Remote assessment of ADHD in children and adolescents: recommendations from the European ADHD Guidelines Group following the clinical experience during the COVID-19 pandemic.

The COVID-19 pandemic led ADHD services to modify the clinical practice to reduce in-person contact as much as possible to minimise viral spread. This had far-reaching effects on day-to-day clinical practice as remote assessments were widely adopted. Despite the attenuation of the acute threat from COVID, many clinical services are retaining some remote practices. The lack of clear evidence-based guidance about the most appropriate way to conduct remote assessments meant that these changes were typically implemented in a localised, ad hoc, and un-coordinated way. Here, the European ADHD Guidelines Group (EAGG) discusses the strengths and weaknesses of remote assessment methods of children and adolescents with ADHD in a narrative review based on available data and expert opinions to highlight key recommendations for future studies and clinical practice. We conclude that going forward, despite remote working in clinical services functioning adequately during the pandemic, all required components of ADHD assessment should still be completed following national/international guidelines; however, the process may need adaptation. Social restrictions, including changes in education provision, can either mask or exacerbate features associated with ADHD and therefore assessment should carefully chart symptom profile and impairment prior to, as well as during an ongoing pandemic. While remote assessments are valuable in allowing clinical services to continue despite restrictions and may have benefits for routine care in the post-pandemic world, particular attention must be paid to those who may be at high risk but not be able to use/access remote technologies and prioritize these groups for conventional face-to-face assessments.

Structure and clinical correlates of obsessive-compulsive symptoms in a large sample of children and adolescents: a factor analytic study across five nations.

The underlying structure of obsessive-compulsive disorder (OCD) remains to be confirmed in child and adolescent populations. In this paper we report the first factor analytic study of individual OCD items from Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). OCD symptoms were assessed using the CY-BOCS symptom checklist in a sample of 854 patients with OCD (7-18 years of age) recruited from clinics in five countries. Pooled data were subjected to exploratory and confirmatory factor analysis (CFA) to identify the optimal factor structure. Various models were tested for age and gender subgroups. Also, the invariance of the solution across age and gender was tested and associations with demographic and clinical factors were explored. A three-factor model provided the best-fit solution. It consisted of the following factors: (1) harm/sexual, (2) symmetry/hoarding, (3) contamination/cleaning. The factor structure was invariant for age and gender across subgroups. Factor one was significantly correlated with anxiety, and factor two with depression and anxiety. Factor three was negatively correlated with tic disorder and attention-deficit/hyperactivity disorder (ADHD). Females had higher scores on factor two than males. The OCD symptom structure in children and adolescents is consistent across age and gender and similar to results from recent child and adolescents although hoarding may not be a separate factor. Our three-factor structure is almost identical to that seen in early studies on adults. Common mental disorders had specific patterns of associations with the different factors.

Severe psychosocial deprivation in early childhood is associated with increased DNA methylation across a region spanning the transcription start site of CYP2E1.

Exposure to adverse rearing environments including institutional deprivation and severe childhood abuse is associated with an increased risk for mental and physical health problems across the lifespan. Although the mechanisms mediating these effects are not known, recent work in rodent models suggests that epigenetic processes may be involved. We studied the impact of severe early-life adversity on epigenetic variation in a sample of adolescents adopted from the severely depriving orphanages of the Romanian communist era in the 1980s. We quantified buccal cell DNA methylation at ~400 000 sites across the genome in Romanian adoptees exposed to either extended (6-43 months; n=16) or limited duration (<6 months; n=17) of severe early-life deprivation, in addition to a matched sample of UK adoptees (n=16) not exposed to severe deprivation. Although no probe-wise differences remained significant after controlling for the number of probes tested, we identified an exposure-associated differentially methylated region (DMR) spanning nine sequential CpG sites in the promoter-regulatory region of the cytochrome P450 2E1 gene (CYP2E1) on chromosome 10 (corrected P=2.98 × 10(-5)). Elevated DNA methylation across this region was also associated with deprivation-related clinical markers of impaired social cognition. Our data suggest that environmental insults of sufficient biological impact during early development are associated with long-lasting epigenetic changes, potentially reflecting a biological mechanism linking the effects of early-life adversity to cognitive and neurobiological phenotypes.

The familial basis of facial emotion recognition deficits in adolescents with conduct disorder and their unaffected relatives.

