Leveraging expertise and optimizing clinical research: Initial success of a pediatric epilepsy surgery collaborative.

OBJECTIVE: Improve data-driven research to inform clinical decision-making with pediatric epilepsy surgery patients by expanding the Pediatric Epilepsy Research Consortium Epilepsy Surgery (PERC-Surgery) Workgroup to include neuropsychological data. This article reports on the process and initial success of this effort and characterizes the cognitive functioning of the largest multi-site pediatric epilepsy surgery cohort in the United States. METHODS: Pediatric neuropsychologists from 18 institutions completed surveys regarding neuropsychological practice and the impact of involvement in the collaborative. Neuropsychological data were entered through an online database. Descriptive analyses examined the survey responses and cognitive functioning of the cohort. Statistical analyses examined which patients were evaluated and if composite scores differed by domain, demographics, measures used, or epilepsy characteristics. RESULTS: Positive impact of participation was evident by attendance, survey responses, and the neuropsychological data entry of 534 presurgical epilepsy patients. This cohort, ages 6 months to 21 years, were majority White and non-Hispanic, and more likely to have private insurance. Mean intelligence quotient (IQ) scores were below to low average, with weaknesses in working memory and processing speed. Full-scale IQ (FSIQ) was lowest for patients with younger age at seizure onset, daily seizures, and magnetic resonance imaging (MRI) abnormalities. SIGNIFICANCE: We established a collaborative network and fundamental infrastructure to address questions outlined by the Epilepsy Research Benchmarks. There is a wide range in the age and IQ of patients considered for pediatric epilepsy surgery, yet it appears that social determinants of health impact access to care. Consistent with other national cohorts, this US cohort has a downward shift in IQ associated with seizure severity.

Neuropsychological assessment in pediatric oncology survivorship care: utilization of services, results of evaluation, and educational and behavioral health outcomes.

PURPOSE: Neuropsychological evaluation has become a standard component of long-term follow-up care for survivors of pediatric cancer. The purpose of the present study was to examine access to, and benefits of, neuropsychological evaluation for survivors. METHODS: A retrospective chart review was conducted on cancer survivors who were referred for neuropsychological evaluation from a multidisciplinary long-term follow-up (LTFU) clinic approximately 5 years following treatment cessation. Descriptive statistics were calculated, and t-tests and chi-square analyses were utilized to examine variables that may impact survivors' access to neuropsychological services. RESULTS: One hundred seven survivors between 6 and 26 years old were referred for a neuropsychological evaluation. Referred male patients were less likely than female patients to schedule an evaluation. Consultation with a neuropsychologist in the LTFU clinic was related to more referrals but did not improve attrition rates (55%). Twenty-four percent of evaluated patients displayed severe cognitive impairment and 75% were diagnosed with a psychological disorder. Utilization of educational and behavioral health services did not significantly change following evaluation. CONCLUSION: Survivors' utilization of neuropsychological services is lower for males than females. The presence of a neuropsychologist in a multidisciplinary team clinic can improve identification of survivors that may benefit from neuropsychological evaluation. Many survivors did not receive recommended services, suggesting patients and families may need additional supports following evaluation. Future research should focus on improving survivors' access to neuropsychological services and identifying barriers to receiving recommended services.

Predictors of behavioral dysregulation and social dysfunction in pediatric patients with epilepsy and obesity: Developmental timing matters.

Childhood obesity has been associated with greater risks of psychopathology, including externalizing behaviors and social dysfunction. However, there has been limited research on the effect of obesity on psychosocial functioning among pediatric patients with epilepsy. Accordingly, this study aimed to examine the association between overweight/obesity and behavioral and social functioning among pediatric patients with epilepsy, as function of their developmental status. We completed a retrospective chart review of data (seizure factors, intellectual functioning, caregiver ratings of aggression/defiance and social problems, sex- and age-adjusted body mass index (BMI) percentile) from 30 school-age children and 30 adolescents with epilepsy evaluated through our institute. Body mass index percentile and overweight/obesity status were not associated with seizure variables. Despite controlling for intellectual functioning, overweight/obesity was associated with greater aggression/defiance among child patients but not adolescents. In contrast, adolescence, but not weight status, was associated with social dysfunction. In brief, while early interventions focused on behavior and weight management among children with epilepsy may mitigate risk of aggression and oppositional behavior, among adolescent patients, therapies directed towards promoting interpersonal skills, sense of social competency, and expansion of social support system may reduce psychosocial maladjustment. Findings highlight need to understand the developmental effects of common medical comorbidities on neurobehavioral functioning among youth with epilepsy.

