International Consensus on Standard Outcome Measures for Neurodevelopmental Disorders: A Consensus Statement.

Importance: The use of evidence-based standardized outcome measures is increasingly recognized as key to guiding clinical decision-making in mental health. Implementation of these measures into clinical practice has been hampered by lack of clarity on what to measure and how to do this in a reliable and standardized way. Objective: To develop a core set of outcome measures for specific neurodevelopmental disorders (NDDs), such as attention-deficit/hyperactivity disorder (ADHD), communication disorders, specific learning disorders, and motor disorders, that may be used across a range of geographic and cultural settings. Evidence Review: An international working group composed of clinical and research experts and service users (n = 27) was convened to develop a standard core set of accessible, valid, and reliable outcome measures for children and adolescents with NDDs. The working group participated in 9 video conference calls and 8 surveys between March 1, 2021, and June 30, 2022. A modified Delphi approach defined the scope, outcomes, included measures, case-mix variables, and measurement time points. After development, the NDD set was distributed to professionals and service users for open review, feedback, and external validation. Findings: The final set recommends measuring 12 outcomes across 3 key domains: (1) core symptoms related to the diagnosis; (2) impact, functioning, and quality of life; and (3) common coexisting problems. The following 14 measures should be administered at least every 6 months to monitor these outcomes: ADHD Rating Scale 5, Vanderbilt ADHD Diagnostic Rating Scale, or Swanson, Nolan, and Pelham Rating Scale IV; Affective Reactivity Index; Children's Communication Checklist 2; Colorado Learning Disabilities Questionnaire; Children's Sleep Habits Questionnaire; Developmental-Disability Children's Global Assessment Scale; Developmental Coordination Disorder Questionnaire; Family Strain Index; Intelligibility in Context Scale; Vineland Adaptive Behavior Scale or Repetitive Behavior Scale-Revised and Social Responsiveness Scale; Revised Child Anxiety and Depression Scales; and Yale Global Tic Severity Scale. The external review survey was completed by 32 professionals and 40 service users. The NDD set items were endorsed by more than 70% of professionals and service users in the open review survey. Conclusions and Relevance: The NDD set covers outcomes of most concern to patients and caregivers. Use of the NDD set has the potential to improve clinical practice and research.

The longitudinal relationship between socioemotional difficulties and irritability in ADHD.

BACKGROUND: Despite higher rates of irritability and socioemotional symptoms in ADHD, consensus is lacking regarding their developmental relationship and whether it differs by ADHD status. This longitudinal study sought to evaluate how peer and emotional difficulties relate to irritability in ADHD and control groups. METHODS: A community sample of 336 participants (45 % ADHD) were recruited for the Children's Attention Project. Participants completed the Affective Reactivity Index and the Strengths and Difficulties Questionnaire's emotional and peer difficulties scales at baseline (mean age 10.5 years) and 18-month follow-up. Latent Change Score models assessed how emotional and peer difficulties related to irritability at baseline and longitudinally. RESULTS: For both groups, more severe baseline difficulties were associated with higher concurrent irritability, and reductions in emotional and peer difficulties were associated with declining irritability. Baseline emotional difficulties predicted change in irritability for the ADHD group, while baseline peer difficulties predicted change in irritability for both groups. Baseline irritability did not predict change in emotional or peer difficulties for either. The ADHD group showed elevated irritability, emotional, and peer difficulties, and stronger baseline correlation between peer difficulties and irritability. LIMITATIONS: Only two timepoints were captured, and associations with ADHD symptom severity and presentation were not investigated. Doing so may facilitate additional insights. CONCLUSIONS: Change in irritability corresponded to change in socioemotional difficulties, and was driven by earlier levels of socioemotional difficulties. ADHD exacerbated aspects of the relationship between socioemotional difficulties and irritability. Socioemotional difficulties drive irritability, so may represent targets for clinical interventions.

