Psychotropic Medication Usage in Pediatric CKD: Reporting from the Chronic Kidney Disease in Children Cohort.

BACKGROUND: Mental health disorders (MHD) within the pediatric chronic kidney disease (CKD) population are prevalent. The frequency is unknown with which psychotropic medications that commonly treat these conditions are used in this population. METHODS: Data from the Chronic Kidney Disease in Children (CKiD) cohort study were utilized to describe the use of psychotropic medications and patient-related characteristics of use. Medications were classified into 3 groups: antidepressants, CNS stimulants, and antipsychotic/mood stabilizing medications. Participant age, sex, CKD severity, and duration of medication use were ascertained. Medication use was evaluated in parallel with CKD disease type, presence of urological comorbidity, and hypertension. Chi-square tests compared subgroup medication use. RESULTS: Among 1074 CKiD participants (median baseline age 9.8 years), 6% (n=60) of participants used psychotropic medications at study entry with 11% reporting incident use of any medication category (n=120). CNS stimulants were most common at baseline. Antidepressants were more frequent among incident users at 7%. Use of two or more medications was rare (3%). Median eGFR at medication initiation was 45 ml/min|1.73m2. CNS stimulants were reported at a higher rate in males compared to females (p<0.05). CONCLUSIONS: 11% of CKiD patients report incident use of any psychotropic medication, with 7% reporting incident use of antidepressants. Future work is warranted to better ascertain the frequency, safety, and efficacy of psychotropic medication usage in relationship to formal MHD diagnoses in the pediatric CKD population.

Common mental health conditions and considerations in pediatric chronic kidney disease.

The mental health of youth with chronic kidney disease (CKD) has been increasingly recognized as an area of clinical need. The development of mental health concerns is influenced by a range of physiological, psychological, and environmental factors. Some of these factors are common across child development, but some are more unique to youth with CKD. Mental health concerns are associated with increased risk for a range of poor medical outcomes (e.g., adherence, risk of transplant rejection) and quality of life concerns. In this educational review, we discuss the current evidence base regarding the development of mental health concerns in youth with CKD. The review covers multiple domains including mood and anxiety disorders, traumatic stress, and neurodevelopmental disorders. Estimated prevalence and hypothesized risk factors are outlined, and the potential impact of mental health on medical care and functional outcomes are reviewed. Finally, we introduce options for intervention to support positive mental health and offer recommendations for building access to mental health care and improving the mental health education/training of medical professionals.

Learning from the past: How lessons from Hinman syndrome can inform the psychological management of lower urinary tract dysfunction.

INTRODUCTION: Pediatric patients with lower urinary tract dysfunction (LUTD) experience a variety of medical and psychosocial concerns that can negatively impact their clinical management and quality of life. When initially described by Drs Hinman and Baumann, patients with a form of severe LUTD, later dubbed Hinman syndrome, were characterized as having a "general attitude of being failures." While this mention was noteworthy as it incorporated an understanding of the interplay between psychological factors and urologic conditions, there have been delays in implementing psychological intervention as a standard of care in patients with LUTD broadly, and perhaps too keen of a focus on youth diagnosed with Hinman syndrome specifically. METHODS: A non-systematic reviewed of LUTD related to psychological management was performed. Clinical recommendations were developed by a multicenter and multidisciplinary team of care providers with topic expertise. OBJECTIVE: The aim of this paper is to propose a systems thinking paradigm for how to involve psychology, or psychological principles, across the spectrum of patients with LUTD with the hope of improving attention to specific aspects of care that may improve clinical management. DISCUSSION: Children across the spectrum of LUTD are likely to benefit from psychological interventions and would benefit from such involvement early on to mitigate the impact of psychosocial concerns on medical outcomes. Pediatric psychologists are well-suited to identify and provide individualized care to patients in greatest need of intervention, such as through pre-procedural preparedness, addressing non-adherence, and with the use of evidence-based, targeted mental health interventions. Psychologists are also apt at implementing interventions while taking into consideration the severity of LUTD, in the context of the patient's psychological, developmental, cultural, familial, and social determinants of health considerations. Youth with severe forms of LUTD, such as Hinman syndrome, likely exemplify the challenges of LUTD that benefit from multidisciplinary intervention. CONCLUSION: Medical and psychological collaboration are key to ensuring symptom mitigation and emotional support for patients across the entire spectrum of LUTD.

