Paediatric asthma and non-allergic comorbidities: A review of current risk and proposed mechanisms.

It is increasingly recognized that children with asthma are at a higher risk of other non-allergic concurrent diseases than the non-asthma population. A plethora of recent research has reported on these comorbidities and progress has been made in understanding the mechanisms for comorbidity. The goal of this review was to assess the most recent evidence (2016-2021) on the extent of common comorbidities (obesity, depression and anxiety, neurodevelopmental disorders, sleep disorders and autoimmune diseases) and the latest mechanistic research, highlighting knowledge gaps requiring further investigation. We found that the majority of recent studies from around the world demonstrate that children with asthma are at an increased risk of having at least one of the studied comorbidities. A range of potential mechanisms were identified including common early life risk factors, common genetic factors, causal relationships, asthma medication and embryologic origins. Studies varied in their selection of population, asthma definition and outcome definitions. Next, steps in future studies should include using objective measures of asthma, such as lung function and immunological data, as well as investigating asthma phenotypes and endotypes. Larger complex genetic analyses are needed, including genome-wide association studies, gene expression-functional as well as pathway analyses or Mendelian randomization techniques; and identification of gene-environment interactions, such as epi-genetic studies or twin analyses, including omics and early life exposure data. Importantly, research should have relevance to clinical and public health translation including clinical practice, asthma management guidelines and intervention studies aimed at reducing comorbidities.

Academic achievement of adolescents with asthma or atopic disease.

BACKGROUND: Over a fifth of children and adolescents suffer with asthma or atopic disease. It is unclear whether asthma impacts academic performance in children and adolescents, and little is known about the association of eczema, food allergy or hayfever and academic performance. OBJECTIVE: To examine whether asthma, eczema, food allergy or hayfever impacts on adolescent academic performance and to assess the role of unmeasured confounding. METHODS: This study used the Childhood and Adolescent Twin Study of Sweden cohort born 1992-1998. At age 9-12 years, parents reported on their child's ever or current asthma, eczema, food allergy and hayfever status (n = 10 963). At age 15, linked national patient and medication register information was used to create current and ever asthma definitions including severe and uncontrolled asthma for the same children. Academic outcomes in Grade 9 (age 15-16 years) included: eligibility for high school (Grades 10-12), and total mark of the best 16 subject units, retrieved from the Grade 9 academic register. Whole cohort analyses adjusted for known covariates were performed, and co-twin control analyses to assess unmeasured confounders. RESULTS: There were no associations found for asthma or food allergy at 9-12 years and academic outcomes in adolescence. In addition, at age 15, there were no statistically significant associations with current, ever, severe or uncontrolled asthma and academic outcomes. Eczema and hayfever at age 9-12 years were found to be positively associated with academic outcomes; however, co-twin control analyses did not support these findings, suggesting the main analyses may be subject to unmeasured confounding. CONCLUSION AND CLINICAL RELEVANCE: Having asthma or an atopic disease during childhood or adolescence does not negatively impact on academic performance. This information can be used by clinicians when talking with children and parents about the implications of living with asthma or atopic disease.

Do symptoms of ADHD at ages 7 and 10 predict academic outcome at age 16 in the general population?

OBJECTIVE: To examine the value of the Conners 10-item scale to predict academic outcomes at age 16 years in schoolchildren aged 7 and 10 years. METHOD: A cohort study of N = 544 children in a municipality of Stockholm County was conducted. Using the parent and teacher version of the Conners 10-item scale, 7- and 10-year-olds were screened for ADHD symptoms and followed-up for school outcome at age 16 years. RESULTS: The best predictors for school outcome at age 16 years were the Conners items, "child failing to finish tasks" and "being inattentive, easily distracted," with a high specificity (90%-97%) but low sensitivity (18%-39%). CONCLUSION: This study indicates a considerable association between certain symptoms of inattentiveness in young schoolchildren and academic underachievement at age 16 years. Screening for one to two symptoms of inattention in schoolchildren identifies 30% to 40% of participants at risk for later poor school attainment.

Cognitive ability and dental fear and anxiety.