BACKGROUND: There is accumulating evidence of impairments in facial emotion recognition in adolescents with conduct disorder (CD). However, the majority of studies in this area have only been able to demonstrate an association, rather than a causal link, between emotion recognition deficits and CD. To move closer towards understanding the causal pathways linking emotion recognition problems with CD, we studied emotion recognition in the unaffected first-degree relatives of CD probands, as well as those with a diagnosis of CD. METHOD: Using a family-based design, we investigated facial emotion recognition in probands with CD (n = 43), their unaffected relatives (n = 21), and healthy controls (n = 38). We used the Emotion Hexagon task, an alternative forced-choice task using morphed facial expressions depicting the six primary emotions, to assess facial emotion recognition accuracy. RESULTS: Relative to controls, the CD group showed impaired recognition of anger, fear, happiness, sadness and surprise (all p < 0.005). Similar to probands with CD, unaffected relatives showed deficits in anger and happiness recognition relative to controls (all p < 0.008), with a trend toward a deficit in fear recognition. There were no significant differences in performance between the CD probands and the unaffected relatives following correction for multiple comparisons. CONCLUSIONS: These results suggest that facial emotion recognition deficits are present in adolescents who are at increased familial risk for developing antisocial behaviour, as well as those who have already developed CD. Consequently, impaired emotion recognition appears to be a viable familial risk marker or candidate endophenotype for CD.

Overcoming barriers to effective early parenting interventions for attention-deficit hyperactivity disorder (ADHD): parent and practitioner views.

BACKGROUND: The importance of early intervention approaches for the treatment of attention-deficit hyperactivity disorder (ADHD) has been increasingly acknowledged. Parenting programmes (PPs) are recommended for use with preschool children with ADHD. However, low 'take-up' and high 'drop-out' rates compromise the effectiveness of such programmes within the community. METHODS: This qualitative study examined the views of 25 parents and 18 practitioners regarding currently available PPs for preschool children with ADHD-type problems in the UK. Semi-structured interviews were undertaken to identify both barriers and facilitators associated with programme access, programme effectiveness, and continued engagement. RESULTS AND CONCLUSIONS: Many of the themes mirrored previous accounts relating to generic PPs for disruptive behaviour problems. There were also a number of ADHD-specific themes. Enhancing parental motivation to change parenting practice and providing an intervention that addresses the parents' own needs (e.g. in relation to self-confidence, depression or parental ADHD), in addition to those of the child, were considered of particular importance. Comparisons between the views of parents and practitioners highlighted a need to increase awareness of parental psychological barriers among practitioners and for better programme advertising generally. Clinical implications and specific recommendations drawn from these findings are discussed and presented.

Barriers to, and facilitators of, parenting programmes for childhood behaviour problems: a qualitative synthesis of studies of parents' and professionals' perceptions.

Disruptive behaviour problems (DBPs) during childhood exert a high burden on individuals, families and the community as a whole. Reducing this impact is a major public health priority. Early parenting interventions are recommended as valuable ways to target DBPs; however, low take-up of, and high drop-out rates from, these programmes seriously reduce their effectiveness. We present a review of published qualitative evidence relating to factors that block or facilitate access and engagement of parents with such programmes using a thematic synthesis approach. 12 papers presenting views of both parents and professionals met our inclusion and quality criteria. A large number of barriers were identified highlighting the array of challenges parents can face when considering accessing and engaging with treatment for their child with behavioural problems. Facilitating factors in this area were also identified. A series of recommendations were made with regard to raising awareness of programmes and recruiting parents, providing flexible and individually tailored support, delivering programmes through highly skilled, trained and knowledgeable therapists, and highlighting factors to consider when delivering group-based programmes. Clinical guidelines should address barriers and facilitators of engagement as well as basic efficacy of treatment approaches.

The relationship between ADHD and key cognitive phenotypes is not mediated by shared familial effects with IQ.

BACKGROUND: Twin and sibling studies have identified specific cognitive phenotypes that may mediate the association between genes and the clinical symptoms of attention deficit hyperactivity disorder (ADHD). ADHD is also associated with lower IQ scores. We aimed to investigate whether the familial association between measures of cognitive performance and the clinical diagnosis of ADHD is mediated through shared familial influences with IQ. METHOD: Multivariate familial models were run on data from 1265 individuals aged 6-18 years, comprising 920 participants from ADHD sibling pairs and 345 control participants. Cognitive assessments included a four-choice reaction time (RT) task, a go/no-go task, a choice-delay task and an IQ assessment. The analyses focused on the cognitive variables of mean RT (MRT), RT variability (RTV), commission errors (CE), omission errors (OE) and choice impulsivity (CI). RESULTS: Significant familial association (rF) was confirmed between cognitive performance and both ADHD (rF=0.41-0.71) and IQ (rF=-0.25 to -0.49). The association between ADHD and cognitive performance was largely independent (80-87%) of any contribution from etiological factors shared with IQ. The exception was for CI, where 49% of the overlap could be accounted for by the familial variance underlying IQ. CONCLUSIONS: The aetiological factors underlying lower IQ in ADHD seem to be distinct from those between ADHD and RT/error measures. This suggests that lower IQ does not account for the key cognitive impairments observed in ADHD. The results have implications for molecular genetic studies designed to identify genes involved in ADHD.