Psychosocial supports within pediatric nephrology practices: A pediatric nephrology research consortium survey.

BACKGROUND: The landscape of available psychosocial services within pediatric nephrology care is poorly characterized. However, the effects of kidney disease on emotional health and health-related quality of life are well documented, as is the impact of social determinants of health on kidney disease outcomes. The objectives of this study were to assess pediatric nephrologists' perceptions of available psychosocial services and to elucidate inequities in access to psychosocial care. METHODS: A web-based survey was distributed to members of the Pediatric Nephrology Research Consortium (PNRC). Quantitative analyses were performed. RESULTS: We received responses from 49 of the 90 PNRC centers. With regards to dedicated services, social work was most commonly available (45.5-100%), followed by pediatric psychology (0-57.1%) and neuropsychology (0-14.3%), with no centers having embedded psychiatry. Availability of psychosocial providers was positively associated with nephrology division size, such that as center size increased, access to various psychosocial providers increased. Notably, the majority of respondents indicated that perceived need for psychosocial support exceeds that which is currently available, even at centers with higher levels of current support. CONCLUSIONS: Within the US, there is wide variability in the availability of psychosocial services within pediatric nephrology centers despite a well-documented necessity for the provision of holistic care. Much work remains to better understand the variation in funding for psychosocial services and in utilization of psychosocial professionals in the pediatric nephrology clinic, and to inform key best practices for addressing the psychosocial needs of patients with kidney disease.

Girl-Powered Nutrition Program: Key Themes from a Formative Evaluation of a Nutrition Program Co-designed and Implemented by Adolescent Girls in Low- and Middle-Income Countries.

BACKGROUND: To improve nutritional knowledge and attitudes of girls and young women, Nutrition International (NI) partnered with the World Association of Girl Guides and Girl Scouts (WAGGGS) to pilot the Girl-Powered Nutrition (GPN) program from 2018 to 2020 in 4 countries (Madagascar, the Philippines, Sri Lanka, and Tanzania). OBJECTIVE: The aim was to share adolescent girls' and programmers' experiences with co-designing and implementing the GPN program in low- and middle-income countries (LMICs). METHODS: A formative evaluation of the GPN program was commissioned by NI and undertaken by Universalia Management Group (Universalia). The evaluation was largely qualitative (employing focus groups, interviews, and document analysis). Based on the results of the formative evaluation, themes related to working with adolescent girls were identified. RESULTS: The involvement of adolescents in the design, implementation, and evaluation of nutrition programming that targets them is essential for meaningful uptake. Sufficient time and respect must be given to the co-design process, including clearly defining adolescents' roles, ensuring transparency and clear communication, and managing adolescents' expectations. Ensuring adequate exposure and suitable timing for adolescent nutrition programming from adequately trained staff were identified as good practices from the evaluation. Program curriculum and activities must be appropriately tailored to adolescent age and stage, target adolescents and their gatekeepers and duty-bearers, and address the underlying issues of poverty, gender inequality, and structural norms that negatively impact adolescents' agency and nutrition. CONCLUSIONS: This research supports and elaborates on several documented and accepted good practices for working with adolescents to improve nutrition knowledge and attitudes. Similar programs with key features such as co-design, suitable timing, curriculum, and exposure of programs by age group, addressing underlying structural issues, the involvement of gatekeepers and duty-bearers, and confidence-building can increase adolescent girls' nutrition knowledge and attitudes.

The pressure's on: understanding neurocognitive and psychological associations with pediatric hypertension to inform comprehensive care.

The prevalence of hypertension is increasing in pediatric populations. While clinical data and practice guidelines identify the impact of hypertension on organ dysfunction and emphasize the importance for end-organ damage screening, the bidirectional effects of pediatric hypertension on neurocognitive and psychological outcomes are understudied. The objective of this review is to highlight the association between hypertension and cognition, attention, learning, and mental health in children and adolescents. In doing so, this review provides a framework and toolkit to integrate neuropsychology and psychology into the screening and management stages of pediatric hypertension. By recognizing the effects of hypertension on cognition, behavior, and mental health, screenings and interventions can be implemented to proactively and comprehensively improve the health outcomes for children with blood pressure concerns.

