Child, parent, and family mental health and functioning in Australia during COVID-19: comparison to pre-pandemic data.

The COVID-19 pandemic presents significant risks to population mental health. Despite evidence of detrimental effects for adults, there has been limited examination of the impact of COVID-19 on parents and children specifically. We aim to examine patterns of parent and child (0-18 years) mental health, parent substance use, couple conflict, parenting practices, and family functioning during COVID-19, compared to pre-pandemic data, and to identify families most at risk of poor outcomes according to pre-existing demographic and individual factors, and COVID-19 stressors. Participants were Australian mothers (81%) and fathers aged 18 years and over who were parents of a child 0-18 years (N = 2365). Parents completed an online self-report survey during 'stage three' COVID-19 restrictions in April 2020. Data were compared to pre-pandemic data from four Australian population-based cohorts. Compared to pre-pandemic estimates, during the pandemic period parents reported higher rates of parent depression, anxiety, and stress (Cohen's d = 0.26-0.81, all p < 0.001), higher parenting irritability (d = 0.17-0.46, all p < 0.001), lower family positive expressiveness (d = - 0.18, p < 0.001), and higher alcohol consumption (22% vs 12% drinking four or more days per week, p < 0.001). In multivariable analyses, we consistently found that younger parent age, increased financial deprivation, pre-existing parent and child physical and mental health conditions, COVID-19 psychological and environmental stressors, and housing dissatisfaction were associated with worse parent and child functioning and more strained family relationships. Our data suggest wide-ranging, detrimental family impacts associated with the COVID-19 pandemic; and support policy actions to assist families with financial supports, leave entitlements, and social housing.

Sustained impact of a sleep intervention and moderators of treatment outcome for children with ADHD: a randomised controlled trial.

BACKGROUND: We aim to (1) determine whether a behavioural sleep intervention for children with attention-deficit/hyperactivity disorder (ADHD) leads to sustained benefits; and (2) examine the factors associated with treatment response. METHODS: This study was a randomised controlled trial of 244 children (5-13 years) with ADHD from Victoria, Australia. All participants had a moderate/severe sleep problem that met American Academy of Sleep Medicine criteria for an eligible sleep disorder by parent report. The two-session intervention covered sleep hygiene and standardised behavioural strategies. The control group received usual care. Parent- and teacher-reported outcomes at 12 months included sleep, ADHD severity, quality of life, daily functioning, behaviour, and parent mental health. Adjusted mixed effects regression analyses examined 12 month outcomes. Interaction analyses were used to determine moderators of intervention outcomes over time. The trial was registered with ISRCTN, http://www.controlled-trials.com (ISRCTN68819261). RESULTS: Intervention children were less likely to have a moderate/severe sleep problem by parent report at 12 months compared to usual care children (28.4% v. 46.5%, p = 0.03). Children in the intervention group fared better than the usual care group in terms of parent-reported ADHD symptoms (Cohen's d: -0.3, p < 0.001), quality of life (d: 0.4, p < 0.001), daily functioning (d: -0.5, p < 0.001), and behaviour (d: -0.3, p = 0.005) 12 months later. The benefits of the intervention over time in terms of sleep were less for children not taking ADHD medication and children with parents experiencing depression. CONCLUSIONS: A behavioural sleep intervention for ADHD is associated with small sustained improvements in child wellbeing. Children who are not taking ADHD medication or have parents with depression may require follow-up booster sleep sessions.

Does a brief, behavioural intervention, delivered by paediatricians or psychologists improve sleep problems for children with ADHD? Protocol for a cluster-randomised, translational trial.

INTRODUCTION: Up to 70% of children with attention-deficit/hyperactivity disorder (ADHD) experience sleep problems. We have demonstrated the efficacy of a brief behavioural intervention for children with ADHD in a large randomised controlled trial (RCT) and now aim to examine whether this intervention is effective in real-life clinical settings when delivered by paediatricians or psychologists. We will also assess the cost-effectiveness of the intervention. METHODS AND ANALYSIS: Children aged 5-12 years with ADHD (n=320) are being recruited for this translational cluster RCT through paediatrician practices in Victoria and Queensland, Australia. Children are eligible if they meet criteria for ADHD, have a moderate/severe sleep problem and meet American Academy of Sleep Medicine criteria for either chronic insomnia disorder or delayed sleep-wake phase disorder; or are experiencing sleep-related anxiety. Clinicians are randomly allocated at the level of the paediatrician to either receive the sleep training or not. The behavioural intervention comprises 2 consultations covering sleep hygiene and standardised behavioural strategies. The primary outcome is change in the proportion of children with moderate/severe sleep problems from moderate/severe to no/mild by parent report at 3 months postintervention. Secondary outcomes include a range of child (eg, sleep severity, ADHD symptoms, quality of life, behaviour, working memory, executive functioning, learning, academic achievement) and primary caregiver (mental health, parenting, work attendance) measures. Analyses will address clustering at the level of the paediatrician using linear mixed effect models adjusting for potential a priori confounding variables. ETHICS AND DISSEMINATION: Ethics approval has been granted. Findings will determine whether the benefits of an efficacy trial can be realised more broadly at the population level and will inform the development of clinical guidelines for managing sleep problems in this population. We will seek to publish in leading international paediatric journals, present at major conferences and through established clinician networks. TRIAL REGISTRATION NUMBER: ISRCTN50834814, Pre-results.