Systematic Review and Meta-Analysis: Clinical Utility of Continuous Performance Tests for the Identification of Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: We aimed to quantify the clinical utility of continuous performance tests (CPTs) for the diagnosis of attention-deficit/hyperactivity disorder (ADHD) compared to a clinical diagnosis in children and adolescents. METHOD: Four databases (MEDLINE, PsycINFO, EMBASE, and PubMed) were screened until January 2023. Risk of bias of included results was judged with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). We statistically pooled the area under the curve, the sensitivity, and the specificity of 3 commonly used CPTs subscales: omission/inattention, commission/impulsivity, and total number of errors/ADHD subscales (PROSPERO registration: CRD42020168091). RESULTS: A total of 19 studies using commercially available CPTs were identified. Results from up to 835 control individuals and 819 cases were combined in the summary receiver operating characteristic (ROC) curve analyses (sensitivity and specificity pooling), and up to 996 cases and 1,083 control individuals in the area under the curve (AUC) analyses. Clinical utility as measured by AUCs could be considered as barely acceptable (between 0.7 and 0.8) for the most part, with the best results for the total/ADHD score, followed by omissions/inattention, and poorest for commission/impulsivity scores. A similar pattern was found when pooling sensitivity and specificity: 0.75 (95% CI = 0.66-0.82) and 0.71 (0.62-0.78) for the total/ADHD score; 0.63 (0.49-0.75) and 0.74 (0.65-0.81) for omissions; and 0.59 (0.38-0.77) and 0.66 (CI = 0.50-0.78) for commissions. CONCLUSION: At the clinical level, CPTs as a stand-alone tool have only a modest to moderate ability to differentiate ADHD from non-ADHD samples. Hence, they should be used only within a more comprehensive diagnostic process. STUDY PREREGISTRATION INFORMATION: A systematic review of screening tools for ADHD in children and adolescents; https://www.crd.york.ac.uk/prospero/; CRD42020168091.

Variation in sleep profiles in children with ADHD and associated clinical characteristics.

BACKGROUND: Sleep difficulties are common in children with attention-deficit/hyperactivity disorder (ADHD). However, sleep problems are multifaceted and little is known about the variation in sleep difficulties across children with ADHD. We examined the profiles of sleep difficulties in children with ADHD and associated clinical factors (e.g. co-occurring mental health conditions, stimulant use and parent mental health). METHODS: Data from two harmonised studies of children with ADHD (total: N = 392, ages 5-13 years) were used. Parents completed measures of children's sleep, co-occurring mental health conditions and their own mental health. Both parents and teachers completed measures of child ADHD symptoms and emotional and conduct symptoms. Latent profile analysis was used to identify sleep profiles, and multinomial logistic regression assessed clinical correlates of the groups. RESULTS: Five sleep profiles were identified: (a) insomnia/delayed sleep phase (36%), (b) generalised sleep difficulties at sleep onset and overnight (25%), (c) high anxious/bedtime resistance difficulties (11%), (d) overnight sleep difficulties including obstructive sleep apnoea and parasomnias (5%) and (e) no sleep difficulties (22%). Compared with the group without sleep difficulties, the generalised, anxious/bedtime resistance and insomnia/delayed sleep phase sleep had greater parent-reported emotional and conduct symptoms, co-occurring anxiety and increased parent mental health difficulties. The generalised and anxious/bedtime resistance groups also had greater parent-reported ADHD symptoms, with the anxious/bedtime resistance sleep group also having more frequent co-occurring depression and teacher-reported emotional symptoms. CONCLUSIONS: The sleep difficulties experienced by children with ADHD are varied. Supports to help children with ADHD need to consider the particular profiles of sleep difficulties experienced and broader clinical characteristics. Tailored intervention approaches are likely needed (including a need to address parent mental health).

Categorical and dimensional approaches to the developmental relationship between ADHD and irritability.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) and irritability commonly co-occur, and follow similar developmental trajectories from childhood to adolescence. Understanding of the developmental relationship between these co-occurrences is limited. This study provides a longitudinal assessment of how ADHD diagnostic status and symptom patterns predict change in irritability. METHODS: A community sample of 337 participants (45.2% ADHD), recruited for the Childhood Attention Project, completed the Affective Reactivity Index (ARI) to measure irritability at baseline (mean age 10.5 years) and follow-up after 18-months. Latent change score models were used to assess how (a) baseline ADHD vs. control group status, (b) baseline symptom domain (inattention, hyperactivity-impulsivity) and (c) longitudinal change in ADHD symptom severity predicted change in irritability. RESULTS: Irritability was significantly higher among the ADHD group than controls; however, change in irritability over time did not differ between groups. When assessed across the entire cohort, change in irritability was predicted by higher symptom count in the hyperactive-impulsive domain, but not the inattentive domain. Greater declines in ADHD symptoms over time significantly predicted greater declines in irritability. Baseline ADHD symptom severity was found to significantly predict change in irritability; however, baseline irritability did not significantly predict change in ADHD symptoms. CONCLUSIONS: ADHD symptoms-particularly hyperactive-impulsive symptoms-predict the degree and trajectory of irritability during childhood and adolescence, even when symptoms are below diagnostic thresholds. The use of longitudinal, dimensional and symptom domain-specific measures provides additional insight into this relationship.