Dental fear and anxiety (DFA), as well as dental behavior management problems, are common in children and adolescents. Several psychological factors in the child, and parental DFA, have been studied and found to correlate to the child's DFA. The aim of this study was to investigate the relationship between cognitive ability and DFA in a population-based group of children with identified behavior and learning problems. In conjunction with a dental examination at 11 yr of age, 70 children were assessed with regard to DFA using the Children's Fear Survey Schedule Dental Subscale (CFSS-DS), and their cognitive ability was assessed using the Wechsler Intelligence Scale for Children. In addition, parental DFA was measured using the Corah Dental Anxiety Scale. The results revealed that DFA was significantly correlated to verbal intelligence quotient (IQ) but not to any other cognitive index. A significant correlation was found between parental DFA and child DFA. The results indicate that the child's verbal capacity may be one factor of importance in explaining dental fear in children.

The association of bullying and health complaints in children with attention-deficit/hyperactivity disorder.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) in schoolchildren is often associated with troublesome relationships with family members and peers as well as difficulties in the classroom. The aims of this study were to assess the associations between attention-deficit/hyperactivity disorder (ADHD), recurrent subjective health complaints, and bullying in the peer group in schoolchildren. METHOD: Cohort study of 577 fourth graders (10-year-olds) in 1 municipality in Stockholm County, Sweden. All children were screened for attention and behavior problems through interviews with their parents and teachers. Children with high scores underwent further clinical and cognitive assessments. Information about health complaints and bullying was collected from the children themselves in a classroom questionnaire. The 516 children for whom there was information from all 3 data sources were included in the final study population. RESULTS: Attention-deficit/hyperactivity disorder was associated with a 2-fold increased risk for recurrent abdominal pain (RAP), sleeping problems, and tiredness, while there was no association with headache. Bullying other students as well as being bullied were strongly associated with ADHD. There was a 2-fold increased risk for all kinds of health complaints among children being bullied, while bullies were more likely to report tiredness than other children. CONCLUSIONS: Evaluation and treatment strategies for ADHD need to include an effective evaluation and treatment of RAP, tiredness, and sleeping disturbances as well as assessment and effective interventions for bullying. Evaluation of ADHD should be considered in children with recurrent health complaints and in children involved in bullying. Antibullying interventions are important to prevent health problems in all children.

Routine developmental screening at 5.5 and 7 years of age is not an efficient predictor of attention-deficit / hyperactivity disorder at age 10.

AIM: The aim of this study was to assess the efficiency of developmental screening for deficits in attention, motor control and perception or attention-deficit/hyperactivity disorder (DAMP/ADHD) at 5.5 and 7 years of age for diagnosing ADHD in grade 4. METHOD: The study population consisted of 442 children from a cohort study of ADHD in 10-year olds in one municipality in Stockholm County. Sensitivity, specificity and positive predictive value of a developmental screening at 5.5 and at 7 years of age for being diagnosed with ADHD at 10 years of age was calculated. RESULTS: The sensitivity was 44%, the specificity 85% and the positive predictive value for having a diagnosis of pervasive ADHD in 4th grade was 15%, when at least two deviations in nine items was used as the cut-off point in 5.5-year screening at Child Health Centres (CHCs). With a cut-off score of at least two deviations in four items rated by parents or and teachers in 1st grade, these estimates were 58%, 81% and 15% respectively. CONCLUSION: This study demonstrates that developmental screening for DAMP/ADHD at 5.5 and 7 years of age does not identify children who are diagnosed with ADHD in grade 4 with a high degree of selectivity.

The Conners' 10-item scale: findings in a total population of Swedish 10-11-year-old children.

AIM: To present normative data for the Swedish version of the Conners' 10-item scale, to validate the scale by comparing children with and without attention deficit/hyperactivity disorder (ADHD), to explore the factor structure of this scale and to investigate behavioural characteristics and gender differences among 10- to 11-year-old children, as rated by parents and teachers respectively. METHODS: Parents and teachers rated 509 10- to 11-year-old children (261 boys and 248 girls) from a population-based cohort in a Swedish municipality. RESULTS: The Conners' 10-item scale discriminated very well between children with and without ADHD. Confirmatory factor analyses confirmed a two-dimensional structure of the scale with items measuring restless/impulsive behaviour in one factor and items measuring emotional lability in another. An ANOVA revealed that parents and teachers reported different behavioural characteristics in boys as compared to girls. CONCLUSION: The Conners' 10-item scale is a valid screening instrument for identification of ADHD. The two subscales can be used separately, in addition to the total score, to get a more detailed picture of the child's behaviour. Parents and teachers pay attention to different aspects of problem behaviour in boys and girls. The less disruptive behaviour of girls needs to be highlighted.

Self-esteem in children with attention and/or learning deficits: the importance of gender.