Children referred for evaluation for ADHD: comorbidity profiles and characteristics associated with a positive diagnosis.

BACKGROUND: The symptoms of attention-deficit/hyperactivity disorder (ADHD) are non-specific, and a range of possible causes and comorbidities need to be considered in children referred for assessment. OBJECTIVE: To examine the factors associated with ADHD diagnosis following multidisciplinary assessment. METHODS: Children underwent multidisciplinary evaluation including parent and teacher questionnaires; semi-structured interview to screen for internalizing and externalizing diagnoses; paediatric, psychology and special education assessments; and case conference. Predictors of ADHD diagnosis were examined in univariable and multivariable logistic regression models. RESULTS: Data from 190 assessments (82% male, mean age 6.8 years) were included. ADHD was diagnosed in 132 (70%) cases, of which 77% had one or more comorbidities. In children not diagnosed with ADHD, 60% had one or more alternate diagnosis made. Teacher-reported ADHD symptom severity and learning difficulties were the strongest predictors of ADHD diagnosis. The pattern of comorbid/alternative diagnoses was similar between those diagnosed with ADHD and those not diagnosed with ADHD. CONCLUSIONS: Direct report from teachers is the most critical element of the clinical dataset for the evaluation for ADHD. These findings emphasize the importance of cross-situational impairment to ADHD diagnosis. The frequency and similarity of diagnoses in both groups highlight the overlapping nature of childhood developmental disorders, and the importance of evaluating for comorbid disorders regardless of the primary diagnosis.

Health-related impairments in young children with ADHD: a community-based study.

BACKGROUND: We aimed to examine health-related impairments in young children with attention-deficit/hyperactivity disorder (ADHD) and non-ADHD controls and explore differences in children with ADHD by gender, ADHD subtype and mental health co-morbidity status. METHODS: Children with ADHD (n = 177) and controls (n = 212) aged 6-8 years were recruited across 43 schools in Melbourne, Australia following a screening (Conners 3 ADHD Index) and case confirmation procedure (Diagnostic Interview Schedule for Children IV). Direct and blinded assessments of height and weight were used to calculate body mass index z-score and to identify overweight/obesity. Parents reported on child global health, sleep problems and physical injuries. Unadjusted and adjusted (socio-demographic factors and co-morbidities) logistic and linear regression were conducted to compare health-related impairments between (1) children with and without ADHD; (2) boys and girls with ADHD; (3) children with ADHD-inattentive and ADHD-combined types; and (4) children with ADHD by internalizing and externalizing disorder status. RESULTS: Children with ADHD had poorer global health than controls when adjusted for socio-demographic characteristics (OR: 2.0; 95% CI 1.1, 3.9); however, this attenuated after adjusting for co-morbidities. In adjusted analyses, children with ADHD had increased odds of moderate/large sleep problems (OR: 3.1; 95% CI 1.4, 6.8), compared with controls. There were no differences between children with and without ADHD in terms of physical injuries or overweight/obesity. Findings were similar when excluding children taking ADHD medication, and health-related impairments did not differ between boys and girls with ADHD. Children with ADHD-combined type had higher BMI z-scores than controls in adjusted analyses (P = 0.04). Children with ADHD and co-occurring internalizing and externalizing co-morbidities were particularly vulnerable to health-related impairments. CONCLUSION: Young children with ADHD experience a number of health-related impairments, which are exacerbated by the presence of internalizing and externalizing co-morbidities. Clinicians should consider the broader health of children with ADHD in clinical consultations.

Association between sleep and working memory in children with ADHD: a cross-sectional study.