Associations Between Anxiety and Home Learning Difficulties in Children and Adolescents with ADHD During the COVID-19 Pandemic.

The COVID-19 pandemic has markedly impacted functioning for children and adolescents including those with attention-deficit/hyperactivity disorder (ADHD). We explored home learning difficulties (HLD) during COVID-19 restrictions in Australian children (aged 5-17) with ADHD, aiming to: (1) describe home learning experiences, and (2) examine associations between child anxiety (i.e., concurrent anxiety symptoms and pre-existing anxiety disorder status) and HLD. Baseline data from the longitudinal ADHD COVID-19 Survey were used (n = 122). Parents reported on school factors and HLD; pre-existing anxiety and co-occurring difficulties; anxiety, ADHD, and oppositional symptoms; demographics; and medications. Parents retrospectively reported more children often looked forward to school pre-pandemic, than during the pandemic. Anxiety symptoms, but not pre-existing anxiety disorder status, were associated with HLD after accounting for covariates. ADHD inattention symptoms were also associated with HLD. Results support recommendations to continue pre-pandemic supports to assist with ADHD symptoms during home learning, and strategies/supports for families are discussed.

Behavioral and Emotional Functioning of Children and Adolescents at the End of Treatment for Acute Lymphoblastic Leukemia Compared to Healthy Peers.

This study describes the behavioral and emotional adjustment of 77 children and adolescents 3 months post-treatment for acute lymphoblastic leukemia (ALL), compared to 52 age and sex-matched healthy peers. Parents, teachers, and self-report ratings on the Behavioral Assessment System for Children, Second Edition (BASC-2) were utilized to measure psychological function. While overall mean scores were in the average range for both groups, parents and teachers rated patients higher on behavior symptoms, internalizing problems and adaptive skill difficulties. No significant differences between groups were observed on self-report, and inter-rater correlations were low to moderate. For the ALL group, maternal university completion was associated with elevations on parent report of behavioral problems, while no other factors predicted either parent or teacher report on other scales. Findings indicate that a subset of patients will require specialist psychosocial support to optimise their adjustment following treatment completion.

How can the education sector support children's mental health? Views of Australian healthcare clinicians.

OBJECTIVES: Policy makers in developed countries have long considered the education system an avenue for supporting mental health care for children. Whilst educators have identified many challenges to providing this support (e.g. non-core role, stigma, overcrowded curriculum), understanding clinicians' views on the role of educators and schools and how clinicians and schools could work together to achieve good mental health outcomes are important questions. However, clinician voices in how schools and health should work together for children's mental health care are frequently missing from the debate. We aimed to report clinicians' views about how the education system could support student's mental health and improve access to mental health care for children and adolescents. METHODS: 143 clinicians (approximately 35 each of child and adolescent psychiatrists, pediatricians, child psychologists and general practitioners (GPs)) from the states of Victoria and South Australia participated in semi-structured phone interviews between March 2018 and February 2019. Inductive content analysis was applied to address the broad study aims. FINDINGS: Key themes emerged: (1) The role of schools in supporting individual children; (2) School based programs to support children and families; and (3) Challenges of implementing these suggestions. Clinicians across all professional groups suggested the education system could play an important role in improving access to mental health services through harnessing existing staff or co-locating mental health clinicians. They also suggested schools could identify at risk children and implement coping and social skills programs. CONCLUSIONS: Schools and educators could play a key role in prevention and early intervention of children's mental health problems. However, before recommending exactly how to do this, key evidence gaps need to be addressed.

Systematic Review and Meta-analysis: Screening Tools for Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.