OBJECTIVE: Our objective was to analyze self-esteem in children within a spectrum of attention disorders, that is, besides attention deficit hyperactivity disorder (ADHD), also children with subthreshold ADHD and even milder attention deficits and/or learning problems. METHODS: From a population-based group of 10-11-year-old children in a Swedish municipality those with ADHD/subthreshold ADHD (n = 30) and those with milder attention and/or learning problems (n = 64) were targeted for the study. The children completed the 'I think I am' scale, reflecting physical appearance, scholastic competence, mental well-being, relationships to parents and to others and global self-esteem. Data from boys and girls were compared and related to the parents' and teachers' ratings on the two dimensions of the Conners' 10-item questionnaire (impulsive-restless behaviour and emotional lability) and to the children's cognitive levels. RESULTS: Significant gender differences were found, girls reporting lower self-esteem concerning mental well-being and poorer relationships with parents and peers. However, children with ADHD/subthreshold ADHD did not report significantly lower global self-esteem when compared to a reference population. CONCLUSION: Self-esteem in children with attention, behaviour and/or learning problems has to be carefully evaluated, especially in girls, and measures are needed to prevent a trajectory towards adolescent psychopathology.

Bullying and attention-deficit- hyperactivity disorder in 10-year-olds in a Swedish community.

The association of attention-deficit-hyperactivity disorder (ADHD) with bullying in the peer group in school was studied in an entire population of 577 fourth graders (10-year-olds) in one municipality in Stockholm, Sweden. The schoolchildren were screened for ADHD in a two-step procedure that included Conners'ratings of behavioural problems: teacher and parent interviews in a first step; and a clinical assessment in the second. Information about bullying was collected from the children themselves in a classroom questionnaire. Five-hundred and sixteen children (89.4%; 252 females, 264 males), for whom there was information from all data sources, were included in the study population. Conners'ratings that were collected from parents early in first grade were available for 382 of these children. Hypotheses were tested by multivariate analyses with adjustment for sex and parental education. Pervasive ADHD was diagnosed in 9.5% (95% confidence interval [CI] 5.6-12.8) of the males and 1.6% (CI 0.1-3.1) of the females. ADHD was associated with bullying other students (adjusted odds ratios (OR) 3.8 [CI 2.0-7.2]) as well as being bullied (often, OR 10.8 [CI 4.0-29.0]; sometimes, OR 2.9 [CI 1.5-5.7]). Bullying other students in fourth grade was associated with high scores in parental reports of behavioural problems at entry into first grade, suggesting a causal link to the ADHD syndrome. Being bullied, on the other hand, was not linked to behavioural problems at school entry. This study demonstrates a connection between ADHD and bullying in the peer group at school. Evaluation and treatment strategies for ADHD need to include assessment and effective interventions for bullying. Evaluation of ADHD should be considered in children involved in bullying.

Dental caries and oral health behavior in children with attention deficit hyperactivity disorder.

Attention deficit hyperactivity disorder (ADHD) is a common developmental disorder. This study tested the hypothesis that children with ADHD exhibit a higher caries prevalence and poorer oral health behavior than children in a control group. Twenty-one children with ADHD and a control group of 79 children, all aged 13 yr, underwent a clinical dental examination and completed two questionnaires on dietary habits and dental hygiene habits. Differences between the groups regarding decayed, missed, or filled surfaces, decayed surfaces, initial caries lesions, and gingival inflammation were non-significant. Forty-eight percent in the ADHD group brushed their teeth every evening compared with 82% in the control group. The corresponding frequencies for brushing the teeth every morning were 48% and 75%. Children with ADHD were 1.74 times more likely to eat or drink more than five times a day than children in the control group. In conclusion, at age 13, children with ADHD do not exhibit a statistically significantly higher caries prevalence but do have poorer oral health behavior than children in a control group. The intervals between dental examinations of children with ADHD should be shorter than for other children to prevent a higher caries incidence in adolescence because of their oral health behavior.

Cognitive strengths and deficits in schoolchildren with ADHD.

