Froehlich discusses medication treatments for preschool children with attention-deficit/hyperactivity disorder (ADHD). Recognition of ADHD in the preschool age group is on the rise, with an increase ...in preschool ADHD rates in US nationally representative samples from 1.0% in 2007 to 2008 to 2.4% in 2016.1 Having a preschool-age child (ie, 3-5 years) with ADHD is associated with numerous negative outcomes in the home (eg, disordered parent-child relationships, elevated family stress2) as well as out-of-home settings (eg, impaired preacademic skills, peer interaction difficulties, expulsion from preschool and childcare settings), underscoring the importance of identification and treatment. Guidelines from the American Academy of Pediatrics and the Society for Developmental-Behavioral Pediatrics (SDBP) recommend behavioral interventions as first-line treatment for preschool-age children with ADHD.
This Viewpoint discusses the issues at stake and potential adverse consequences of the Accreditation Council for Graduate Medial Education’s proposal to remove the requirement for pediatric training ...programs to have board-certified developmental-behavioral pediatrician faculty members.
Attention-deficit/hyperactivity disorder (ADHD) is 1 of the most common neurobehavioral disorders of childhood and can profoundly affect children's academic achievement, well-being, and social ...interactions. The American Academy of Pediatrics first published clinical recommendations for evaluation and diagnosis of pediatric ADHD in 2000; recommendations for treatment followed in 2001. The guidelines were revised in 2011 and published with an accompanying process of care algorithm (PoCA) providing discrete and manageable steps by which clinicians could fulfill the clinical guideline's recommendations. Since the release of the 2011 guideline, the
has been revised to the fifth edition, and new ADHD-related research has been published. These publications do not support dramatic changes to the previous recommendations. Therefore, only incremental updates have been made in this guideline revision, including the addition of a key action statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying process of care algorithm has also been updated to assist in implementing the guideline recommendations. Throughout the process of revising the guideline and algorithm, numerous systemic barriers were identified that restrict and/or hamper pediatric clinicians' ability to adopt their recommendations. Therefore, the subcommittee created a companion article (available in the Supplemental Information) on systemic barriers to the care of children and adolescents with ADHD, which identifies the major systemic-level barriers and presents recommendations to address those barriers; in this article, we support the recommendations of the clinical practice guideline and accompanying process of care algorithm.
The aim of this work was 2-fold: (1) to evaluate current knowledge and identify key directions in the study of sluggish cognitive tempo (SCT); and (2) to arrive at a consensus change in terminology ...for the construct that reflects the current science and may be more acceptable to researchers, clinicians, caregivers, and patients.
An international Work Group was convened that, in early 2021, compiled an online archive of all research studies on SCT and summarized the current state of knowledge, noted methodological issues, and highlighted future directions, and met virtually on 10 occasions in 2021 to discuss these topics and terminology.
Major progress has been made over the last decade in advancing our understanding of SCT across the following domains of inquiry: construct measurement and stability; genetic, environmental, pathophysiologic, and neuropsychological correlates; comorbid conditions; functional impairments; and psychosocial and medication interventions. Findings across these domains are summarized, and potential avenues to pursue in the next generation of SCT-related research are proposed. Following repeated discussions on terminology, the Work Group selected “cognitive disengagement syndrome” (CDS) to replace “SCT” as the name for this construct. This term was deemed to best satisfy considerations that should apply when selecting terms for a condition or syndrome, as it does not overlap with established terms for other constructs, is not offensive, and reflects the current state of the science.
It is evident that CDS (SCT) has reached the threshold of recognition as a distinct syndrome. Much work remains to further clarify its nature (eg, transdiagnostic factor, separate disorder, diagnostic specifier), etiologies, demographic factors, relations to other psychopathologies, and linkages to specific domains of functional impairment. Investigators are needed with interests and expertise spanning basic, clinical, and translational research to advance our understanding and to improve the lives of individuals with this unique syndrome.
Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral condition and the second most common chronic illness in children. The observance of specific behaviors in multiple ...settings have remained the most successful method for diagnosing the condition, and although there are differences in specific areas of the brain, and a high heritability estimate (∼76%), they are not diagnostically specific. Medications, and particularly stimulant medication, have undergone rigorous studies to document their efficacy dating back to the 1970s. Likewise, behavioral interventions in the form of parent training and classroom programs have demonstrated robust efficacy during the same time period. Both medication and behavioral interventions are symptomatic treatments. The availability of only symptomatic treatments places ADHD in the same category as other chronic conditions such as diabetes and asthma. Successful treatment of most individuals requires ongoing adherence to the therapy. Improved communication between patients and their families, primary and mental health providers, and school personnel is necessary for effective ADHD treatment. Further enhancement of electronic systems to facilitate family, school, and provider communication can improve monitoring of ADHD symptoms and functional performance. The American Academy of Pediatrics ADHD guidelines were initially developed to help primary care clinicians address the needs of their patients with ADHD and were further refined with the second revision in 2019.
Although the study of cognitive disengagement syndrome (CDS; previously called sluggish cognitive tempo) first emerged in the 1980s, very little is known about treating CDS or its impact on ...evidence-based interventions for attention-deficit/hyperactivity disorder (ADHD) with which it frequently co-occurs. The objective of this leading article was to investigate the existing evidence on medication treatment and CDS, including studies that have examined CDS response to medication and CDS as a moderator of ADHD treatment response. A total of seven studies were identified. At present, the limited existing literature suggests that psychostimulants such as methylphenidate and lisdexamfetamine, as well as atomoxetine, may improve CDS symptoms, although replication and research on related medications is needed. However, there are indications that CDS symptoms may predict a reduced response to methylphenidate in children with ADHD. Although untested, research on the neurobiological, neuropsychological, and behavioral correlates of CDS point to a possible benefit of other ADHD medications (e.g., guanfacine), medications that treat narcolepsy (e.g., modafinil), and medications traditionally used to treat depression and anxiety (e.g., viloxazine, bupropion, fluvoxamine), some of which have also recently been used in ADHD management. The article concludes with recommendations for future research on pharmacologic treatment and CDS.