OBJECTIVE/BACKGROUND: This study aimed to examine the relationship between sleep problems and working memory in children aged 5-13 years with attention-deficit/hyperactivity disorder (ADHD). PATIENTS/METHODS: Children with ADHD were recruited into a randomized controlled trial from 21 paediatric practices in VIC, Australia. Cross-sectional data for intervention and control children were pooled at 6 months post randomization for the current analyses (n = 189). Children who met the Diagnostic Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for ADHD and had a parent-reported moderate/severe sleep problem that fulfilled diagnostic criteria for a behavioural sleep disorder were recruited into the study. Sleep was assessed by detailed parent (Children's Sleep Habits Questionnaire) and self-reports (Self-Sleep Report). Working memory was measured using the Working Memory Test Battery for Children (low and very low working memory defined as <25th and <10th percentiles, respectively). Analyses were adjusted for child age and gender, internalizing and externalizing comorbidities, and socio-economic status. RESULTS: Self-reported sleep problem severity was associated with poorer working memory; for each standard deviation increase in self-reported sleep problems, working memory scores decreased by -3.8 points (95% confidence interval (CI): -6.7, -0.8; p = 0.01). There was some evidence that self-reported sleep problems were associated with low (p = 0.06) and very low working memory (p = 0.01). There was minimal evidence that parent-reported sleep problems were associated with poorer working memory with the exception of bedtime resistance problems. CONCLUSIONS: Behavioural sleep problems and working memory are associated in children with ADHD, particularly when sleep is assessed by self-report.

Behavioural sleep problems in children with attention-deficit/hyperactivity disorder (ADHD): protocol for a prospective cohort study.

INTRODUCTION: Children with attention-deficit/hyperactivity disorder (ADHD) commonly experience behavioural sleep problems, yet these difficulties are not routinely assessed and managed in this group. Presenting with similar symptoms to ADHD itself, sleep problems are complex in children with ADHD and their aetiology is likely to be multifactorial. Common internalising and externalising comorbidities have been associated with sleep problems in children with ADHD; however, this relationship is yet to be fully elucidated. Furthermore, limited longitudinal data exist on sleep problems in children with ADHD, thus their persistence and impact remain unknown. In a diverse sample of children with ADHD, this study aims to: (1) quantify the relationship between sleep problems and internalising and externalising comorbidities; (2) examine sleep problem trajectories and risk factors; and (3) examine the longitudinal associations between sleep problems and child and family functioning over a 12-month period. METHODS AND ANALYSIS: A prospective cohort study of 400 children with ADHD (150 with no/mild sleep problems, 250 with moderate/severe sleep problems) recruited from paediatric practices across Victoria, Australia. The children's parents and teacher provide data at baseline and 6-month and 12-month post enrolment. KEY MEASURES: Parent report of child's sleep problem severity (no, mild, moderate, severe); specific sleep domain scores assessed using the Child Sleep Habits Questionnaire; internalising and externalising comorbidities assessed by the Anxiety Disorders Interview Schedule for Children IV/Parent version. ANALYSES: Multiple variable logistic and linear regression models examining the associations between key measures, adjusted for confounders identified a priori. ETHICS AND DISSEMINATION: Ethics approval has been granted. Findings will contribute to our understanding of behavioural sleep problems in children with ADHD. Clinically, they could improve the assessment and management of sleep problems in this group. We will seek to publish in leading paediatric journals, present at conferences and inform Australian paediatricians through the Australian Paediatric Research Network.

Paediatricians' decision making about prescribing stimulant medications for children with attention-deficit/hyperactivity disorder.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is now the most common reason for a child to present to a paediatrician in Australia. Stimulant medications are commonly prescribed for children with ADHD, to reduce symptoms and improve function. In this study we investigated the factors that influence paediatricians' decisions about prescribing stimulant medications. METHOD: In-depth, semi-structured interviews were conducted with paediatricians (n = 13) who were purposively recruited so as to sample a broad demographic of paediatricians working in diverse clinical settings. Paediatricians were recruited from public outpatient and private paediatrician clinics in Victoria, Australia. The interviews were audio-recorded and transcribed verbatim for thematic analysis. Paediatricians also completed a questionnaire describing their demographic and practice characteristics. RESULTS: Our findings showed that the decision to prescribe is a dynamic process involving two key domains: (1) weighing up clinical factors; and (2) interacting with parents and the patient along the journey to prescribing. Five themes relating to this process emerged from data analysis: comprehensive assessments that include history, examination and information from others; influencing factors such as functional impairment and social inclusion; previous success; facilitating parental understanding including addressing myths and parental confusion; and decision-making model. CONCLUSIONS: Paediatricians' decisions to prescribe stimulant medications are influenced by multiple factors that operate concurrently and interdependently. Paediatricians do not make decisions about prescribing in isolation; rather, they actively involve parents, teachers and patients, to arrive at a collective, well-informed decision.