Reflections From School Communities in Underserved Populations on Childhood COVID-19 Vaccination.

OBJECTIVES: Outbreaks in vaccine-preventable diseases among children have increased, primarily among under- or unvaccinated subgroups. The influence and interaction of a child's school community on parental health care decisions, such as vaccination, has not been explored. Our study examined childhood coronavirus disease 2019 (COVID-19) vaccine hesitancy within the context of school communities. METHODS: This study combines data from 4 independent research studies funded by the National Institutes of Health Rapid Acceleration of Diagnostics Underserved Populations Return to School Initiative. We examined focus group data to better understand the apprehension surrounding parental and child COVID-19 vaccination among underserved school populations. RESULTS: Across all study sites, 7 main themes emerged with regard to COVID-19-related vaccination concerns for children: (1) potential side effects, (2) vaccine development, (3) misinformation (subthemes: content of vaccine and negative intent of the vaccine), (4) vaccine effectiveness, (5) timing of vaccine administration/availability for children, (6) fear of needles, and (7) mistrust. CONCLUSIONS: School settings offered unique access to youth and family perspectives in underserved communities. Our studies highlighted several factors contributing to COVID-19 vaccine hesitancy in school communities, which align with existing literature on vaccine hesitancy. These concerns centered primarily on potential harm of vaccines, as well as misinformation, mistrust, and timing of vaccines. Related recommendations for increasing vaccination rates are provided. Developing specific strategies that address parent and child concerns will be critical to reducing health inequities related to COVID-19 vaccination.

A Proactive, Systematic Approach to Building the Capacity of Technical Assistance Providers.

Technical assistance (TA) is a major capacity building strategy used by the government sector to promote health outcomes in the United States. However, there is minimal literature about how to develop TA provider capacities. This article describes a systematic and proactive approach for developing TA provider capacity, referred to as Technical Assistance for Technical Assistance Providers (TAFTAP), which draws on three implementation science frameworks (Interactive Systems Framework for Dissemination and Implementation, Getting To Outcomes, and R = MC2). We present an application of TAFTAP within a federal agency providing a readiness-informed TA approach to health departments of states, territories, and tribal areas implementing comprehensive tobacco prevention control programs. Pilot data suggest that TAFTAP is a promising approach for improving the quality of TA delivery. At the end of the 2-year project period, TAFTAP recipients provided generally positive qualitative feedback about the support they received. They chose to sustain the readiness-informed TA by incorporating it into a future funding announcement. Downstream state-level TA grantee recipients reported positive outcomes (e.g., accelerated progress, enjoying more one-on-one time with TA providers) from receiving the TA innovation from TAFTAP recipients. We suggest that funding agencies and training and TA centers consider this approach to bolster the capacity and motivation of TA providers for downstream benefit to health and human services staff and their clients. Practical steps for employing TAFTAP to advance health outcomes are included in this article.

Community voices on factors influencing COVID-19 concerns and health decisions among racial and ethnic minorities in the school setting.

Racial and ethnic minority communities have been disproportionately affected by COVID-19, but the uptake of COVID-19 mitigation strategies like vaccination and testing have been slower in these populations. With the continued spread of COVID-19 while in-person learning is a priority, school-aged youth and their caregivers must make health-related decisions daily to ensure health at school. It is critical to understand factors associated with COVID-related health decisions such as vaccination, testing, and other health behaviors (e.g., wearing masks, hand washing). Community-engaged campaigns are necessary to overcome barriers to these health behaviors and promote health equity. The aim of this study was to examine COVID-19-related concerns and influences on health decisions in middle and high schools serving primarily racial and ethnic minority, low-income families. Seven focus groups were conducted with school staff, parents, and students (aged 16 years and older). Qualitative data were analyzed using a general inductive approach. Factors related to COVID-19 concerns and health decisions centered on (1) vaccine hesitancy, (2) testing hesitancy, (3) developmental stage (i.e., ability to engage in health behaviors based on developmental factors like age), (4) cultural and family traditions and beliefs, (5) compatibility of policies and places with recommended health behaviors, (6) reliability of information, and (7) perceived risk. We explore sub-themes in further detail. It is important to understand the community's level of concern and identify factors that influence COVID-19 medical decision making to better address disparities in COVID-19 testing and vaccination uptake.

Assessing cross-sector stakeholder readiness to advance and sustain statewide behavioral integration beyond a State Innovation Model (SIM) initiative.