OBJECTIVE: This systematic review and meta-analysis aimed to determine the accuracies of a broad range of screening tools for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents, and to compare the diagnostic accuracy of tools between population-based and clinical/high-risk samples, and across reporters. METHOD: MEDLINE, PsycINFO, EMBASE, and PubMed were searched up until February 20, 2020, with no language restrictions. Studies reporting diagnostic accuracy of a screening tool against a diagnosis of ADHD in children and adolescents <18 years of age were eligible for inclusion. Meta-analyses were undertaken to provide pooled estimates of the area under the curve (AUC), and sensitivity and specificity of groups of measures. RESULTS: A total of 75 studies published between 1985 and 2021 reporting on 41 screening tools that were grouped into 4 categories (Achenbach System of Empirically Based Assessment [ASEBA], DSM-IV symptom scales, SDQ, and Other Scales) were retained. The pooled AUC for studies using a combined ADHD symptoms score was 0.82 (95% CI = 0.78-0.86), although this varied considerably across reporters (0.67-0.92) and populations (CI = 0.60-0.95). None of the measures met minimal standards for acceptable sensitivity (0.8) and specificity (0.8). CONCLUSION: Most tools have excellent overall diagnostic accuracy as indicated by the AUC. However, a single measure completed by a single reporter is unlikely to have sufficient sensitivity and specificity for clinical use or population screening.

A novel school-based approach to screening for attention deficit hyperactivity disorder.

Current approaches to screening for ADHD result in high rates of false positives. A proof of concept study to investigate the added benefits in the school-based detection of ADHD of adding a standardised teacher to teacher interview to traditional parent and teacher report questionnaires. A school-based study of diagnostic accuracy of ADHD using a novel 2-stage screening process. Participants were all 1026 pupils enrolled in grades 1 to 6 (ages 6-12 years) of a school in Hunan Province, China. The primary outcome was a diagnosis of ADHD on the Kiddie Schedule for Affective Disorders and Schizophrenia Present Lifetime version. 230 (22.4%) of the 1026 students screened positive at Stage 1 (parent and teacher questionnaires) (Sensitivity 0.86 [95% CI, 0.75 to 0.96], specificity 0.80 [95% CI, 0.78-0.83], false positive rate 0.20 (95% CI, 0.18 to 0.23), false negative rate was 0.14 (95% CI, 0.12 to 0.16). 65 remained screen-positive at the Stage 2 screen (teacher to teacher SNAP-IV interview). 36/65 (55.4%) of these Stage 2 screen positive participants and 1/144 (0.7%) of the screen negative subjects met DSM-IV criteria for ADHD (sensitivity 0.83 [95% CI, 0.71-0.95]; specificity of 0.97 [95% CI, 0.96-0.98]; false positive rate 0.03 [95% CI, 0.01 to 0.04], false negative rate 0.16 [95% CI, 0.15 to 0.19]. Adding teacher to teacher interviews to traditional questionnaire-based screening has the potential to improve the clinical utility of school-based screening for ADHD reducing the proportion of false positives, without a negative impact on sensitivity.

A brief clinician training program to manage sleep problems in ADHD: what works and what do clinicians and parents think?

OBJECTIVE/BACKGROUND: Brief behavioural sleep interventions have been shown to be effective in treating sleep problems in children with ADHD. Little research, however, has focused on the translational aspects of these programs from the consumer perspective. This study aimed to explore clinician and parent views of a brief training program in managing sleep problems in children with ADHD. PARTICIPANTS: Fifty-nine community-based clinicians (32 paediatricians, 27 psychologists) were trained to deliver a brief behavioural sleep intervention as part of the Sleeping Sound with ADHD translational trial; 183 families were allocated to receive the sleep intervention and 115 provided follow-up data. METHODS: Clinicians reported on competency, confidence and perceived barriers pre- and post-training. Parents reported on usefulness of the program and frequency of sleep strategy use at 3 months post-randomisation. Parent-report of severity of the child sleep problem was also measured at 3 and 6 months post-randomisation. RESULTS: Clinicians' feelings of competency and confidence in managing sleep difficulties increased from pre-to post-training, while perceptions of barriers decreased. Parent-reported usefulness of the program and frequency of sleep use varied by program domain and sleep strategy. Increased parent-reported use of sleep strategies was associated with improved sleep at 3 and 6 months post-randomisation. CONCLUSIONS: A brief sleep training program leads to improvements in clinician confidence and competence in managing sleep problems in children with ADHD and positive parent perspectives. The findings highlight the potential for the Sleeping Sound with ADHD program to be optimized to better help parents in their implementation of sleep strategies.