Changes in neuropsychological and behavioral functioning in children with and without obstructive sleep apnea following Tonsillectomy.

The most common treatment for sleep disordered breathing (SDB) is adenotonsillectomy (AT). Following AT, SDB resolves in most cases, and gains in cognitive and behavior scores are consistently reported, although persistent neuropsychological deficits or further declines also have been noted. This study presents results of the comprehensive 1-year follow-up neuropsychological examinations for children in the Washtenaw County Adenotonsillectomy Cohort I (95% return rate). After adjusting for normal developmental and practice-effect related changes in control children, significant improvements 1 year following AT were noted in polysomnography and sleepiness, as well as parental reports of behavior, although cognitive outcomes were mixed. Children undergoing AT with and without polysomnography-confirmed obstructive sleep apnea improved across a range of academic achievement measures, a measure of delayed visual recall, short-term attention/working memory, and executive functioning, along with parental ratings of behavior. On the other hand, measures of verbal abstraction ability, arithmetic calculations, visual and verbal learning, verbal delayed recall, sustained attention, and another measure of visual delayed recall demonstrated declines in ability, while other measures did not improve over time. These findings call into question the expectation that AT resolves most or all behavioral and cognitive difficulties in children with clinical, office-based diagnoses of SDB.

Potential risk factors for cigarette use among a sample of college JUUL users.

Objective: To examine the relationship between demographics, other tobacco use, and JUUL dependency on combustible cigarette use among college JUUL users. Participants: Undergraduates (n = 595) at a large southwestern university who used JUUL weekly completed a cross-sectional online survey in March 2019. Methods: Logistic regressions examined associations between covariates and ever use/past 30-day use of cigarettes. Results: As age increased, odds of ever trying a cigarette increased (AOR = 1.87; 95% CI = 1.45-2.41); however, as age of JUUL initiation increased, odds of ever (AOR = 0.80; 95% CI = 0.65-0.99) or past 30-day (AOR = 0.78; 95% CI = 0.63-0.97) cigarette use decreased. Those moderately (AOR = 2.03; 95% CI = 1.07-3.82) or highly (AOR = 8.01; 95% CI = 3.08-20.83) dependent on JUUL were more likely to have tried cigarettes than those not dependent. However, dependence was not associated with past 30-day use. Conclusions: JUUL users may not transition to combustible cigarettes during college. Longitudinal studies are needed to examine transitions in JUUL users' tobacco product use after college.

Use of continuation or maintenance electroconvulsive therapy in adolescents with severe treatment-resistant depression.

Retrospective data are presented for 6 adolescents ranging in age from 14 to 17 years, who were diagnosed with severe treatment-resistant major depression (TRD). Subjects were treated with one or more index courses of electroconvulsive therapy (ECT) followed by continuation ECT (C-ECT, up to 6 months of ECT) or maintenance ECT (M-ECT; ECT beyond 6 months) when necessary. Electroconvulsive therapy was continued until remission or until minimal residual symptoms were evident. Pharmacotherapy and psychotherapy were reintroduced during C-ECT or M-ECT. Premorbid functioning was achieved by 5 of 6 cases. Cognitive deficits were not evident. In fact, comparison of pre-ECT and post-ECT neuropsychological functioning revealed a trend toward improved auditory and verbal memory on most of the results. We concluded that C-ECT and M-ECT are useful and safe treatment strategies for selected adolescents with severe treatment-resistant depression, and symptom remission may be achieved without experiencing cognitive impairment.

Associations Between ADHD Subtype Symptomatology and Social Functioning in Children With ADHD, Autism Spectrum Disorder, and Comorbid Diagnosis: Utility of Diagnostic Tools in Treatment Considerations.