Integrated care is recognized as a promising approach to comprehensive health care and reductions in health care costs. However, the integration of behavioral health and primary care is complex and often difficult to implement. Successful and sustainable integration efforts require coordination and alignment both within health care organizations and across multiple sectors. Furthermore, implementation progress and outcomes are shaped by the readiness of stakeholders to work together toward integrated care. In the context of a Colorado State Innovation Model (SIM) effort, we examined stakeholder readiness to advance and sustain partnerships for behavioral health integration beyond the period of grant funding. Partnership readiness was assessed using the Readiness for Cross-sector Partnerships Questionnaire (RCP) in spring 2019. Participants from 67 organizations represented seven sectors: government, health care, academic, practice transformation, advocacy, payer, and other. RCP analyses indicated a moderate level of readiness among Colorado stakeholders for partnering to continue the work of behavioral health integration initiated by SIM. Stakeholders indicated their highest readiness levels for general capacity and lowest for innovation-specific capacity. Five thematic categories emerged from the open-ended questions pertaining to partnership experiences: (a) collaboration and relationships, (b) capacity and leadership, (c) measurement and outcomes, (d) financing integrated care, and (e) sustainability of the cross-sector partnership. Partnering across sectors to advance integrated behavioral health and create more equitable access to services is inherently complex and nonlinear in nature. The RCP usefully identifies opportunities to strengthen the sustainability of integrated care efforts.

R = MC2 readiness building process: A practical approach to support implementation in local, state, and national settings.

Effective implementation of evidence-based interventions is a persistent challenge across community settings. Organizational readiness - or, the motivation and collective capacity of an entity to adopt and sustain an innovation - is important to facilitate implementation. Drawing on the R = MC2 readiness framework, we developed a readiness building process to tailor support for implementation. The process is composed of the following stages: assessment, feedback and prioritization, and strategize. In this article, we describe the application of the readiness building process through three case examples representing interventions at different ecological levels: local, state, and national. The case examples illuminate challenges and practical considerations for using the readiness building process, including the significance of on-going leadership engagement and collaboration between support system and delivery system staff. To further the research and practice of implementation readiness, we suggest examining the impact of readiness building on implementation outcomes and developing an empirically-informed repository of change management strategies matched to readiness constructs.

The Readiness for Integrated Care Questionnaire (RICQ): An instrument to assess readiness to integrate behavioral health and primary care.

Integration of behavioral health and primary care services is a promising approach for reducing health disparities. The growing national emphasis on care coordination has mobilized efforts to integrate behavioral health and primary care services across the United States. These efforts align with broader health care system goals of improving health care quality, health equity, utilization efficiency, and patient outcomes. Drawing from our work on a multiyear integrated care initiative (Integrated Care Leadership Program; ICLP) and an implementation science heuristic for organizational readiness (Readiness = Motivation x General Capacity and Innovation-Specific Capacity; R = MC2), this article describes the development and implementation of a tool to assess organizational readiness for integrated care, referred to as the Readiness for Integrated Care Questionnaire (RICQ). The tool was piloted with 11 health care practices that serve vulnerable, underprivileged populations. Initial results from the RICQ revealed that participating practices were generally high in motivation, innovation-specific capacities, and general capacities at the start of ICLP. Additionally, analyses indicated that practices particularly needed support with increasing staff capacities (general knowledge and skills), improving access to and use of resources, and simplifying the steps in integrating care so the effort appears less daunting and difficult to health care team members. We discuss insights from the initial use of RICQ and practical implications of the new tool for driving integrated care efforts that can contribute to health equity. (PsycINFO Database Record

Long-Term Sustainability of Evidence-Based Prevention Interventions and Community Coalitions Survival: a Five and One-Half Year Follow-up Study.

