observed among adolescents, as well as how the core symptoms change with maturity. The diagnostic process is discussed, as well as approaches to the care of adolescents to improve adherences. Both psychosocial and pharmacologic interventions are reviewed, and there is a discussion of these patients' transition into young adulthood. The article also indicates that research is needed to identify the unique adolescent characteristics of ADHD and effective psychosocial and pharmacologic treatments.

This study examines the impact of interrater reliability on the diagnosis of attention-deficit hyperactivity disorder (ADHD). A screening of 6171 elementary school children identified 1573 children with a high risk for ADHD according to teacher rating. Follow-up parent interviews and information from teachers were collected on 243 children. Before screening, health care professionals had diagnosed ADHD in 40% of the identified children. There was low agreement between the parent and teacher reports of ADHD symptoms according to DSM-IV-based questionnaires: Inattentive (r =.34, kappa = 0.27), Hyperactive/Impulsive (r =.27, kappa = 0.22), and Performance Impairment (r =.31, kappa = 0.07). When the two-setting requirement was strictly enforced, poor interrater agreement decreased diagnostic rates for all three types of ADHD in this clinical sample: Inattentive (15%-5%), Hyperactive/Impulsive (11%-3%), and Combined (23%-7%). Parent and teacher agreement was low concerning ADHD symptoms and performance. The recommendation of multiple informants significantly decreased the prevalence. Allowing for observer disagreement by using more lenient core symptom scores could reduce the effect.

Methylphenidate is commonly used for the treatment of attention-deficit hyperactivity disorder (ADHD). Its efficacy in improving the core symptoms of ADHD, as well as some of the aggressive and oppositional behaviours, is well documented, based on a large volume of research. Methylphenidate has a wide margin of safety and relatively mild adverse effects, most commonly appetite suppression and insomnia. Methylphenidate is a rapidly absorbed medication that, in its d-isomer form, readily penetrates the CNS, particularly the striatum. It appears to function by blocking the reuptake of dopamine. Both the plasma concentrations and behavioural effects of methylphenidate demonstrate a time to maximum of between 1 and 3 hours, with the maximum behavioural effects occurring when the plasma concentrations are increasing. Because of the rapid onset of action, the effects of methylphenidate can be dramatic but usually last only about 4 hours with the immediate-release formulation. The behavioural responses of individuals are also highly variable, so that it is necessary to start treatment at a low dosage and increase up to a maximally effective dosage (usually starting at 10-15 mg/day with increases of 10-15mg at weekly intervals to a maximum dosage of 60 mg/day, irrespective of formulation). Because of the variability in behavioural responses, assessment of plasma concentrations is not clinically useful nor does weight help in deciding an appropriate dosage. The difficulties in administering methylphenidate multiple times a day, particularly during the school day, have been alleviated in the past few years by the development of extended-release preparations with varying behavioural effects lasting 8-12 hours. The 8-hour preparations (Metadate) CD and Ritalin) LA) utilise a microbead technology, while the 12-hour preparation (Concerta) utilises an osmotic pump system. All extended-release formulations effectively control the symptoms of ADHD. While pharmacokinetic differences appear to exist between some of these new formulations, there are currently no clinical data available to demonstrate clinical efficacy differences between them.

Objective: s To determine the psychometric properties of the Vanderbilt Attention Deficit/Hyperactivity Disorder Parent Rating Scale (VADPRS), which utilizes information based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV). The VADPRS was created to collect uniform patient data and minimize the time burden of lengthy interviews., Methods: Participant data (N = 243) was used from the first 2 years of a longitudinal study on communication among physicians, teachers, and parents in diagnosing, treating, and managing children with attention deficit/hyperactivity disorder (ADHD). The reliability, factor structure, and concurrent validity of the VADPRS were evaluated and compared with ratings of children in clinical and nonclinical samples on the Vanderbilt ADHD Teacher Rating Scale and the Computerized Diagnostic Interview Schedule for Children-IV, Parent version., Results: The internal consistency and factor structure of the VADPRS are acceptable and consistent with DSM-IV and other accepted measures of ADHD., Conclusion: The VADPRS is a reliable, cost-effective assessment for ADHD in clinical and research settings.

This study evaluates a measurement model for Attention Deficit/Hyperactivity Disorder (ADHD). The DSM-IV divides 18 symptoms into two groups, inattentive and hyperactive/impulsive. Elementary school teachers rated 21,161 children in 4 locations: Spain, Germany, urban US, and suburban US. Confirmatory factor analysis suggested that the 2-factor model (inattention, hyperactivity/impulsivity) shows the best fit. A third factor, impulsivity, was too slight to stand-alone. Children with academic performance problems were distinguished by inattention, but children with behavior problems typically had elevations in inattention, hyperactivity, and impulsivity. Between-site differences were statistically significant, but so small that we conclude that same measurement model fits all 4 samples in 2 continents.

Background: Psychotropic medications have become an integral component in the treatment of children with mental illnesses., Methods: Selective reviews of the empirical evidence for the efficacy of psychotropic medications and studies of their use patterns were reviewed., Results: Very strong efficacy for at least the short-term benefits and safety of stimulant medications was found and some good efficacy and safety evidence for the treatment of anxiety and depressive disorders with seratonin reuptake inhibitors (SSRI) was also found. Efficacy for tricyclic antidepressants to treat attention deficit hyperactivity disorder was found but the presence of significant side effects makes them less the drugs of choice. Other medications are presented but with less rigorous evidence. Studies of use found that stimulant medications are extensively prescribed in the US by both psychiatrists and primary care physicians. SSRI are also prescribed extensively but not to the extent of stimulants and are more frequently prescribed by psychiatrists., Conclusions: There is now good evidence for the efficacy of some psychotropic agents and their use is an integral component in the management of childhood mental illnesses.

Research literature relating to the prevalence of attention-deficit/hyperactivity disorder (ADHD) and co-occurring conditions in children from primary care settings and the general population is reviewed as the basis of the American Academy of Pediatrics clinical practice guideline for the assessment and diagnosis of ADHD. Epidemiologic studies revealed prevalence rates generally ranging from 4% to 12% in the general population of 6 to 12 year olds. Similar or slightly lower rates of ADHD were revealed in pediatric primary care settings. Other behavioral, emotional, and learning problems significantly co-occurred with ADHD. Also reviewed were rating scales and medical tests that could be employed in evaluating ADHD. The utility of using both parent- and teacher-completed rating scales that specifically assess symptoms of ADHD in the diagnostic process was supported. Recommendations were made regarding the assessment of children with suspected ADHD in the pediatric primary care setting.