The Difficulties in Emotion Regulation Scale-Parent Report: A Psychometric Investigation Examining Adolescents With and Without ADHD.

Emotion dysregulation is associated with attention deficit/hyperactivity disorder (ADHD) and confers risk for behavior problems and functional impairment; however, there is little guidance on best practices for measurement in adolescents. We developed a parent-report version of the Difficulties in Emotion Regulation Scale (DERS-P). Evidence of reliability and validity was evaluated in a large community online sample (Study 1: n = 978; Mage = 13.52 years; SD = 1.93) and in two samples of adolescents with ADHD (Study 2, Sample 1: n = 78; Mage = 12.12 years, SD = 0.91; Sample 2: n = 206; Mage = 15.35 years; SD = 0.85). A four-factor solution of the DERS-P was obtained in Study 1 and confirmed in Study 2, with factors demonstrating acceptable internal consistency. The community sample was generally rated as less dysregulated than the ADHD samples. Support was obtained for convergent, concurrent, and incremental validity evidence. These findings provide preliminary evidence for the DERS-P as a psychometrically sound parent-report measure of emotion dysregulation in 11- to 17-year-old adolescents.

Psychometric Properties of the Impairment Rating Scale in Samples of Adults With Attention Deficit Hyperactivity Disorder.

Adults with attention deficit hyperactivity disorder (ADHD) are impaired in numerous domains. However, psychometrically sound measures assessing broad-ranging impairment, particularly brief scales for diagnostic purposes, are scarce. The Impairment Rating Scale (IRS), originally developed to assess ADHD-related impairment in children, has been adapted to a 12-item self-report measure of impairment in adults. In this study, the psychometric properties of the adult IRS were examined in three samples. In Studies 1 and 2, the adult IRS demonstrated good convergent, divergent, and incremental validity among college students and an online sample of adults, respectively. In the same studies, an appropriate clinical cutoff score was identified (IRS item score ≥1) using diagnostic tests. In Study 3, the adult IRS demonstrated good interrater reliability between ratings provided by romantic partners. Overall, findings support the clinical utility of the adapted IRS for assessing the impairment diagnostic criterion for ADHD in adults.

Exploring how adolescents with ADHD use and interact with technology.

INTRODUCTION: The ubiquity of technology is reshaping the way teens express themselves and interact with peers. Considering that teens with attention-deficit/hyperactivity disorder (ADHD) experience a range of social impairments and that risk behaviors have the potential to be more widespread and damaging online, understanding how teens with ADHD use the Internet is important. METHODS: The current study included 58 teens (72.4% boys; 13-16 years old) from the United States of America with ADHD. Study aims were to examine these teens' Internet use frequency, preferred online activities, Facebook interactions, and online risk behaviors (i.e., cyberbullying and sexting). Associations between online behaviors and offline symptoms and behaviors were explored to identify potential risk and protective factors. RESULTS: Findings suggested that teens with ADHD use technology in similar ways as do the general population of teens described in previous research but appeared at unique risk of cyberbullying behaviors. Offline risks were associated with online risk behaviors. Using Facebook was associated with online risks (e.g., weak online connections) and offline risks (e.g., poorer social skills and more internalizing symptoms). CONCLUSIONS: Online social platforms permit the exploration of social behaviors via naturalistic observation. It is imperative researchers gain understanding of the increasingly prevalent online social worlds of teens. Such an understanding may enable researchers to formulate effective social interventions for teens with ADHD.

Screening Amazon's Mechanical Turk for Adults With ADHD.

Objective: Researchers are increasingly using Amazon's Mechanical Turk (MTurk; www.mturk.com ) to recruit study participants. However, the utility of MTurk for investigations of ADHD in adulthood is unknown. Method: A total of 6,526 MTurk workers (median age range = 26-35 years) completed an online screening survey assessing their diagnostic histories and symptoms of ADHD, as well as relevant demographic correlates and diagnostic comorbidity. Results: The prevalence of MTurk workers who reported being diagnosed as children and as adults, and the percentage of workers whose ADHD appeared to persist from childhood into adulthood, are consistent with those observed in "offline" samples. Relative to MTurk workers diagnosed with ADHD as adults, workers diagnosed with ADHD as children were more likely to be male and without college degrees, as well as less likely to have comorbid depression or anxiety disorders. Conclusion: Amazon's MTurk holds promise as a recruitment tool for studying adults with ADHD.