This study examines (1) coalition survival, (2) prevalence of evidence-based prevention interventions (EBPIs) to reduce substance abuse implemented as part of the Tennessee Strategic Prevention Framework (SPF) State Incentive Grant (SIG), (3) EBPI sustainability, and (4) factors that predict EBPI sustainability. Secondary data were collected on 27 SPF SIG-funded coalitions and 88 EBPI and non-EBPI implementations. Primary data were collected by a telephone interview/web survey five and one-half years after the SPF SIG ended. Results from secondary data show that 25 of the 27 coalitions survived beyond the SPF SIG for one to five and one-half years; 19 coalitions (70%) were still active five and one-half years later. Further, 88 EBPIs and non-EBPIs were implemented by 27 county SPF SIG coalitions. Twenty-one (21) of 27 coalitions (78%) implemented one to three EBPIs, totaling 37 EBPI implementations. Based on primary survey data on 29 of the 37 EBPI implementations, 28 EBPIs (97%) were sustained between two and five and one-half years while 22 EBPI implementations (76%) were sustained for five and one-half years. When controlling for variability among coalitions (nesting of EBPIs in coalitions), increases in data resources (availability of five types of prevention data) was a strong predictor of length of EBPI sustainability. Positive change in extramural funding resources and level of expertise during SPF SIG implementation, as well as level of coalition formalization at the end of the SPF SIG predicted EBPI sustainability length. One intervention attribute (trialability) also predicted length of sustainability. Implications are discussed.

A Pilot Study: Cardiac Parameters in Children Receiving New-Generation Antidepressants.

OBJECTIVE: Because of concerns about potential associations between high doses of citalopram and QTc prolongation in adults, this study examined whether such associations are operant in children. We hypothesized that therapeutic doses of nontricyclic antidepressant medications (non-TCAs) prescribed to children would be cardiovascularly safe. STUDY DESIGN: The sample consisted of 49 psychiatrically referred children and adolescents 6 to 17 years old of both sexes treated with a non-TCA (citalopram, escitalopram, fluoxetine, paroxetine, sertraline, bupropion, duloxetine, venlafaxine, mirtazapine). To standardize the doses of different antidepressants, we converted doses of individual medicines into "citalopram equivalent doses" (CEDs) based on dosing recommendation for individual antidepressants. Correlation analysis was carried out to compare the continuous and weight-based CED to variables of interest. A QTc grouping was defined as normal, borderline, or abnormal, and CED was compared across QTc groupings using linear regression. An antidepressant dosage group was defined as low or high dose, and a t test compared variables of interest across dosage groups. RESULTS: No significant associations were found between total or weight-corrected CEDs of any antidepressant examined and QTc or any other electrocardiogram or blood pressure parameters. In patients taking citalopram or escitalopram, a significant correlation was found between PR interval and total daily dose, which disappeared when weight-based doses were used or when corrected by age. CONCLUSIONS: Although limited by a relatively small sample size, these results suggest that therapeutic doses of non-TCA antidepressants when used in children do not seem to be associated with prolonged QTc interval or other adverse cardiovascular effects.

Impaired Frontal-Limbic White Matter Maturation in Children at Risk for Major Depression.

Depression is among the most common neuropsychiatric disorders. It remains unclear whether brain abnormalities associated with depression reflect the pathological state of the disease or neurobiological traits predisposing individuals to depression. Parental history of depression is a risk factor that more than triples the risk of depression. We compared white matter (WM) microstructure cross-sectionally in 40 children ages 8-14 with versus without parental history of depression (At-Risk vs. Control). There were significant differences in age-related changes of fractional anisotropy (FA) between the groups, localized in the anterior fronto-limbic WM pathways, including the anterior cingulum and the genu of the corpus callosum. Control children exhibited typical increasing FA with age, whereas At-Risk children exhibited atypical decreasing FA with age in these fronto-limbic regions. Furthermore, dorsal cingulate FA significantly correlated with depressive symptoms for At-Risk children. The results suggest maturational WM microstructure differences in mood-regulatory neurocircuitry that may contribute to neurodevelopmental risk for depression. The study provides new insights into neurodevelopmental susceptibility to depression and related disabilities that may promote early preventive intervention approaches.

Altered Intrinsic Functional Brain Architecture in Children at Familial Risk of Major Depression.

BACKGROUND: Neuroimaging studies of patients with major depression have revealed abnormal intrinsic functional connectivity measured during the resting state in multiple distributed networks. However, it is unclear whether these findings reflect the state of major depression or reflect trait neurobiological underpinnings of risk for major depression. METHODS: We compared resting-state functional connectivity, measured with functional magnetic resonance imaging, between unaffected children of parents who had documented histories of major depression (at-risk, n = 27; 8-14 years of age) and age-matched children of parents with no lifetime history of depression (control subjects, n = 16). RESULTS: At-risk children exhibited hyperconnectivity between the default mode network and subgenual anterior cingulate cortex/orbital frontal cortex, and the magnitude of connectivity positively correlated with individual symptom scores. At-risk children also exhibited 1) hypoconnectivity within the cognitive control network, which also lacked the typical anticorrelation with the default mode network; 2) hypoconnectivity between left dorsolateral prefrontal cortex and subgenual anterior cingulate cortex; and 3) hyperconnectivity between the right amygdala and right inferior frontal gyrus, a key region for top-down modulation of emotion. Classification between at-risk children and control subjects based on resting-state connectivity yielded high accuracy with high sensitivity and specificity that was superior to clinical rating scales. CONCLUSIONS: Children at familial risk for depression exhibited atypical functional connectivity in the default mode, cognitive control, and affective networks. Such task-independent functional brain measures of risk for depression in children could be used to promote early intervention to reduce the likelihood of developing depression.

