Anxiety in children with attention-deficit/hyperactivity disorder

OBJECTIVES: Although anxiety is common in children with attention-deficit/hyperactivity disorder (ADHD), it is unclear how anxiety influences the lives of these children. This study examined the association between anxiety comorbidities and functioning by comparing children with ADHD and no, 1, or ≥2 anxiety comorbidities. Differential associations were examined by current ADHD presentation (subtype). METHODS: Children with diagnostically confirmed ADHD (N = 392; 5-13 years) were recruited via 21 pediatrician practices across Victoria, Australia. Anxiety was assessed by using the Anxiety Disorders Interview Schedule for Children-IV. Functional measures included parent-reported: quality of life (QoL; Pediatric Quality of Life Inventory 4.0), behavior and peer problems (Strengths and Difficulties Questionnaire), daily functioning (Daily Parent Rating of Evening and Morning Behavior), and school attendance. Teacher-reported behavior and peer problems (Strengths and Difficulties Questionnaire) were also examined. Linear and logistic regression controlled for ADHD severity, medication use, comorbidities, and demographic factors. RESULTS: Children with ≥2 anxiety comorbidities (n = 143; 39%) had poorer QoL (effect size: -0.8) and more difficulties with behavior (effect size: 0.4) and daily functioning (effect size: 0.3) than children without anxiety (n = 132; 36%). Poorer functioning was not observed for children with 1 anxiety comorbidity (n = 95; 26%). Two or more anxiety comorbidities were associated with poorer functioning for children with both ADHD-Inattentive and ADHD-Combined presentation. CONCLUSIONS: Children with ADHD demonstrate poorer QoL, daily functioning and behavior when ≥2 anxiety comorbidities are present. Future research should examine whether treating anxiety in children with ADHD improves functional outcomes.

Service use in children aged 6-8 years with attention deficit hyperactivity disorder

OBJECTIVE: This study investigated prevalence, types and predictors of professional service use in families of children identified with attention deficit hyperactivity disorder (ADHD) in the community.

DESIGN: SETTING: children with ADHD were identified through 43 schools using parent and teacher screening questionnaires (Conners 3 ADHD Index) followed by case confirmation using the Diagnostic Interview Schedule for Children Version IV. Parents completed a survey about professional service use in the last 12 months.

MAIN OUTCOME MEASURES: data on variables potentially associated with service use were collected from parents (interview and questionnaires), teachers (questionnaires) and children (direct assessment). Logistic regression was used to examine predictors of service use in univariate and multivariable analyses.

RESULTS: The sample comprised 179 children aged 6-8 years with ADHD. Over one-third (37%) had not received professional services in the last 12 months. The strongest predictors of service use were older child age (adjusted OR=3.0, 95% CI 1.0 to 8.9, p=0.05), and the degree to which the child's behaviour impacted on the family (adjusted OR=2.0, 95% CI 1.3 to 3.3, p=0.007), after controlling for ADHD subtype and severity, externalising comorbidities, academic achievement and parent-reported impairment.

CONCLUSIONS: A substantial proportion of children with ADHD are not accessing professional services. Our findings suggest that the child's age and the impact of the child's behaviour on the family are the strongest predictors of service use. Given the demonstrated benefits from various interventions in ADHD, there is a need to improve case identification and referral for services.

Association between autism symptoms and family functioning in children with attention-deficit/hyperactivity disorder: a community-based study

Autism spectrum disorder (ASD) symptoms are elevated in populations of children with attention-deficit/hyperactivity disorder (ADHD). This study examined cross-sectional associations between ASD symptoms and family functioning in children with and without ADHD. Participants were recruited to a longitudinal cohort study, aged 6-10 years (164 ADHD; 198 controls). ADHD cases were ascertained using community-based screening and diagnostic confirmation from a diagnostic interview. ASD symptoms were measured using the Social Communication Questionnaire. Outcome variables were parent mental health, family quality of life (FQoL), couple conflict and support, and parenting behaviours. After adjustment for a range of child and family factors (including other mental health comorbidities), higher ASD symptoms were associated with poorer FQoL across all three domains; emotional impact (p = 0.008), family impact (p = 0.001) and time impact (p = 0.003). In adjusted analyses by subgroup, parents of children with ADHD+ASD had poorer parent self-efficacy (p = 0.01), poorer FQoL (p ≤ 0.05), with weak evidence of an association for less couple support (p = 0.06), compared to parents of children with ADHD only. Inspection of covariates in the adjusted analyses indicated that the association between ASD symptoms and most family functioning measures was accounted forby child internalising and externalising disorders, ADHD severity, and socioeconomic status; however, ASD symptoms appear to be independently associated with poorer FQoL in children with ADHD. The presence of ASD symptoms in children with ADHD may signal the need for enhanced family support.