Objective: To assess associations between objective-/caregiver-report measures of attention functioning and social impairment among children with ADHD, autism spectrum disorder (ASD), and co-occurring ASD + ADHD. Method: Patients with ADHD (N = 27), ASD (N = 23), and ASD + ADHD (N = 44) completed measures of intellectual functioning (Wechsler tests) and attention functioning (Continuous Performance Test-Second Edition [CPT-II]) as part of a neurocognitive assessment. Caregivers completed the Conners Third Edition to assess day-to-day inattentiveness, hyperactivity/impulsivity, and the Social Responsiveness Scale (SRS) to assess social functioning. Results: Among patients with ADHD, attention measures contributed to 48% of the variance in total SRS scores, with caregiver-reported hyperactivity/impulsivity as the strongest factor. In contrast, among those with ASD + ADHD, attention measures accounted for 40% of the variance, largely due to inattention problems. No associations between domains were observed among patients with ASD. Conclusion: Differential ADHD symptoms are associated with social impairment among children with ADHD versus ASD + ADHD; whereas, no associations were observed among those with ASD.

Sleep and neurobehavioral functioning in survivors of pediatric cancer.

OBJECTIVES: Sleep problems are a common late effect in survivors of pediatric cancer. Growing literature suggests deficits in sleep functioning may be related to more impairing neurobehavioral outcomes. The purpose of the present study was to evaluate the prevalence of parent reported sleep concerns in survivors of pediatric cancer, as well as evaluate the relationship between sleep and neurobehavioral functioning utilizing both parent and teacher input. METHODS: The study included parent-teacher dyads of 75 survivors of pediatric cancer between the ages of six and 17 who completed a clinical neuropsychological evaluation with embedded measures of neurobehavioral functioning and sleep, including excessive daytime sleepiness and snoring. Bivariate correlations and multiple linear regressions were conducted to evaluate the relationship between sleep and neurobehavioral functioning. RESULTS: No significant difference in parent reported sleep concerns was found with regard to demographic, diagnostic, or treatment variables. Daytime sleepiness was significantly elevated for 28% of the sample; snoring was not identified as a significant concern. Daytime sleepiness was significantly associated with worse neurobehavioral outcomes as reported by parents and teachers, including inattention, hyperactivity/impulsivity, peer difficulties, anxiety, depression, somatic complaints, and aggressive behaviors. Daytime sleepiness was not significantly related to report of learning problems. CONCLUSIONS: Results further support that daytime sleepiness, as reported by parents, impacts approximately one third of survivors of pediatric cancer and is associated with worse neurobehavioral outcomes across home and school environments. As a result, it is vital that sleep functioning is a target of assessment in annual survivorship care. Future longitudinal studies are needed to further delineate the directionality of the sleep-neurobehavioral relationship in survivors.

Young Adult JUUL Users' Beliefs About JUUL.

PURPOSE: The purpose of this study was to test beliefs (risks to individual health, tobacco industry affiliation, and harm to others) with young adult current JUUL users to prompt decreased JUUL use. METHODS: An explanatory sequential mixed-method design was used. Undergraduates aged 18-24 years at a large southwest university who owned and used a JUUL at least once a week completed an online survey (n = 667) in March 2019. Participant reactions to 6 JUUL-specific statements (harm to lungs and brain, tobacco industry ownership, communication device inside JUUL, harm to others and the environment) were assessed. Then, 51 participants completed an in-person interview 1-2 weeks later to explain what influenced their responses. RESULTS: Across beliefs, females were more likely and those who used other tobacco products were less likely to say they would reduce JUUL use. Beliefs about harm to the brain, others, and the environment had the most influence on interview participants. Tobacco industry affiliation with JUUL was not viewed negatively and likely would not affect participant decisions. CONCLUSIONS: Messaging developed for other tobacco products may not have the same impact with young adult JUUL users. These findings provide guidance to tobacco use regulators by informing marketing message regulations to prevent initiation or prolonged use of JUUL and other pod-based products.

Neurocognitive Profiles of Pediatric Patients with ESES, Generalized Epilepsy, or Focal Epilepsy.