Parental adjustment following their child's completion of acute lymphoblastic leukemia treatment.

BACKGROUND: Few studies haveexamined parent and family adaptation in the early period following the end of childhood cancer treatment. We examined parent adjustment at the end of their child's treatment for acute lymphoblastic leukemia (ALL). METHODS: Parents of childhood cancer survivors (CCS), who were 3 months post-ALL treatment, and parents of typically developing children completed measures of psychological and family functioning. Parents of CCS also completed distress and posttraumatic stress symptom (PTSS) questionnaires related to their child's cancer experience. RESULTS: One hundred twenty-nine parents were recruited: 77 parents of CCS and 52 comparison parents. Overall mean psychological symptoms of depression, anxiety and stress, and family functioning were within normal limits for both groups. Parents of CCS endorsed higher scores for stress, depression, and family problems; however, mean scores for emotional distress were low for both groups, in particular the comparison group. Parents of CCS endorsed low rates of PTSS. Fifty-one percent of parents of CCS scored above the distress thermometer (DT-P) clinical cutoff (>4), with items elevated across all six DT-P domains. However, most parents did not indicate a wish to speak to a health professional about their symptoms. CONCLUSION: Specialist psychosocial intervention may be indicated for only a subset of parents at the end of treatment. As per psychosocial standards of care, effective screening at this timepoint is warranted. Further examination of appropriate timing of psychosocial information and support services that are tailored to parents' circumstances is needed. eHealth approaches may be appropriate.

A systematic review of the persistence of childhood mental health problems into adulthood.

Many adult mental disorders have their origins in childhood yet our knowledge about this largely comes from studies assessing adults utilising retrospective recall of age of onset. In this systematic review we evaluate the current state of knowledge of how childhood exposure to mental health problems is associated with adult mental disorders using data from prospective longitudinal studies. We identified 40 studies that assessed mental health in childhood or adolescence and reassessed adults for mental disorders. Although there was substantial heterogeneity across studies in terms of methodology and findings, there was a clear pattern that experiencing mental health problems prior to 14 years of age increases risk of adult mental disorder. Importantly, elevated symptoms rather than diagnosis in childhood were generally more strongly associated with adult disorder. These findings provide strong support for the argument that prevention needs to be targeted to children in the primary school years and early intervention efforts to those who are beginning to experience elevated symptoms rather than waiting until a diagnosable disorder is evident.

Neural correlates of irritability in a community sample of children.

Irritability has been associated with aberrant patterns of neural activation, yet little is known about structural brain correlates of irritability. As such, we aimed to investigate associations between irritability and gray matter volume (GMV) in a community sample of children enriched for irritability. The sample comprised children (n=162) aged 9-11 years with and without Attention-Deficit/Hyperactivity Disorder (ADHD), participating in a cohort study with magnetic resonance imaging data available. Mixed effects linear regression analyses tested the associations between irritability symptoms and regional GMV (extracted using Freesurfer). Irritability was associated with smaller gray matter volume across multiple brain regions implicated in executive functioning, and emotion and reward processing including frontal regions and the cingulate.

Clinicians' perceptions of the Australian Paediatric Mental Health Service System: Problems and solutions.