Relationship between executive functioning and symptoms of attention-deficit/hyperactivity disorder and autism spectrum disorder in 6-8 year old children

This study examined relationships between executive functioning (EF) and ADHD/ASD symptoms in 339 6-8 year-old children to characterise EF profiles associated with ADHD and ADHD + ASD. ADHD status was assessed using screening surveys and diagnostic interviews. ASD symptoms were measured using the Social Communication Questionnaire, and children completed assessments of EF. We found the EF profile of children with ADHD + ASD did not differ from ADHD-alone and that lower-order cognitive skills contributed significantly to EF. Dimensionally, ASD and inattention symptoms were differentially associated with EF, whereas hyperactivity symptoms were unrelated to EF. Differences between categorical and dimensional findings suggest it is important to use both diagnostic and symptom based approaches in clinical settings when assessing these children's functional abilities.

The diagnosis of attention-deficit/hyperactivity disorder in Australian children: current paediatric practice and parent perspective

Aims In a sample of newly diagnosed children with attention-deficit/hyperactivity disorder (ADHD), the aims were to examine (1) paediatrician assessment and management practices; (2) previous assessments and interventions; (3) correspondence between parent-report and paediatrician identification of comorbidities; and (4) parent agreement with diagnosis of ADHD. Methods Design: cross-sectional, multi-site practice audit with questionnaires completed by paediatricians and parents at the point of ADHD diagnosis. Setting: private/public paediatric practices in Western Australia and Victoria, Australia. Main outcome measures: paediatricians: elements of assessment and management were indicated on a study-designed data form. Parents: ADHD symptoms and comorbidities were measured using the Conners 3 ADHD Index and Strengths and Difficulties Questionnaire, respectively. Sleep problems, previous assessments and interventions, and agreement with ADHD diagnosis were measured by questionnaire. Results Twenty-four paediatricians participated, providing data on 137 patients (77% men, mean age 8.1 years). Parent and teacher questionnaires were used in 88% and 85% of assessments, respectively. Medication was prescribed in 75% of cases. Comorbidities were commonly diagnosed (70%); however, the proportion of patients identified by paediatricians with internalising problems (18%), externalising problems (15%) and sleep problems (4%) was less than by parent report (51%, 66% and 39%). One in seven parents did not agree with the diagnosis of ADHD. Conclusions Australian paediatric practice in relation to ADHD assessment is generally consistent with best practice guidelines; however, improvements are needed in relation to the routine use of questionnaires and the identification of comorbidities. A proportion of parents do not agree with the diagnosis of ADHD made by their paediatrician.

Behavioural differences between EEG-defined subgroups of children with Attention-Deficit/Hyperactivity Disorder

Objective: This study investigated the presence and nature of EEG clusters within a clinically-referred sample of children with Attention-Deficit/Hyperactivity Disorder (AD/HD), and whether behavioural differences exist between clusters.

Method: Participants were 155 boys with AD/HD and 109 age- and gender-matched controls. EEG was recorded during an eyes-closed resting condition and Fourier transformed to provide estimates for total power, and relative delta, theta, alpha, and beta. EEG data were grouped into 3 regions, and subjected to Cluster Analysis. Behavioural data for each cluster were compared against the remaining AD/HD subjects.

Results: Four EEG clusters were found. These were characterised by (a) elevated beta activity, (b) elevated theta with deficiencies of alpha and beta, (c) elevated slow wave with less fast wave activity, and (d) elevated alpha. An exploratory analysis of behavioural correlates with these EEG subtypes indicated the presence of interesting trends that need further investigation.

Conclusions: This study found that the AD/HD EEG profiles reported in past studies are robust and not substantially affected by the inclusion of children with other comorbid conditions. The observed group differences in behavioural profiles indicated that different patterns of EEG activity have importance in determining behaviour.

Significance: This is the first study to link behavioural profiles of children with AD/HD to specific EEG abnormalities.

