Treatment planning for children with attention-deficit/hyperactivity disorder: treatment utilization and family preferences

William B Brinkman, Jeffery N EpsteinDepartment of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USABackground: Attention-deficit/hyperactivity disorder (ADHD) is a common condition that often results in child and family functional impairments. Although there are evidence-based treatment modalities available, implementation of and persistence with treatment plans vary with patients. Family preferences also vary and may contribute to variability in treatment utilization.Objective: The objective of this study is to describe the evidence-based treatments available for ADHD, identify patterns of use for each modality, and examine patient and parent treatment preferences.Method: Literature review.Results: Treatment options differ on benefits and risks/costs. Therefore, treatment decisions are preference sensitive and depend on how an informed patient/parent values the tradeoffs between options. Literature on patient and parent ADHD treatment preferences is based on quantitative research assessing the construct of treatment acceptability and qualitative and quantitative research that assesses preferences from a broader perspective. After a child is diagnosed with ADHD, a variety of factors influence the initial selection of treatment modalities that are utilized. Initial parent and child preferences are shaped by their beliefs about the nature of the child's problems and by information (and misinformation) received from a variety of sources, including social networks, the media, and health care providers. Subsequently, preferences become further informed by personal experience with various treatment modalities. Over time, treatment plans are revisited and revised as families work with their health care team to establish a treatment plan that helps their child achieve goals while minimizing harms and costs.Conclusions: Studies have not been able to determine the extent to which utilization rates are consistent with the underlying distribution of informed patient/parent treatment preferences. There are challenges to ensure that patient/parent preferences are consistently well informed, elicited, and discussed in the treatment planning process. Interventions are needed to promote such interactions.Keywords: attention-deficit/hyperactivity disorder, ADHD, adherence, preferences, physician–patient/parent communication, collaborative/shared decision makin

Non-pharmacological approaches for treating children with ADHD inattentive type

The behavioral difficulties of children with attention-deficit/hyperactivity disorder (ADHD) inattentive type differ from those of children with ADHD combined or hyperactive/impulsive type. Existing evidence-based interventions primarily target the disruptive and impulsive behaviors exhibited by children with ADHD combined and hyperactive/impulsive type. A number of recent advances have been made in the non-pharmacological treatment of behavioral difficulties associated with ADHD inattentive type. Additional research using randomized controlled research designs and long-term follow-up evaluation is necessary before these interventions may be considered established evidence-based interventions for patients with ADHD inattentive type

The Transition to Middle School is Associated with Changes in the Developmental Trajectory of ADHD Symptomatology in Young Adolescents with ADHD

The attention deficit hyperactivity disorder (ADHD) symptom presentation of young adolescents with ADHD was examined in association with the transition to middle school. This study used data collected in the Multimodal Treatment Study of ADHD, which included children between 7 and 9 years of age with a diagnosis of ADHD (n=258) and grade- and sex-matched controls (n=112). The trajectory of ADHD symptoms before, during, and after the transition to middle school was modeled using hierarchical linear modeling. A clear developmental reduction in ADHD symptomatology was observed for all three ADHD symptom domains. For young adolescents with ADHD, the transition to middle school was associated with a disruption in the developmental decline of inattention, hyperactivity, and impulsivity symptoms as measured by parent ratings. This effect was also observed for teacher ratings of inattention and hyperactivity. These results support the assertion that the environmental changes associated with transitioning to middle school coincide with a transient reversal in ADHD symptom decline among children with ADHD

Abundances of neutron-capture elements in the Hot Extreme-Helium Stars V1920 Cygni and HD 124448

Analysis of HST STIS ultraviolet spectra of two hot extreme helium stars (EHes): V1920 Cyg and HD 124448 provide the first measurements of abundances of neutron-capture elements for EHes. Although the two stars have similar abundances for elements up through the iron-group, they differ strikingly in their abundances of heavier elements: V1920 Cyg is enriched by a factor of 30 in light neutron-capture elements (Y/Fe, Zr/Fe) relative to HD 124448. These differences in abundances of neutron-capture elements among EHes mirrors that exhibited by the RCrB stars, and is evidence supporting the view that there is an evolutionary connection between these two groups of hydrogen-deficient stars. Also, the abundances of Y and Zr in V1920 Cyg provide evidence that at least one EHe star went through a s-process synthesis episode in its earlier evolution.Comment: 4 pages (embedded figure and table), accepted for publication in ApJ Letter

Association of Pyrethroid Pesticide Exposure With Attention-Deficit/Hyperactivity Disorder in a Nationally Representative Sample of U.S. Children