Bisphenol A (BPA) has been linked to changes in the dopamine system and development of an Attention-Deficit/Hyperactivity Disorder (ADHD) phenotype in animal models, with differing effects in males ...compared to females. We examined the association between urinary BPA concentrations and ADHD in a national sample of U.S. children, and whether this association differs by child sex.
We used data from the 2003–2004 National Health and Nutrition Examination Survey, a cross-sectional, nationally representative sample of the U.S. population. Participants were 8-15 years of age (N=460). Using a diagnostic interview to ascertain the presence of ADHD in the past year, multivariable logistic regression examined the link between concurrent urinary BPA concentrations and ADHD status.
Of the 460 participants, 7.1% 95% CI: 4.4–11.3 met Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV) criteria for ADHD. Children who had BPA concentrations at or above the median of the sample had higher prevalence of meeting criteria for ADHD (11.2% 95% CI: 6.8–17.8) than those with BPA concentrations below the median (2.9% 95% CI: 1.1–7.2). Higher urinary BPA concentrations were associated with ADHD (adjusted odds ratio aOR: 5.68 95% CI: 1.6–19.8 for BPA concentrations above vs. below the median). In sex-stratified analyses, these associations were stronger in boys (aOR=10.9 95% CI: 1.4–86.0) than in girls (aOR=2.8 95% CI: 0.4–21.3), although the BPA by sex interaction term was not significant (p=0.25).
We found evidence that higher urinary BPA concentrations were associated with ADHD in U.S. children; these associations were stronger in boys than in girls. Considering the widespread use of BPA and growing literature on neurobehavioral effects of BPA in children, further study is warranted to determine if reducing exposure to BPA may represent an important avenue for ADHD prevention.
•Childhood BPA exposure is associated with ADHD in national sample of U.S. children.•Association between BPA and ADHD is stronger in boys but nonsignificant in girls.•Higher levels of BPA associated with higher inattentive symptoms counts.•No association between overall and hyperactive-impulsive symptom counts and BPA.
To examine the effects of stimulant medication on the sleep functioning of children with attention-deficit/hyperactivity disorder (ADHD) and identify predictors of sleep problems as a side effect of ...taking stimulant medication.
One hundred sixty-three stimulant-naïve children (72% boys) aged 7 to 11 years diagnosed with ADHD (120 with ADHD predominantly inattentive type, 43 with ADHD combined type) participated in a 4-week, randomized, double-blind, placebo-controlled trial of once-daily (long-acting) methylphenidate (MPH). Parents completed weekly side-effect ratings including an item related to sleep problems.
Ten percent of patients had parent-rated sleep problems before the initiation of medication. Rates of parent-rated sleep problems during MPH titration generally increased with increasing MPH dose (placebo: 8%; low dose: 18%; medium dose: 15%; high dose: 25%). Differences emerged between children with (n = 16) or without (n = 147) preexisting sleep problems. Although 23% of children without preexisting sleep problems went on to have sleep problems at the highest MPH dose, only 37.5% of children with preexisting sleep problems still had sleep problems at the highest MPH dose. Lower weight and lower body mass index (BMI) were associated with increased sleep problems during MPH titration.
This study demonstrated a general association between increased MPH dose and increased sleep problems in children with ADHD, particularly for children of lower weight/BMI. However, a substantial proportion of children with preexisting sleep difficulties no longer had sleep problems on the highest MPH dose, which may help explain mixed findings reported to date in studies examining the impact of MPH on sleep functioning in children with ADHD and suggests that MPH dose titration should not be avoided solely on the basis of a child's premorbid sleep problems. Future research is needed to replicate and extend these findings to more specific domains of sleep functioning and to identify differences between children with persistent or improved sleep functioning as a result of MPH use.
Objective: The purpose of this study was to examine the association of exposures to tobacco smoke and environmental lead with attention deficit hyperactivity disorder (ADHD). Methods: Data were ...obtained from the National Health and Nutrition Examination Survey 1999-2002. Prenatal and postnatal tobacco exposure was based on parent report; lead exposure was measured using blood lead concentration. ADHD was defined as having current stimulant medication use and parent report of ADHD diagnosed by a doctor or health professional. Results: Of 4,704 children 4-15 years of age, 4.2% were reported to have ADHD and stimulant medication use, equivalent to 1.8 million children in the United States. In multivariable analysis, prenatal tobacco exposure odds ratio (OR) = 2.5; 95% confidence interval (CI), 1.2-5.2 and higher blood lead concentration (first vs. fifth quintile, OR = 4.1; 95% CI, 1.2-14.0) were significantly associated with ADHD. Postnatal tobacco smoke exposure was not associated with ADHD (OR = 0.6; 95% CI, 0.3-1.3; p = 0.22). If causally linked, these data suggest that prenatal tobacco exposure accounts for 270,000 excess cases of ADHD, and lead exposure accounts for 290,000 excess cases of ADHD in U.S. children. Conclusions: We conclude that exposure to prenatal tobacco and environmental lead are risk factors for ADHD in U.S. children.
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