OBJECTIVES: Despite substantial investment by governments, the prevalence of mental health disorders in developed countries remains unchanged over the past 20 years. As 50% of mental health conditions present before 14 years of age, access to high-quality mental health care for children is crucial. Barriers to access identified by parents include high costs and long wait times, difficulty navigating the health system, and a lack of recognition of the existence and/or severity of the child's mental health disorder. Often neglected, but equally important, are clinician views about the barriers to and enablers of access to high-quality mental health care. We aimed to determine perspectives of Australian clinicians including child and adolescent psychiatrists, paediatricians, psychologists and general practitioners, on barriers and enablers within the current system and components of an optimal system. METHODS: A total of 143 clinicians (approximately 35 each of child and adolescent psychiatrists, paediatricians, child psychologists and general practitioners) from Victoria and South Australia participated in semi-structured phone interviews between March 2018 and February 2019. Inductive content analysis was applied to address the broad study aims. FINDINGS: Clinician-identified barriers included multi-dimensional family factors, service fragmentation, long wait times and inadequate training for paediatricians and general practitioners. Rural and regional locations provided additional challenges but a greater sense of collaboration resulting from the proximity of clinicians in rural areas, creating an opportunity to develop support networks. Suggestions for an optimal system included novel ways to improve access to child psychiatry expertise, training for paediatricians and general practitioners, and co-located multidisciplinary services. CONCLUSION: Within the current mental health system for children, structural, training and workforce barriers prevent optimal access to care. Clinicians identified many practical and systemic ideas to improve the system. Implementation and evaluation of effectiveness and cost effectiveness of these ideas is the next challenge for Australia's children's mental health.

A pilot randomised placebo-controlled trial of cannabidiol to reduce severe behavioural problems in children and adolescents with intellectual disability.

AIMS: Severe behavioural problems (SBP) are a major contributor to morbidity in children with intellectual disability (ID). Medications used to treat SBP in ID are associated with a high risk of side effects. Cannabidiol has potential therapeutic effects in SBP. This pilot study aimed to investigate the feasibility of conducting a randomised placebo-controlled trial of cannabidiol to reduce SBP in children with ID. METHODS: This is a double-blind, placebo-controlled, two-armed, parallel-design, randomised controlled trial of cannabidiol in children aged 8-16 years with ID and SBP. Participants were randomised 1:1 to receive either 98% cannabidiol in oil (Tilray, Canada) or placebo orally for 8 weeks. The dose was up-titrated over 9 days to 20 mg/kg/day in two divided doses, with a maximum dose of 500 mg twice/day. The feasibility and acceptability of all study components were assessed. RESULTS: Eight children were randomised, and all completed the full study protocol. There were no serious adverse events or drop-outs. Protocol adherence for key study components was excellent: study visits 100%, medication adherence 100%, blood tests 92% and questionnaire completion 88%. Parents reported a high degree of acceptability with the study design. All parents reported they would recommend the study to other families with children with similar problems. There was an efficacy signal in favour of active drug. CONCLUSIONS: The findings suggest that the study protocol is feasible and acceptable to patients with ID and SBP and their families.

Persistence of disruptive mood dysregulation disorder in children with attention-deficit/hyperactivity disorder.

Disruptive mood dysregulation disorder (DMDD) is common in children with ADHD yet it is not known how persistent DMDD is in this population. As such we aimed to investigate the persistence of disruptive mood dysregulation disorder (DMDD) in a community sample of children with ADHD. The sample comprised children (n = 136) participating in a cohort study with data available at age 7 and age 10. DMDD status was ascertained using proxy items from the Diagnostic Interview Schedule for Children, Version IV. Of those with DMDD at age 7 (n = 30), eight (21.1%) had DMDD that persisted at age 10. In the first study investigating the longitudinal course of DMDD in ADHD one in five children with ADHD+DMDD at age 7 continued to meet diagnostic criteria for DMDD three years later.

Peer Victimization and Poor Academic Outcomes in Adolescents With ADHD: What Individual Factors Predict Risk?

Objective: Examine individual factors associated with peer victimization (PV) in adolescents with attention-deficit/hyperactivity disorder (ADHD) and to examine the association between PV and educational outcomes. Method: Participants were 121 adolescents (Mage = 13.62, SD = 1.03; 89% boys) with diagnosed ADHD. Using path analysis, we tested whether general adolescent factors (ADHD symptoms, comorbid autism spectrum disorder, cognitive and social functioning, and age) were associated with experiences of PV, and associations between PV and academic outcomes. Results: Deficits in working memory (WM) and peer relationship problems were weakly and moderately associated with PV, respectively. PV was in turn was associated with adolescents' attitudes about school, academic competence, and academic achievement. Conclusion: Adolescents with poor social skills and/or WM difficulties who have ADHD may be particularly vulnerable to being victimized by peers. Failure to identify and manage PV during early adolescence may be connected to poor educational outcomes.