Rates of Intimate Partner Violence Perpetration and Victimization Among Adults With ADHD.

OBJECTIVE: Research has demonstrated an association between ADHD and intimate partner violence (IPV). However, it is unclear whether adults with ADHD persisting from childhood are especially at risk, and whether ADHD is a unique risk factor beyond well-established predictors of IPV. METHOD: Adults with ( n = 95) and without childhood histories of ADHD ( n = 121) who were recruited from Amazon's Mechanical Turk reported their levels of IPV perpetration and victimization, and provided data on additional risk factors of IPV (e.g., childhood maltreatment, alcohol abuse). RESULTS: While controlling for additional risk factors, adults diagnosed with ADHD as children, particularly those with elevated current ADHD symptoms (ADHD-Persist), reported higher rates of IPV perpetration and victimization than adults with ADHD histories but low current symptoms (ADHD-Desist) and adults who were never diagnosed with ADHD (control). CONCLUSION: Adults with ADHD histories and elevated current symptoms are most likely to report IPV perpetration and victimization.

Is the Positive Bias an ADHD Phenomenon? Reexamining the Positive Bias and its Correlates in a Heterogeneous Sample of Children.

The goals of this study were to (a) evaluate the presence of the positive bias (PB) in elementary-school-aged children with and without ADHD when PB is defined at the individual level through latent profile analysis and (b) examine the extent to which several correlates (i.e., social functioning, aggression, depression, and anxiety) are associated with the PB. Participants were 233 youth (30% female; 8 to 10 years of age), 51% of whom met criteria for ADHD. During an individual evaluation, children and parents completed a battery of questionnaires to assess child competence, depression, anxiety, and aggression. Children also participated in a novel group session with same-sex unfamiliar peers (half of the group was comprised of children with ADHD) to engage in group problem-solving tasks and free play activities. After the group session, peers and staff completed ratings of each child's behavior (e.g., likeability, rule following). The best fitting LPA model for parent and self-ratings of competence revealed four profiles: High Competence/Self-Aware; Variable Competence/Self-Aware; Low Competence/Self-Aware; and Low Competence/PB, in which the PB was present across domains. Only 10% of youth showed a PB and youth with ADHD were no more likely to display the PB than their non-ADHD peers with similar levels of low competence. Lastly, the Low Competence/Self-Aware profile demonstrated higher levels of anxiety and depression than the Low Competence/PB profile; the profiles did not differ on aggression or peer or staff ratings of social/behavioral functioning. Implications for understanding the PB in children with and without ADHD are discussed.

Childhood Maltreatment, Emotional Lability, and Alcohol Problems in Young Adults At-Risk for ADHD: Testing Moderation and Moderated Moderation.

Childhood maltreatment and alcohol problems are common among young adults with attention-deficit hyperactivity disorder (ADHD). However, little is known about the degree to which maltreatment and alcohol problems are associated; potential pertinent mediating or moderating mechanisms, such as emotional lability; and whether this association varies by sex. We examined, in a sample of adults at risk for ADHD (N = 122, 37% male), the association between childhood maltreatment and alcohol problems, whether emotional lability mediated or moderated this association, and whether either role of emotional lability differed between men and women. Emotional lability moderated the association between emotional neglect and alcohol problems; maltreatment increased risk for alcohol problems for those scoring high tovery high on emotional lability, but not for those with very low-moderate levels. The association between emotional abuse and alcohol problems depended both on emotional lability and sex; emotional abuse decreased the risk for alcohol problems among men very low/low on emotional lability, but not for men who were moderate to very high on emotional lability, or for women. These findings have implications for the way in which targeting maltreatment and emotional lability may be incorporated into prevention and intervention programs to prevent alcohol problems among men and women at risk for ADHD.

Substance Use in Undergraduate Students With Histories of Attention-Deficit/Hyperactivity Disorder (ADHD): The Role of Impulsivity.