Efficacy of Cognitive Processes in Young People with High-Functioning Autism Spectrum Disorder Using a Novel Visual Information-Processing Task

Autism spectrum disorders (ASD) are characterised by a unique pattern of preserved abilities and deficits within and across cognitive domains. The Complex Information Processing Theory proposes this pattern reflects an altered capacity to respond to cognitive demands. This study compared how complexity induced by time constraints on processing affect cognitive function in individuals with ASD and typically-developing individuals. On a visual information-processing task, the Subtle Cognitive Impairment Test, both groups exhibited sensitivity to time-constraints. Further, 65 % of individuals with ASD demonstrated deficits in processing efficiency, possibly attributable to the effects of age and clinical comorbidities, like attention deficit hyperactivity disorder. These findings suggest that for some ASD individuals there are significant impairments in processing efficiency, which may have implications for education and interventions. © 2014 Springer Science+Business Media New York.

Autism spectrum disorder symptoms in children with ADHD: a community-based study

This study examined the prevalence of autism spectrum disorder (ASD) symptoms in a community-based sample of children with attention-deficit/hyperactivity disorder (ADHD) and non-ADHD controls. We also examined the relationship between ASD symptoms and ADHD subtype, ADHD symptom severity and child gender. Participants were 6-10-year-old children (164 ADHD; 198 non-ADHD control) attending 43 schools in Melbourne, Australia, who were participating in the Children's Attention Project. ADHD was assessed in two stages using the parent and teacher Conners' 3 ADHD index and the Diagnostic Interview Schedule for Children IV (DISC-IV). ASD symptoms were identified using the Social Communication Questionnaire (SCQ). Unadjusted and adjusted linear and logistic regression examined continuous and categorical outcomes, respectively. Children with ADHD had more ASD symptoms than non-ADHD controls (adjusted mean difference=4.0, 95% confidence interval (CI) 2.8; 5.3, p<0.001, effect size=0.7). Boys with ADHD had greater ASD symptom severity than girls with ADHD (adjusted mean difference=2.9, 95% CI 0.8; 5.2, p=0.01, effect size=0.4). Greater ADHD symptom severity was associated with greater ASD symptom severity (regression co-efficient=1.6, 95% CI 1.2; 2.0, p<0.001). No differences were observed by ADHD subtype. Greater hyperactive/impulsive symptoms were associated with greater ASD symptoms (regression coefficient=1.0; 95% CI 0.0; 2.0, p=0.04) however, this finding attenuated in adjusted analyses (p=0.45). ASD symptoms are common in children with ADHD. It is important for clinicians to assess for ASD symptoms to ensure appropriate intervention.

The development of a screening questionnaire for childhood cruelty to animals

Childhood cruelty to animals may be a marker of poor prognosis amongst conduct disordered children. However, other than semistructured interviews with parents or children, there are no screening instruments for this behavior. The aim of this study was to develop such an instrument. In the first phase of the study, a parent-report questionnaire, Children's Attitudes and Behaviors Towards Animals (CABTA) was designed and piloted on 360 elementary school children, enabling community norms and a factor structure for the instrument to be derived. In the second phase, the questionnaire was completed by the parents of a small sample of children (N= 17) to establish its test-retest reliability. In the third phase of the study, the CABTA was completed by the parents of 19 children who had been diagnosed with either a Disruptive Behavioral Disorder or Attention Deficit Hyperactivity Disorder, and the results were compared with the outcome of a semistructured interview with parents regarding their child's behavior toward animals. The results of the various phases of the study indicated that the CABTA consists of two factors, Typical and Malicious Cruelty to animals, and is a reliable and valid tool for detecting childhood cruelty to animals. Possible use and adaptations of the CABTA as a screening instrument in clinical and community samples are discussed.

Women's cognitive and emotional processing during sexual arousal : the effects of erotic film and absorption