BACKGROUND: Few studies provide detailed analyses of the various aspects of the entire cognitive profile of children with ADHD. MATERIAL AND METHODS: Cognitive test data were analysed for 10- to 11-year-old children with (1) ADHD, (2) subthreshold ADHD and (3) milder attention and/or learning problems, and compared with normative data. RESULTS: Thirty-two had ADHD and 10 met the criteria for subthreshold ADHD, prevalence rates of 5.4% and 1.6%, respectively. On a group level, children with ADHD/subthreshold ADHD, and those with milder attention and/or learning problems had almost identical cognitive profiles for the 13 subtests comprising the WISC III, with particularly low results on the arithmetic, coding, information and digit span subtests (ACID profile). When analyzed individually, a complete or incomplete ACID profile (three of four subtests) was equally common in children with ADHD/subthreshold ADHD and in children with milder problems, found in about 1/5. The relative strengths of both groups were in areas demanding logical thinking, reasoning and common sense. CONCLUSION: The specific ACID profile is as common in children with ADHD as in those with minor attention and/or learning problems. The cognitive weaknesses reflected in the ACID profile might play a role as an underlying factor in various developmental disorders.

Salivary cortisol levels and dental anxiety in children with attention deficit hyperactivity disorder.

Attention deficit hyperactivity disorder (ADHD) is a common developmental disorder. The present study tested the hypotheses that children with ADHD, particularly those exhibiting severe hyperactivity and impulsivity, have a different stress reaction (measured by salivary cortisol) during a dental recall visit and are more dentally anxious than children in a control group. Eighteen children with ADHD and a control group of 71 children, all 13 yr of age, underwent a clinical dental examination and completed the Corah Dental Anxiety Scale (CDAS). Four saliva samples were gathered for analysis of cortisol: one prior to dental examination, one after, and two the following morning. The subgroup ADHD with hyperactivity/impulsivity had statistically significantly lower cortisol levels than the control group 30 min after awakening. When cortisol values were plotted on a timeline, this subgroup always had lower cortisol concentrations than children in the control group. There was a significant correlation between CDAS scores and cortisol concentrations prior to the dental examination in both the ADHD and the control group. Behavioral expressions of anxiety in children with ADHD may be different from those in other children, not only due to the characteristics of their disorder, but also because of lower stress reactivity.

Oral health, dental anxiety, and behavior management problems in children with attention deficit hyperactivity disorder.

Attention deficit hyperactivity disorder (ADHD) is a common developmental disorder. The aim of this study was to investigate whether children with ADHD have a higher caries prevalence, a higher degree of dental anxiety, or more dental behavior management problems (BMP) than children of a control group. Twenty-five children with ADHD and a control group of 58 children, all aged 11 yr, were included in the study. The children underwent a clinical dental examination, and bitewing radiographs were taken. The parents completed the Dental Subscale of Children's Fear Survey Schedule (CFSS-DS). Dental records from the subjects were obtained, and data regarding notes on behavior management problems (BMP) of the children when between 3 and 10 yr of age were compiled. Compared with controls, children with ADHD had significantly higher decayed, missing or filled surfaces (DMFS) (2.0 +/- 3.0 vs. 1.0 +/- 1.5) and significantly higher decayed surfaces (DS) (1.7 +/- 3.6 vs. 0.5 +/- 0.9). Differences between the groups regarding CFSS-DS scores were non-significant. In the ADHD group, the prevalence of BMP increased when the children were between 7 and 9 yr of age. In conclusion, children with ADHD exhibited a higher caries prevalence, did not exhibit a higher degree of dental anxiety, and had more BMP than children of a control group.

Health complaints in children with attention-deficit/hyperactivity disorder.

AIM: To assess recurrent subjective health complaints in Swedish schoolchildren with attention-deficit/hyperactivity disorder (ADHD). METHODS: Cohort study of 577 fourth-graders (10-y-olds) in one municipality in Stockholm County. All children were screened for attention and behaviour problems through interviews with their parents and teachers. Children with high scores underwent further clinical and cognitive assessments. Information about health complaints was collected from the children themselves in a classroom questionnaire. The 516 children for whom there was information from all three data sources were included in the final study population. Hypotheses were tested in multivariate analyses with adjustment for sex and parental education. RESULTS: Recurrent abdominal pain (RAP), sleeping problems and tiredness were associated with ADHD (stratified relative risks: 2.2 [1.4-3.4], 1.7 [1.1-2.7] and 2.7 [1.7-4.1], respectively), while there was no association with headache. CONCLUSION: This study indicates that treatment strategies for children with ADHD need to include an effective evaluation and treatment of RAP, tiredness and sleeping disturbances. Evaluation of ADHD should be considered in children with recurrent health complaints.

How do children with attention deficit hyperactivity disorder interact in a clinical dental examination? A video analysis.