To date, the neurocognitive profile and comorbid psychiatric risks associated with ESES, a syndrome that commonly coincides with a seizure disorder, in contrast to generalized or partial/focal epilepsy without ESES remains unclear. Accordingly, this preliminary study aimed to characterize the neurocognitive differences across pediatric patients with ESES, generalized or focal epilepsy, and risk for comorbid diagnoses (mood disorder, autism, intellectual disability, learning disability, ADHD). We included data from a total of 79 pediatric patients, including those with recently diagnosed ESES (N = 12), generalized epilepsy (GE, N = 25), left focal epilepsy (LFE; N = 20), or right focal epilepsy (RFE; N = 22). All patients completed a neurocognitive evaluation as part of their medical workup and treatment for epilepsy. Cognitive domains assessed include intellectual functioning, verbal/non-verbal reasoning, working memory, processing speed, receptive language, learning and memory. Results showed that children with GE performed more poorly across intellectual functioning, verbal and non-verbal reasoning, working memory, processing speed, and receptive vocabulary; whereas, these areas were most preserved among those with RFE. Working memory and processing speed among those recently diagnosed with ESES was also modestly stronger compared to the GE group. A greater proportion of patients with GE met diagnostic criteria for a learning disability relative to other epilepsy types, although the rates of ADHD, autism spectrum, intellectual disability, and mood disorder were comparable across groups. Findings provide supporting evidence that GE may be associated with greater cognitive risks when refractory to treatment, highlighting the need for earlier intervention services to circumvent adverse effects on adaptive and behavioral functioning. Neuropsychological differences between ESES versus other epilepsy subtypes may emerge as a late-effect of the neurological condition and/or related medication treatment, implicating a greater need for developmentally focused investigations.

Addiction vs. dependence: A mixed methods analysis of young adult JUUL users.

OBJECTIVE: JUUL-brand electronic cigarettes (e-cigarettes) contain higher levels of nicotine than other e-cigarettes. The current study examined the relationship between young adults' self-reported addiction and measured JUUL dependence. METHODS: This study used a sequential, explanatory mixed methods design. Data were collected from a large, southwestern college in the US. College students who were weekly JUUL users and owned a JUUL device (n = 595) completed a cross-sectional online survey, then a subsample (n = 51) participated in in-person interviews. All data were collected between March-April 2019. T-tests were used to examine differences between JUUL dependence and self-reported addiction, and logistic regressions were employed to examine factors that may influence self-reported addiction to JUUL, nicotine, and other e-cigarettes. Interviews were independently coded by 2 coders (kappa ranged from 0.46 to 0.99) then analyzed for corresponding themes. RESULTS: Participants who had a higher JUUL dependence were more likely to report addiction to several substances/products, including nicotine, JUULs, cigarettes, other e-cigarettes, alcohol, and marijuana. Interview participants minimized JUUL addiction by comparing JUUL to other socially acceptable addictions and describing JUUL addiction as a habit. Interview participants suggested addiction to nicotine was more stigmatizing than JUUL. The number of days participants used JUUL per week, use of traditional tobacco products, and measured JUUL dependence were each associated with self-reported JUUL addiction. CONCLUSIONS: Social construction of self-reported addictions may be changing young audiences' views of addiction to JUUL. Research is needed to see if using the phrase 'nicotine dependence' rather than 'JUUL addiction' influences young adults' JUUL use.

Brief Report: Neuropsychological Testing and Informant-Ratings of Children with Autism Spectrum Disorder, Attention-Deficit/Hyperactivity Disorder, or Comorbid Diagnosis.

This study aimed to examine the neuropsychological correlates of child patients diagnosed with ADHD, autism spectrum disorder (ASD), or comorbid ASD + ADHD through a multidisciplinary ASD evaluation clinic. Patients completed standardized tests of intellectual, attention, social-affective/cognitive, and executive functioning; and a semi-structured assessment commonly used for autism diagnosis. The majority of patients were medicated for ADHD concerns during testing. Parents and teachers also completed inventories of day-to-day social and attentional functioning. Group effects were found across objective social measures but not across related respondent-ratings. In contrast, group differences were observed in parent-ratings of attention difficulties, but not on standardized tests of attention or executive functioning. Findings underscore importance of integrating objective and functional measures when assessing ASD and/or ADHD.

Differential Diagnosis of Autism Spectrum Disorder Versus Language Disorder in Children Ages 2 to 5 Years: Contributions of Parent-Reported Development and Behavior.