Sexual arousal is a complex and dynamic element of women’s sexuality. Accounts vary, however most multidimensional models highlight the cognitive, affective and physiological components of the female sexual arousal response. While literature examining the peripheral physiological changes that occur during female sexual arousal abounds, there has been a dearth of literature pertaining to the cognitive and affective components. Thus, while many authors have included cognitive and emotions as independent components of the female sexual arousal response, there has been little empirical research to validate this approach. The aim of the current thesis was to examine the cognitive and affective components of female sexual arousal in more depth, investigating the nature of the relationship between these components under various experimental conditions. In order to do so, two integrated studies were conducted, each highlighting the effects of either external or internal variables on women’s subjective sexual arousal, absorption, positive affect and negative affect. Study One was designed to evaluate women’s emotional and cognitive processing of two elements of erotic film – foreplay and erotic context. 60 women were asked to report their subjective sexual arousal, absorption, positive affect and negative affect in response to one of four erotic film excerpts. The erotic excerpts varied in accordance with the degree of foreplay (low vs. high) depicted and the context in which the sexual activities took place (novel vs. habitual context). Women in the study responded more favourably to the high foreplay erotic film excerpt, subsequently reporting higher degrees of subjective sexual arousal, absorption and positive affect. Women also responded favourably to the erotic excerpt filmed in a novel context, reporting greater subjective sexual arousal as a result. The environment in which the sexual encounters were filmed failed to have an effect however, on women’s absorption or their positive or negative affect. The results of Study One suggest that stimulus specific variables, such as the degree of foreplay depicted, have a significant influence on female cognitive and emotional processing of erotic film. The results also suggest that a relationship exists between absorption, subjective sexual arousal and positive affect, albeit a correlational one. Specifically, there was evidence of parallel processing during sexual arousal, as participant reported sexual arousal, absorption and positive affect all increased and decreased in unison. Based on the results it was suggested that future research attempt to experimentally manipulate one of these variables, to examine its direct effect on the remaining variable. Thus, Study Two aimed to examine the effects of absorption on women’s cognitive and emotional processing of erotica. Study Two manipulated absorption at two levels (high vs. low), examining the impact of these states on participants’ subsequent absorption, subjective sexual arousal and positive and negative affect. 62 women were asked to read one of two sets of test session instructions. The first, participant-oriented instruction set, instructed participants to immerse themselves in the erotic film excerpt, as if they were active participants in the sexual exchange. The second, spectator-oriented instruction set, directed participants to observe and evaluate the erotic film. These instructions were designed to elicit high and low degrees of absorption, respectively. The utility of this approach when manipulating female absorption, was demonstrated by self reported ratings of absorption, given at the conclusion of the film presentation. Participants were also asked to report their subjective sexual arousal and positive and negative affect at the conclusion of the erotic film presentation. The findings of this study suggest that the adoption of a participant-oriented (high absorption) perspective elicits more favourable responses from participants than a spectator-oriented (low absorption) perspective, with participants in the former experimental group reporting greater degrees of subjective sexual arousal and positive affect. Negative affect was equivalent across experimental conditions, with the participants reporting that they experienced little to no aversive feelings during either of the experimental conditions. The results suggest that the degree to which a women immerses and absorbs herself in a sexual stimulus has a significant impact in her subsequent cognitive and affective processing of that stimulus. More specifically, it appears that women respond more favourably when they are highly absorbed and immersed in a stimulus, reporting greater subjective sexual arousal and positive affect. Overall, the results of Studies One and Two highlight the dynamic and complex nature of female sexual arousal. It appears that women have definite cognitive and affective responses to sexual stimuli. The magnitude of these responses may be mediated by a number of factors however, including the intrinsic qualities of the stimulus and the degree to which the woman attends to the stimulus. Both these variables act to either enhance or inhibit the sexual arousal response. There results have important implications for current sexuality literature. While women’s cognitions and emotions in response to erotic film were generally highly correlated, in some instances they differed, warranting their inclusion as separate elements in models of female sexual arousal. Furthermore, it might be suggested that the inclusion of an additional variable – absorption – into current models of female sexual arousal would prove beneficial, aiding researchers to better understand and predict the arousal process. As such, recommendations are made for a revised model of female sexual arousal. In terms of future directions, the results of the present thesis have implications for the treatment of sexual dysfunctions, suggesting that clinicians need to understand the internal and external variables that might contribute to the aetiology and maintenance of their presenting problems.

Assessing cost-effectiveness in mental health: helping policy-makers prioritize and plan health services

Objective: We assessed, from a health sector perspective, options for change that could improve the efficiency of Australia's current mental health services by directing available resources toward 'best practice' cost-effective services.

Method: We summarize cost-effectiveness results of a range of interventions for depression, schizophrenia, attention deficit hyperactivity disorder and anxiety disorders that have been presented in previous papers in this journal. Recommendations for change are formulated after taking into account 'second-filter criteria' of equity, feasibility of implementing change, acceptability to stakeholders and the strength of the evidence. In addition, we estimate the impact on total expenditure if the recommended mental health interventions for depression and schizophrenia are to be implemented in Australia.