Mild Traumatic Brain Injury and Attention-Deficit Hyperactivity Disorder in Young Student Athletes.

A recent meta-analysis documented a significant statistical association between mild traumatic brain injury (mTBI) and attention deficit hyperactivity disorder (ADHD) (Adeyemo et al., 2014), but the direction of this effect was unclear. In this study, we hypothesized that ADHD would be an antecedent risk factor for mTBI. Participants were student athletes ages 12 to 25 who had sustained a mTBI and Controls of similar age and sex selected from studies of youth with and without ADHD. Subjects were assessed for symptoms of ADHD, concussion severity, and cognitive function. mTBI subjects had a significantly higher rate of ADHD than Controls, and in all cases the age of onset of ADHD was before mTBI onset. mTBI+ADHD subjects also had more severe concussion symptoms (fatigue and poor concentration) than mTBI-ADHD subjects. These results support ADHD as an antecedent risk factor for mTBI in student athletes and that its presence complicates the course of mTBI.

A Systematic Evaluation of the QTc Interval and Antidepressants in Youth: An Electronic Health Record Study.

OBJECTIVE: The US Food and Drug Administration announced that citalopram was associated with dose-related prolongation of the QTc interval in adults. This study aimed to assess how antidepressants affect QTc intervals in children. The authors hypothesized that some antidepressants would show an association with QTc prolongation. METHODS: An electronic medical record review was conducted of children aged 5 to 18 years in the Partners Healthcare system with at least 1 prescription of an antidepressant or methadone between February 1990 and August 2011. The authors extracted lifetime diagnoses and QTc interval of patients who had received an electrocardiogram 14 to 90 days after antidepressant or methadone prescription (N = 297). The mean QTc per medication was calculated as compared with the mean of all QTc measurements across medications. The number of patients taking medications who had QTc values in normal, borderline, abnormal, or high were also calculated. RESULTS: Mean QTc values for all medications were in the normal range. The highest mean QTc was in patients on escitalopram (436 milliseconds). The mean QTc for sertraline (416 milliseconds) was significantly lower than all other drugs measured (t(331) = -2.21, p < .05). After controlling for confounding effects, none of the differences in mean QTc compared with other study drugs reached statistical significance. The greatest percentages of abnormal and high QTc values were found among patients taking paroxetine (18.8%), followed by escitalopram (15.4%). None of the children had documented ventricular arrhythmia. CONCLUSION: The results suggest that most antidepressants are not associated with prolonged QTc at doses typically prescribed for children.

Functional and structural brain correlates of risk for major depression in children with familial depression.

Despite growing evidence for atypical amygdala function and structure in major depression, it remains uncertain as to whether these brain differences reflect the clinical state of depression or neurobiological traits that predispose individuals to major depression. We examined function and structure of the amygdala and associated areas in a group of unaffected children of depressed parents (at-risk group) and a group of children of parents without a history of major depression (control group). Compared to the control group, the at-risk group showed increased activation to fearful relative to neutral facial expressions in the amygdala and multiple cortical regions, and decreased activation to happy relative to neutral facial expressions in the anterior cingulate cortex and supramarginal gyrus. At-risk children also exhibited reduced amygdala volume. The extensive hyperactivation to negative facial expressions and hypoactivation to positive facial expressions in at-risk children are consistent with behavioral evidence that risk for major depression involves a bias to attend to negative information. These functional and structural brain differences between at-risk children and controls suggest that there are trait neurobiological underpinnings of risk for major depression.

Emotion regulation ability varies in relation to intrinsic functional brain architecture.