Early diagnosis of autism spectrum disorder (ASD) has focused on differentiating children with ASD from neurotypical children. However, many children presenting with concern for ASD are ultimately diagnosed with language disorder (LD). This study aimed to identify differences in parent-rated development and behavior among children ages 2 to 5 years presenting with concern for ASD who were diagnosed with either ASD or LD. Children with ASD were rated as more socially withdrawn and more delayed in social development and self-help skills than those with LD. Parent-rated developmental delays were positively correlated with scores on an autism screening measure and with social withdrawal and pervasive developmental problems among children with ASD. Among those with LD, parent-rated social and self-help development were positively correlated with social withdrawal and attention problems. Thus, parent ratings of social withdrawal and development of social and self-help skills may facilitate differential diagnosis of ASD and LD in children ages 2 to 5 years.

Neuropsychological and behavioral functioning in children with and without obstructive sleep apnea referred for tonsillectomy.

Adenotonsillectomy (AT) is among the most common pediatric surgical procedures and is performed as often for obstructive sleep apnea (OSA) as for recurrent tonsillitis. This study compared behavioral, cognitive, and sleep measures in 27 healthy control children recruited from a university hospital-based pediatric general surgery clinic with 40 children who had OSA (AT/OSA+) and 27 children who did not have OSA (AT/OSA-) scheduled for AT. Parental ratings of behavior, sleep problems, and snoring, along with specific cognitive measures (i.e., short-term attention, visuospatial problem solving, memory, arithmetic) reflected greater difficulties for AT children compared with controls. Differences between the AT/OSA- and control groups were larger and more consistent across test measures than were those between the AT/OSA+ and control groups. The fact that worse outcomes were not clearly demonstrated for the AT/OSA+ group compared with the other groups was not expected based on existing literature. This counterintuitive finding may reflect a combination of factors, including age, daytime sleepiness, features of sleep-disordered breathing too subtle to show on standard polysomnography, and academic or environmental factors not collected in this study. These results underscore the importance of applying more sophisticated methodologies to better understand the salient pathophysiology of childhood sleep-disordered breathing.

Visual Attention and Math Performance in Survivors of Childhood Acute Lymphoblastic Leukemia.

OBJECTIVE: Attentional and academic difficulties, particularly in math, are common in survivors of childhood acute lymphoblastic leukemia (ALL). Of cognitive deficits experienced by survivors of childhood ALL, attention deficits may be particularly responsive to intervention. However, it is unknown whether deficits in particular aspects of attention are associated with deficits in math skills. The current study investigated relationships between math calculation skills, performance on an objective measure of sustained attention, and parent- and teacher-reported attention difficulties. METHOD: Twenty-four survivors of childhood ALL (Mage = 13.5 years, SD = 2.8 years) completed a computerized measure of sustained attention and response control and a written measure of math calculation skills in the context of a comprehensive clinical neuropsychological evaluation. Parent and teacher ratings of inattention and impulsivity were obtained. RESULTS: Visual response control and visual attention accounted for 26.4% of the variance observed among math performance scores after controlling for IQ (p < .05). Teacher-rated, but not parent-rated, inattention was significantly negatively correlated with math calculation scores. CONCLUSIONS: Consistency of responses to visual stimuli on a computerized measure of attention is a unique predictor of variance in math performance among survivors of childhood ALL. Objective testing of visual response control, rather than parent-rated attentional problems, may have clinical utility in identifying ALL survivors at risk for math difficulties.

Development and validation of PediaTrac™: A web-based tool to track developing infants.