Attention deficit hyperactivity disorder (ADHD) is currently the most common behavioural disorder in school-age children. The aim of this study was to perform a detailed analysis of behavioural interactions between the dentist and the child patient with ADHD. All children born in 1991 (n = 555) in one Swedish municipality were screened for attention and learning problems, and assessed for ADHD. Twenty-two children with ADHD, and a control group of 47 children without attention and learning problems, were included in the study. The dental recall visit was recorded on video. The interaction between the dentist and the child was analysed in detail and scored as verbal and non-verbal initiatives and responses. Compared to the children in the control group, the children with ADHD made significantly more initiatives, especially initiatives that did not focus on the examination or the dentist. The children with ADHD had fewer verbal responses and more missing responses. In conclusion, the problems in communication resulted in less two-way communication between the dentist and the children with ADHD than the interaction between the dentist and the children in the control group. The children with ADHD had particular difficulties staying focused on the examination.

[Children with mild mental retardation in the special schools. "Top of the iceberg"?]. / Barn med lindrig utvecklingsstörning i grundsärskolan. "Toppen av ett isberg"?

Mild mental retardation (MMR), in UK learning disabilities, is defined as an IQ in the interval between 50-70 in combination with defined adaptive criteria (ICD-10 and DSM-IV). We have analysed the prevalence, the functional assessments, associated impairments and medical aspects of the children who attended grade 1-9 in the special schools for children with mild mental retardation in the northern part of Stockholm in 2001. The prevalence was 0.4%. We assume that this prevalence represents the "top of the ice-berg", i.e., comprising those with IQ's in the lower IQ interval (IQ 50-60), since 63% of the children in this MMR-group had been diagnosed already at the time of school-start or the 3 first years at school, 76% had been medically assessed and 45% had at least one additional neuroimpairment. The "true" prevalence of MMR in this age-group is not known. Our conclusion is that we have probably identified less than half of the total group with MMR and that the unidentified group--"those who are under the surface" run the risk of never having their cognitive dysfunctions identified. MMR has wide implications for the individual in today's society. That means that there is a need of clear guidelines for diagnosis and assessments. With such guidelines and with increasing knowledge and acceptance in the society, more children and families will be offered appropriate measures and support.

A retrospective study of dental behavior management problems in children with attention and learning problems.

Attention and learning problems in children are common. The aim of this study was to investigate whether children with attention and learning problems had more dental behavior management problems (BMP), more cancelled and missed appointments, and more traumatic dental injuries compared with a control group. All children born in 1991 attending mainstream schools (n = 555) in one Swedish municipality were screened for behavioral and learning problems. Conners' 10-item questionnaire and a questionnaire focused on executive and learning problems were used. A total of 128 screen-positive patients were index cases and 131 screen-negative patients control cases. The dental records of these children were studied from 1 yr of age until the child reached 10 yr. Behavior management problems on at least one occasion were more common in the index group (54% vs. 37%). The percentage of appointments at which the children exhibited BMP was higher in the index group (13% vs. 7%). No differences were found for cancelled or missed appointments or dental traumatic injuries between the two groups. In conclusion, the results of this study show that children with attention and learning problems had significantly more dental behavior management problems compared with a control group.

Preterm children have disturbances of white matter at 11 years of age as shown by diffusion tensor imaging.

Preterm birth frequently involves white matter injury and affects long-term neurologic and cognitive outcomes. Diffusion tensor imaging has been used to show that the white matter microstructure of newborn, preterm children is compromised in a regionally specific manner. However, until now it was not clear whether these lesions would persist and be detectible on long-term follow-up. Hence, we collected diffusion tensor imaging data on a 1.5-T scanner, and computed fractional anisotropy and coherence measures to compare the white matter integrity of children born preterm to that of control subjects. The subjects for the preterm group (10.9 +/- 0.29 y; n = 9; birth weight or= 2500; gestational age, >or= 37 wk). We found that the preterm group had lower fractional anisotropy values in the posterior corpus callosum and bilaterally in the internal capsules. In the posterior corpus callosum this difference in fractional anisotropy values may partially be related to a difference in white matter volume between the groups. An analysis of the coherence measure failed to indicate a group difference in the axonal organization. These results are in agreement with previous diffusion tensor imaging findings in newborn preterm children, and indicate that ex-preterm children with attention deficits have white matter disturbances that are not compensated for or repaired before 11 y of age.