BACKGROUND: Emerging adulthood (18-25 years old) is regarded as a time of identity exploration that includes a peak in risky behaviors, such as substance use and misuse. Attention-deficit/hyperactivity disorder (ADHD) is also associated with greater levels of risky behaviors, including substance use and misuse; however, there is a lack of research on substance use by emerging adults with ADHD, in particular the potential mechanisms that may facilitate this risk. OBJECTIVES: The present study builds on the existing research regarding the association between ADHD and substance use by examining roles of multiple facets of impulsivity in facilitating this association during emerging adulthood. METHODS: In a sample of 197 undergraduate students (24 students with an ADHD diagnostic history), we assessed for components of impulsivity (e.g., urgency, sensation-seeking) and rates of alcohol abuse, tobacco use, cannabis use, illicit drug use, and stimulant medication misuse within the past year. RESULTS: Findings indicate that facets of impulsivity, as a whole, explained the association between an ADHD diagnostic history and both illicit drug use and alcohol abuse such that students with ADHD histories tended to report higher levels of impulsivity, which increased risk of alcohol abuse and illicit drug use. Higher levels of specific facets of impulsivity, particularly negative urgency, also facilitated associations between having ADHD and engaging in most forms of substance use tested herein. Conclusions/Importance: Specific facets of impulsivity appear to be important mediators of the association between ADHD and substance use, and should be considered as potential targets of substance use interventions for this population.

ADHD Symptoms as Risk Factors for Intimate Partner Violence Perpetration and Victimization.

Preliminary evidence underscores links between attention-deficit hyperactivity disorder (ADHD) symptoms and intimate partner violence (IPV) perpetration and victimization. However, little is known about whether ADHD symptoms are uniquely associated with IPV perpetration and victimization beyond well-established risk factors of IPV commonly associated with the disorder. In a cross-sectional design, 433 college students rated their ADHD symptoms as well as frequencies of psychological and physical IPV perpetration and victimization. Additional risk factors of IPV included childhood maltreatment, primary psychopathy, alcohol abuse, and illicit drug use. Correlational analyses indicated that students with greater ADHD symptom severity reported higher rates of psychological and physical IPV perpetration, and higher rates of psychological IPV victimization. Regression analyses indicated that ADHD symptoms were not additive risk factors of psychological IPV perpetration and victimization. Students reporting any alcohol abuse or illicit drug use endorsed high rates of psychological IPV perpetration and victimization, regardless of their level of ADHD symptoms. However, students who reported no alcohol abuse or drug use, but did report greater ADHD symptom severity-particularly inattention, indicated higher rates of psychological IPV perpetration and victimization than those reporting no alcohol abuse or drug use and low ADHD symptoms. These findings extend prior research by indicating that alcohol abuse and illicit drug use moderate associations between ADHD symptoms and psychological IPV perpetration and victimization. Investigations are needed to identify mechanisms of the association between ADHD symptoms and IPV perpetration and victimization, particularly those abusing alcohol and drugs, for appropriate prevention and intervention efforts to be developed.

ADHD and Depression Symptoms in Parent Couples Predict Response to Child ADHD and ODD Behavior.

Parents of children with attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) often have elevated ADHD and depressive symptoms, both of which increase the risk of ineffective parenting and interparental discord. However, little is known about whether child ADHD/ODD behavior and parent ADHD or depressive symptoms uniquely or synergistically predict the quality of parenting and interparental communication during triadic (mother-father-child) interactions. Ninety parent couples, including 51 who have children diagnosed with ADHD, were randomly assigned to interact with a 9-12 year-old confederate child (84 % male) exhibiting either ADHD/ODD-like behavior or typical behavior. Parents reported their own ADHD and depressive symptoms, and parents and observers rated the quality of parenting and interparental communication during the interaction. Actor-partner interdependence modeling indicated that child ADHD/ODD behavior predicted less positive and more negative parenting and communication, independent of adult ADHD and depressive symptoms. Parent couples including two parents with elevated ADHD communicated more positively while managing children exhibiting ADHD/ODD behavior than couples managing children behaving typically or couples with only one parent with elevated ADHD symptoms. Couples including one parent with, and one parent without, elevated ADHD or depressive symptoms parented less positively and more negatively, and communicated more negatively, when managing children exhibiting ADHD/ODD behavior than when managing children behaving typically. Taken together, depending on the similarity of ADHD and depressive symptom levels in parent couples, adults managing children exhibiting ADHD/ODD behavior may parent or communicate positively or negatively. Findings highlight the need to consider the psychopathology of both parents when treating children with ADHD in two-parent homes.