OBJECTIVE: PediaTrac™, a 363-item web-based tool to track infant development, administered in modules of ∼40-items per sampling period, newborn (NB), 2--, 4--, 6--, 9-- and 12--months was validated. Caregivers answered demographic, medical, and environmental questions, and questions covering the sensorimotor, feeding/eating, sleep, speech/language, cognition, social-emotional, and attachment domains. METHODS: Expert Panel Reviews and Cognitive Interviews (CI) were conducted to validate the item bank. Classical Test Theory (CTT) and Item Response Theory (IRT) methods were employed to examine the dimensionality and psychometric properties of PediaTrac with pooled longitudinal and cross-sectional cohorts (N = 132). RESULTS: Intraclass correlation coefficients (ICC) for the Expert Panel Review revealed moderate agreement at 6 -months and good reliability at other sampling periods. ICC estimates for CI revealed moderate reliability regarding clarity of the items at NB and 4 months, good reliability at 2--, 9-- and 12--months and excellent reliability at 6 -months. CTT revealed good coefficient alpha estimates (α ≥ 0.77 for five of the six ages) for the Social-Emotional/Communication, Attachment (α ≥ 0.89 for all ages), and Sensorimotor (α ≥ 0.75 at 6-months) domains, revealing the need for better targeting of sensorimotor items. IRT modeling revealed good reliability (r = 0.85-0.95) for three distinct domains (Feeding/Eating, Social-Emotional/Communication and Attachment) and four subdomains (Feeding Breast/Formula, Feeding Solid Food, Social-Emotional Information Processing, Communication/Cognition). Convergent and discriminant construct validity were demonstrated between our IRT-modeled domains and constructs derived from existing developmental, behavioral and caregiver measures. Our Attachment domain was significantly correlated with existing measures at the NB and 2-month periods, while the Social-Emotional/Communication domain was highly correlated with similar constructs at the 6-, 9- and 12-month periods. CONCLUSION: PediaTrac has potential for producing novel and effective estimates of infant development via the Sensorimotor, Feeding/Eating, Social-Emotional/Communication and Attachment domains.

Depressive symptomatology in school-aged children with obstructive sleep apnea syndrome: incidence, demographic factors, and changes following a randomized controlled trial of adenotonsillectomy.

Study Objectives: Depressive symptoms following adenotonsillectomy (AT) relative to controls were examined in children with obstructive sleep apnea syndrome (OSAS). Methods: The Childhood Adenotonsillectomy Trial (CHAT) multisite study examined the impact of AT in 453 children aged 5 to 9.9 years with polysomnographic evidence of OSAS without prolonged desaturation, randomized to early adenotonsillectomy (eAT) or watchful waiting with supportive care (WWSC). One hundred seventy-six children (eAT n = 83; WWSC n = 93) with complete evaluations for depressive symptomatology between baseline and after a 7-month intervention period were included in this secondary analysis. Results: Exact binomial test assessed proportion of depressive symptomatology relative to norms, while effects of AT and OSAS resolution were assessed through linear quantile mixed-models. Treatment group assignment did not significantly impact depression symptoms, although self-reported depression symptoms improved over time (p < 0.001). Resolution of OSAS symptoms demonstrated a small interaction effect in an unexpected direction, with more improvement in parent ratings of anxious/depressed symptoms for children without resolution (p = 0.030). Black children reported more severe depressive symptoms (p = 0.026) and parents of overweight/obese children reported more withdrawn/depressed symptoms (p = 0.004). Desaturation nadir during sleep was associated with self-report depressed (r = -0.17, p = 0.028), parent-reported anxious/depressed (r = -0.15, p = 0.049), and withdrawn/depressed (r = -0.24, p = 0.002) symptoms. Conclusions: Increased risk for depressed and withdrawn/depressed symptoms was detected among children with OSAS, and different demographic variables contributed to risk in self-reported and parent-reported depression symptoms. Arterial oxygen desaturation nadir during sleep was strongly associated with depressed symptoms. However, despite improvements in child-reported depressed symptoms over time, changes were unrelated to either treatment group or OSAS resolution status. Trials Registration: Childhood Adenotonsillectomy Study for Children with OSAS (CHAT), https://clinicaltrials.gov/show/NCT00560859, NCT00560859.

DSM-IV diagnoses and obstructive sleep apnea in children before and 1 year after adenotonsillectomy.

OBJECTIVE: Obstructive sleep apnea, a common indication for adenotonsillectomy in children, has been linked to behavioral morbidity. We assessed psychiatric diagnoses in children before and after adenotonsillectomy and examined whether baseline sleep apnea predicted improvement after surgery. METHOD: Subjects of this prospective cohort study were children ages 5.0 to 12.9 years old who had been scheduled for adenotonsillectomy (n = 79) or care for unrelated surgical conditions (n = 27, among whom 13 had surgery after baseline assessment). Before intervention and 1 year later, subjects underwent structured diagnostic interviews and polysomnography. The main outcome measure was frequency of DSM-IV attention and disruptive behavior disorder diagnoses at baseline and follow-up. RESULTS: At baseline, attention and disruptive behavior disorders were diagnosed in 36.7% of adenotonsillectomy subjects and 11.1% of controls (p < .05); attention-deficit/hyperactivity disorder was found in 27.8% and 7.4%, respectively (p < .05). One year later, group differences were nonsignificant; attention and disruptive behavior disorders were diagnosed in only 23.1% (p < .01), and 50% of subjects with baseline attention-deficit/hyperactivity disorder no longer met diagnostic criteria. Obstructive sleep apnea on polysomnography at baseline did not predict concurrent psychiatric morbidity or later improvement. CONCLUSIONS: Attention and disruptive behavior disorders, diagnosed by DSM-IV criteria, were more common before clinically indicated adenotonsillectomy than 1 year later. Surgery may be associated with reduced morbidity, even among subjects lacking polysomnographic evidence of obstructive sleep apnea.