This study investigated the neural basis of individual variation in emotion regulation, specifically the ability to reappraise negative stimuli so as to down-regulate negative affect. Brain functions in young adults were measured with functional Magnetic Resonance Imaging during three conditions: (i) attending to neutral pictures; (ii) attending to negative pictures and (iii) reappraising negative pictures. Resting-state functional connectivity was measured with amygdala and dorsolateral prefrontal cortical (DLPFC) seed regions frequently associated with emotion regulation. Participants reported more negative affect after attending to negative than neutral pictures, and less negative affect following reappraisal. Both attending to negative vs neutral pictures and reappraising vs attending to negative pictures yielded widespread activations that were significantly right-lateralized for attending to negative pictures and left-lateralized for reappraising negative pictures. Across participants, more successful reappraisal correlated with less trait anxiety and more positive daily emotion, greater activation in medial and lateral prefrontal regions, and lesser resting-state functional connectivity between (a) right amygdala and both medial prefrontal and posterior cingulate cortices, and (b) bilateral DLPFC and posterior visual cortices. The ability to regulate emotion, a source of resilience or of risk for distress, appears to vary in relation to differences in intrinsic functional brain architecture.

Can unipolar and bipolar pediatric major depression be differentiated from each other? A systematic review of cross-sectional studies examining differences in unipolar and bipolar depression.

INTRODUCTION: While pediatric mania and depression can be distinguished from each other, differentiating between unipolar major depressive disorder (unipolar MDD) and bipolar major depression (bipolar MDD) poses unique clinical and therapeutic challenges. Our aim was to examine the current body of knowledge on whether unipolar MDD and bipolar MDD in youth could be distinguished from one another in terms of clinical features and correlates. METHODS: A systematic literature search was conducted on studies assessing the clinical characteristics and correlates of unipolar MDD and bipolar MDD in youth. RESULTS: Four scientific papers that met our priori inclusion and exclusion criteria were identified. These papers reported that bipolar MDD is distinct from unipolar MDD in its higher levels of depression severity, associated impairment, psychiatric co-morbidity with oppositional defiant disorder, conduct disorder and anxiety disorders, and family history of mood and disruptive behavior disorders in first-degree relatives. LIMITATIONS: Though we examined a sizeable and diverse sample, we were only able to identify four cross sectional informative studies in our review. Therefore, our conclusions should be viewed as preliminary. CONCLUSIONS: These findings can aid clinicians in differentiating the two forms of MDD in youth.

Can manic switches be predicted in pediatric major depression? A systematic literature review.

BACKGROUND: The rate of switching from major depression to bipolar disorder is high in children. Predicting who is at risk for switching poses unique challenges and is of high clinical relevance. Our aim was to examine the existing scientific literature elucidating if certain clinical correlates predict ultimate bipolar switches in children initially presenting with a depressive episode. METHODS: We conducted a systematic literature search of studies assessing the risk factors for bipolar switching in youth. In all, seven studies fit our a priori criteria and were thus included in our qualitative review. RESULTS: Together, these papers found that manic switches in pediatric depression can be predicted by several risk factors, including positive family history of mood disorders, emotional and behavioral dysregulation, subthreshold mania, and psychosis. LIMITATIONS: We identified only seven prospective informative studies for our review. The majority of subjects included in these studies were referred and Caucasian. Thus, the results may not generalize to other community samples and other ethnicities. CONCLUSIONS: These findings can help alert clinicians of the risk of manic switches.

Glutamatergic dysregulation in pediatric psychiatric disorders: a systematic review of the magnetic resonance spectroscopy literature.

OBJECTIVE: As the major excitatory neurotransmitter in the brain, glutamate plays a critical role in normal brain function; thus, its dysregulation could lead to psychopathology in youth. A growing body of literature has investigated the role of glutamate in the pathophysiology of childhood psychiatric disorders through magnetic resonance spectroscopy (MRS). The aim of this study was to review the existing literature to gauge the specificity of such findings. DATA SOURCES: PubMed was searched for all scientific, peer-reviewed articles published in English that included MRS measurements of glutamatergic metabolites in pediatric psychiatric populations through August 14, 2013. STUDY SELECTION: 50 articles were included in this review. These studies included measurements of glutamate or related metabolites with MRS in children with psychiatric disorders. DATA EXTRACTION: All relevant data (eg, population; number, sex, and age of subjects; method of comparison; treatment history; MRS Tesla; brain regions of interest; glutamatergic findings; other findings; and comorbidities) were extracted from the included articles. The direction and significance of glutamate dysregulation and brain region(s) examined were used to compare the studies. RESULTS: Most consistently, increases in glutamatergic metabolites were found in the anterior cingulate cortex (ACC) and other regions in youth with attention-deficit/hyperactivity disorder (ADHD). Limited data suggested increases in glutamatergic metabolites in youth with autism spectrum disorders, emotional dysregulation, and high risk for schizophrenia and decreases in youth with major depression, bipolar disorder, and obsessive-compulsive disorder. There was limited but consistent evidence for normalization of glutamatergic levels with treatment, particularly in bipolar disorder and ADHD. CONCLUSIONS: A relatively small number of studies have examined the role of glutamatergic dysregulation in pediatric psychiatric disorders. Some consistencies can be found, but interpretation of the data is limited by differences in methodology, including age of subjects, severity of current symptoms, treatment, and scanning parameters.