Background Pyrethroid pesticides cause abnormalities in the dopamine system and produce an ADHD phenotype in animal models, with effects accentuated in males versus females. However, data regarding behavioral effects of pyrethroid exposure in children is limited. We examined the association between pyrethroid pesticide exposure and ADHD in a nationally representative sample of US children, and tested whether this association differs by sex. Methods Data are from 8–15 year old participants (N = 687) in the 2001–2002 National Health and Nutrition Examination Survey. Exposure was assessed using concurrent urinary levels of the pyrethroid metabolite 3-phenoxybenzoic acid (3-PBA). ADHD was defined by either meeting Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria on the Diagnostic Interview Schedule for Children (DISC) or caregiver report of a prior diagnosis. ADHD symptom counts were determined via the DISC. Multivariable logistic regression examined the link between pyrethroid exposure and ADHD, and poisson regression investigated the link between exposure and ADHD symptom counts. Results Children with urinary 3-PBA above the limit of detection (LOD) were twice as likely to have ADHD compared with those below the LOD (adjusted odds ratio [aOR] 2.42; 95 % confidence interval [CI] 1.06, 5.57). Hyperactive-impulsive symptoms increased by 50 % for every 10-fold increase in 3-PBA levels (adjusted count ratio 1.50; 95 % CI 1.03, 2.19); effects on inattention were not significant. We observed possible sex-specific effects: pyrethroid biomarkers were associated with increased odds of an ADHD diagnosis and number of ADHD symptoms for boys but not girls. Conclusions We found an association between increasing pyrethroid pesticide exposure and ADHD which may be stronger for hyperactive-impulsive symptoms compared to inattention and in boys compared to girls. Given the growing use of pyrethroid pesticides, these results may be of considerable public health import

Ethnicity as a Moderator of Treatment Effects on Parent-Child Interaction for Children With ADHD

Objective: To examine ethnic differences in observed parenting and child behavior and the moderating effects of ethnicity on the relationship between treatment and parent and child behavior. Method: Observations of 508 children with ADHD (ages 7–9) and their caregivers, collected during the Multimodal Treatment Study of ADHD, were analyzed using univariate and mixed-model ANOVAs. Results: Although baseline parenting practices differed by ethnic group, ethnicity did not moderate the relationship between treatment and either parenting or child behavior. Conclusion: Consistent with data from normative samples, parents of children with ADHD differed by ethnicity in their utilization of certain parenting strategies. However, different ethnic groups did not differ on benefit received from treatments for ADHD, measured by parent and child behavior. Although ethnicity did not emerge as a moderator, ethnic minority family engagement in treatment may be increased by recognizing different parenting strategies and modifying interventions accordingly. (J. of Att. Dis. 2010; 13(6) 592-600

Parent Agreement on Ratings of Children's Attention Deficit/Hyperactivity Disorder and Broadband Externalizing Behaviors

Mothers and fathers often disagree in their ratings of child behavior, as evidenced clinically and as supported by a substantial literature examining parental agreement on broadband rating scales. The present study examined mother-father agreement on Diagnostic and Statistical Manual-based symptom-specific ratings of Attention-Deficit/Hyperactivity Disorder (ADHD), as compared to agreement on broadband ratings of externalizing behavior. Based on mother and father ratings of 324 children who participated in the Multimodal Treatment Study of Children with ADHD (MTA), parental agreement was computed and patterns of disagreement examined. Mother-father ratings were significantly correlated; however, a clear pattern of higher ratings by mothers was present. Agreement on attention-deficit/hyperactivity disorder symptom-specific ratings was significantly lower than that for broadband externalizing behaviors and oppositional defiant disorder symptoms. Of several moderator variables tested, parental stress was the only one that predicted the discrepancy in ratings. Disagreement between parents is clinically significant and may pose complications to the diagnostic process

Obesity and treatment meanings in bariatric surgery candidates: a qualitative study

Background This study used a qualitative approach to comprehend how the morbid obese conceptualize and deal with obesity and obesity treatment, with the particular aim of exploring the expectations and beliefs about the exigencies and the impact of bariatric surgery. Methods The study population included 30 morbid obese patients (20 women and 10 men) with a mean age of 39.17 years (SD = 8.81) and a mean body mass index of 47.5 (SD = 8.2) interviewed individually before surgery using open-ended questions. The interviews were audiotaped, transcribed, and then coded according to grounded analysis methodology. Results Three main thematic areas emerged from the data: obesity, eating behavior, and treatment. Obesity is described as a stable and hereditary trait. Although participants recognize that personal eating behavior exacerbates this condition, patients see their eating behavior as difficult to change and control. Food seems to be an ever-present dimension and a coping strategy, and to follow an adequate diet plan is described as a huge sacrifice. Bariatric surgery emerges as the only treatment for obesity, and participants highlight this moment as the beginning of a new life where health professionals have the main role. Bariatric surgery candidates see their eating behavior as out of their control, and to commit to its demands is seen as a big sacrifice. For these patients, surgery is understood as a miracle moment that will change their lives without requiring an active role or their participation. Conclusion According to these results, it is necessary to validate them with qualitative and quantitative studies; it is necessary to promote a new awareness of the weight loss process and to empower patients before and after bariatric surgery.Bolsa de doutoramento SFRH/BD/37069/2007 da Fundação para a Ciência e a Tecnologia (FCT

Parent-Reported Homework Problems in the MTA Study: Evidence for Sustained Improvement with Behavioral Treatment

Parent-report of child homework problems was examined as a treatment outcome variable in the MTA-Multimodal Treatment Study of Children with Attention-Deficit/ Hyperactivity Disorder (ADHD). Five hundred seventy-nine children ages 7.0 to 9.9 were randomly assigned to either medication management, behavioral treatment, combination treatment, or routine community care. Results showed that only participants who received behavioral treatment (behavioral and combined treatment) demonstrated sustained improvements in homework problems in comparison to routine community care. The magnitude of the sustained effect at the 10-month follow-up assessment was small to moderate for combined and behavioral treatment over routine community care (d=.37, .40, respectively). Parent ratings of initial ADHD symptom severity was the only variable found to moderate these effects