Pediatric sleep questionnaire: prediction of sleep apnea and outcomes.

OBJECTIVES: To further validate a questionnaire about symptoms of childhood obstructive sleep apnea (OSA) and to compare the questionnaire with polysomnography in their ability to predict outcomes of adenotonsillectomy. DESIGN: Retrospective analysis of data from a longitudinal study. SETTING: University-based sleep disorders laboratory. PARTICIPANTS: The Washtenaw County Adenotonsillectomy Cohort, comprising 105 children aged 5.0 to 12.9 years at entry. Intervention Parents completed the 22-item Sleep-Related Breathing Disorder (SRBD) scale of the Pediatric Sleep Questionnaire, and children underwent polysomnography before and 1 year after clinically indicated adenotonsillectomy (n = 78, usually for suspected OSA) or unrelated surgical care (n = 27). MAIN OUTCOME MEASURES: Findings from commonly used hyperactivity ratings, attention tests, and sleepiness tests. RESULTS: At baseline, a high SRBD scale score (1 SD above the mean) predicted an approximately 3-fold increased risk of OSA on polysomnography (odds ratio, 2.80; 95% confidence interval, 1.68-4.68). One year later, OSA and symptoms had largely resolved, but a high SRBD score still predicted an approximately 2-fold increased risk of residual OSA on polysomnography (odds ratio, 1.89; 95% confidence interval, 1.13-3.18). Compared with several standard polysomnographic measures of OSA, the baseline SRBD scale better predicted initial hyperactivity ratings and 1-year improvement, similarly predicted sleepiness and its improvement, and similarly failed to predict attention deficit or its improvement. CONCLUSIONS: The SRBD scale predicts polysomnographic results to an extent useful for research but not reliable enough for most individual patients. However, the SRBD scale may predict OSA-related neurobehavioral morbidity and its response to adenotonsillectomy as well or better than does polysomnography.

Effects of Adenotonsillectomy on Parent-Reported Behavior in Children With Obstructive Sleep Apnea.

Objectives: The childhood obstructive sleep apnea syndrome (OSAS) is associated with behavioral abnormalities. Studies on the effects of OSAS treatment on behavior are conflicting, with few studies using a randomized design. Further, studies may be confounded by the inclusion of behavioral outcome measures directly related to sleep. The objective of this study was to determine the effect of adenotonsillectomy on behavior in children with OSAS. We hypothesized that surgery would improve behavioral ratings, even when sleep symptom items were excluded from the analysis. Methods: This was a secondary analysis of Child Behavior Checklist (CBCL) data, with and without exclusion of sleep-specific items, from the Childhood Adenotonsillectomy Trial (CHAT). CBCL was completed by caregivers of 380 children (7.0+1.4 [range 5-9] years) with OSAS randomized to early adenotonsillectomy (eAT) versus 7 months of watchful waiting with supportive care (WWSC). Results: There was a high prevalence of behavioral problems at baseline; 16.6% of children had a Total Problems score in the clinically abnormal range. At follow-up, there were significant improvements in Total Problems (p < .001), Internalizing Behaviors (p = .04), Somatic Complaints (p = .01), and Thought Problems (p = .01) in eAT vs. WWSC participants. When specific sleep-related question items were removed from the analysis, eAT showed an overall improvement in Total (p = .02) and Other (p = .01) problems. Black children had less improvement in behavior following eAT than white children, but this difference attenuated when sleep-related items were excluded. Conclusions: This large, randomized trial showed that adenotonsillectomy for OSAS improved parent-rated behavioral problems, even when sleep-specific behavioral issues were excluded from the analysis.