Mild traumatic brain injury and ADHD: a systematic review of the literature and meta-analysis.

OBJECTIVE: This study investigated the association between mild traumatic brain injury (mTBI) and ADHD, which increases risk of injuries and accidents. METHOD: We conducted a systematic review and meta-analysis of studies that examined the relationship between mTBI and ADHD. RESULTS: Five studies, comprising 3,023 mTBI patients and 9,716 controls, fit our a priori inclusion and exclusion criteria. A meta-analysis found a significant association between ADHD and mTBI, which was significant when limited to studies that reported on ADHD subsequent to mTBI and when the direction of the association was not specified, but not for studies that reported mTBI subsequent to ADHD. Heterogeneity of effect size and publication biases were not evident. CONCLUSION: The literature documents a significant association between mTBI and ADHD. Further clarification of the relationship and direction of effect between mTBI and ADHD and treatment implications could have large clinical, scientific, and public health implications.

Further evidence that severe scores in the aggression/anxiety-depression/attention subscales of child behavior checklist (severe dysregulation profile) can screen for bipolar disorder symptomatology: a conditional probability analysis.

BACKGROUND: Previous work shows that children with high scores (2SD, combined score≥210) on the Attention Problems, Aggressive Behavior, and Anxious-Depressed (A-A-A) subscales of the Child Behavior Checklist (CBCL) are more likely than other children to meet criteria for bipolar (BP)-I disorder. However, the utility of this profile as a screening tool has remained unclear. METHODS: We compared 140 patients with pediatric BP-I disorder, 83 with attention deficit hyperactivity disorder (ADHD), and 114 control subjects. We defined the CBCL-Severe Dysregulation profile as an aggregate cutoff score of ≥210 on the A-A-A scales. Patients were assessed with structured diagnostic interviews and functional measures. RESULTS: Patients with BP-I disorder were significantly more likely than both control subjects (Odds Ratio [OR]: 173.2; 95% Confidence Interval [CI], 21.2 to 1413.8; P<0.001) and those with ADHD (OR: 14.6; 95% CI, 6.2 to 34.3; P<0.001) to have a positive CBCL-Severe Dysregulation profile. Receiver Operating Characteristics analyses showed that the area under the curve for this profile comparing children with BP-I disorder against control subjects and those with ADHD was 99% and 85%, respectively. The corresponding positive predictive values for this profile were 99% and 92% with false positive rates of <0.2% and 8% for the comparisons with control subjects and patients with ADHD, respectively. LIMITATIONS: Non-clinician raters administered structured diagnostic interviews, and the sample was referred and largely Caucasian. CONCLUSIONS: The CBCL-Severe Dysregulation profile can be useful as a screen for BP-I disorder in children in clinical practice.

Autistic traits in children with and without ADHD.

OBJECTIVE: To assess the implications of autistic traits (ATs) in youth with attention-deficit/hyperactivity disorder (ADHD) without a diagnosis of autism. METHODS: Participants were youth with (n = 242) and without (n = 227) ADHD and controls without ADHD in whom a diagnosis of autism was exclusionary. Assessment included measures of psychiatric, psychosocial, educational, and cognitive functioning. ATs were operationalized by using the withdrawn + social + thought problems T scores from the Child Behavior Checklist. RESULTS: A positive AT profile was significantly overrepresented among ADHD children versus controls (18% vs 0.87%; P < .001). ADHD children with the AT profile were significantly more impaired than control subjects in psychopathology, interpersonal, school, family, and cognitive domains. CONCLUSIONS: A substantial minority of ADHD children manifests ATs, and those exhibiting ATs have greater severity of illness and dysfunction.