Results: There are cost-effective treatment options for mental disorders that are currently underutilized (e.g. cognitive–behavioural therapy (CBT) for depression and anxiety, bibliotherapy for depression, family interventions for schizophrenia and clozapine for the worst course of schizophrenia). There are also less cost-effective treatments in current practice (e.g. widespread use of olanzapine and risperidone in the treatment of established schizophrenia and, within those atypicals, a preference for olanzapine over risperidone). Feasibility of funding mechanisms and training of staff are the main second-filter issues for CBT and family interventions. Acceptability to various stakeholders is the main barrier to implementation of more cost-effective drug treatment regimens. More efficient drug intervention options identified for schizophrenia would cost A$68 million less than current practice. These savings would more than cover the estimated A$36M annual cost of delivering family interventions to the 51% of people with schizophrenia whom we estimated to be eligible and this would lead to an estimated 12% improvement in their health status. Implementing recommended strategies for depression would cost A$121M annually for the 24% of people with depression who seek care currently, but do not receive an evidence-based treatment.

Conclusions: Despite considerable methodological problems, a range of cost-effective and less cost-effective interventions for major mental disorders can be discerned. The biggest hurdle to implementation of more efficient mental health services is that this change would require reallocation of funds between interventions, between disorders and between service providers with different funding mechanisms.

Mindfulness training for the management of children with ADHD

This thesis investigated the use of mindfulness as an intervention for children with ADHD. Findings indicate significant improvements in attentional, behavioural, and affective deficit symptoms following participation in a mindfulness-based intervention, demonstrating that mindfulness may be a worthwhile alternative or adjunct to ADHD treatment.

Oxidative stress in psychiatric disorders : evidence base and therapeutic implications

Oxidative stress has been implicated in the pathogenesis of diverse disease states, and may be a common pathogenic mechanism underlying many major psychiatric disorders, as the brain has comparatively greater vulnerability to oxidative damage. This review aims to examine the current evidence for the role of oxidative stress in psychiatric disorders, and its academic and clinical implications. A literature search was conducted using the Medline, Pubmed, PsycINFO, CINAHL PLUS, BIOSIS Previews, and Cochrane databases, with a time-frame extending to September 2007. The broadest data for oxidative stress mechanisms have been derived from studies conducted in schizophrenia, where evidence is available from different areas of oxidative research, including oxidative marker assays, psychopharmacology studies, and clinical trials of antioxidants. For bipolar disorder and depression, a solid foundation for oxidative stress hypotheses has been provided by biochemical, genetic, pharmacological, preclinical therapeutic studies and one clinical trial. Oxidative pathophysiology in anxiety disorders is strongly supported by animal models, and also by human biochemical data. Pilot studies have suggested efficacy of N-acetylcysteine in cocaine dependence, while early evidence is accumulating for oxidative mechanisms in autism and attention deficit hyperactivity disorder. In conclusion, multi-dimensional data support the role of oxidative stress in diverse psychiatric disorders. These data not only suggest that oxidative mechanisms may form unifying common pathogenic pathways in psychiatric disorders, but also introduce new targets for the development of therapeutic interventions.

Play preference of children with ADHD and typically developing children in Brazil : a pilot study

Background/aim: Children with attention deficit hyperactivity disorder (ADHD) have been reported to have play deficits, which can cause problems in occupational development. The aim of this paper was to report research findings on children with ADHD and typically developing children in relation to preference of play partners, play places, toys and type of play.

Methods: Thirty-two school aged children from lowsocioeconomic status were divided into two groups. One group of 16 children with ADHD were matched with 16 typically developing children.

Results and conclusion: There were no significant differences between the two groups in relation to play partners, with classmates being the most frequent play partner for both groups. There were significant differences between the two groups in preferred place to play. Children with ADHD preferred to play in school and typically developing children preferred to play on the street. There were significant differences in relation to toys and type of play engaged in with children with ADHD preferring educational materials and typically developing children preferring electronic games. These findings add to knowledge of Brazilian children with ADHD and their play preferences. Comparisons are made with research with Australian children with and without ADHD.

Unique neuropsychological profiles in adhd subtype presentations

Learning and memory for verbal and visual information was compared in children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD) of Combined Type and Predominantly Inattentive Type. Compared to a typically developing group, the ADHD groups were found to have unique difficulties. These findings add to the current research knowledge.