Eunethydis: a statement of the ethical principles governing the relationship between the European group for ADHD guidelines, and its members, with commercial for-profit organisations.

The Eunethydis ADHD Guidelines group set out here the ethical principles governing the relationship between the group and industry. The principles set out here are provided to ensure that this is both done and seen to be done. The impetus for these guidelines comes from within the Group and is linked to the recognition for the need for an open and transparent basis for Group-industry relations, especially in the light of the present concern that the pharmaceutical industry may be exerting a growing influence on the actions of researchers and clinicians in the ADHD field.

Cognitive control in adolescents with neurofibromatosis type 1.

Neurofibromatosis Type 1 (NF1) is a genetic disorder characterized by partial loss of growth control that affects the central nervous system. NF1 has been consistently associated with cognitive dysfunction, although there is no consensus on the cognitive profile in NF1 or on brain-cognition relationships. To clarify the pattern of cognitive dysfunction, performance of 16 NF1 patients and 16 age- and sex-matched controls (mean age = 14.5 years, SD = 1.3) was compared on computerized tasks measuring perception, executive functioning (inhibitory control, cognitive flexibility, and working memory), and motor control. A further aim of this study was to contrast performance on tasks or task parts requiring varying levels of cognitive control to find out whether this could explain potential difficulties experienced by this population in different cognitive domains or at different stages of information processing. Repeated measures analyses of variance showed that group differences, indicating poorer performance of NF1 patients, varied as a function of the level of cognitive control required. Evidence was also found for more basic motor skill problems in NF1 patients. Furthermore, NF1 patients were generally slower than controls. Results are discussed in the context of what is known about brain-cognition relationships in NF1.

Inattentive/overactive children with histories of profound institutional deprivation compared with standard ADHD cases: a brief report.

BACKGROUND: The Inattention/Overactivity/Impulsiveness (I/OA) behavioural cluster diagnostic of ADHD is recognized as a characteristic outcome of early institutional care. METHODS: We compared the symptom and neuropsychological profiles of children with a history of I/OA and early severe deprivation (D-I/OA: n=13) with standard clinical ADHD cases (S-ADHD; N=20) and children who had experienced deprivation but were not pervasively I/OA (ERA-controls; n=22). The mean age of testing was around 13 years. D-I/OA and ERA-controls were selected from the English and Romanian Adoptees (ERA) study and had spent their early lives in the extremely depriving Romanian institutions of the Ceausescu regime and were later adopted into UK families. RESULTS: ADHD symptoms for male D-I/OA and S-ADHD cases showed marked similarities across symptom domains. In contrast, girls with D-I/OA were more similar to ERA controls than to ADHD cases. Longitudinal data suggested that this was due to a remission of symptoms in D-I/OA girls. Neuropsychological profiles of males and females with D-I/OA, however, were similar: both were more impaired than S-ADHD and ERA controls. DISCUSSION: Children with D-I/OA were more neuropsychologically impaired than S-ADHD despite the fact that only boys showed a persistent pattern of ADHD symptoms. These results need replication in a larger sample with groups matched for gender.

Co-transmission of conduct problems with attention-deficit/hyperactivity disorder: familial evidence for a distinct disorder.

Common disorders of childhood and adolescence are attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD). For one to two cases in three diagnosed with ADHD the disorders may be comorbid. However, whether comorbid conduct problems (CP) represents a separate disorder or a severe form of ADHD remains controversial. We investigated familial recurrence patterns of the pure or comorbid condition in families with at least two children and one definite case of DSM-IV ADHDct (combined-type) as part of the International Multicentre ADHD Genetics Study (IMAGE). Using case diagnoses (PACS, parental account) and symptom ratings (Parent/Teacher Strengths and Difficulties [SDQ], and Conners Questionnaires [CPTRS]) we studied 1009 cases (241 with ADHDonly and 768 with ADHD + CP), and their 1591 siblings. CP was defined as > or =4 on the SDQ conduct-subscale, and T > or = 65, on Conners' oppositional-score. Multinomial logistic regression was used to ascertain recurrence risks of the pure and comorbid conditions in the siblings as predicted by the status of the cases. There was a higher relative risk to develop ADHD + CP for siblings of cases with ADHD + CP (RRR = 4.9; 95%CI: 2.59-9.41); p < 0.001) than with ADHDonly. Rates of ADHDonly in siblings of cases with ADHD + CP were lower but significant (RRR = 2.9; 95%CI: 1.6-5.3, p < 0.001). Children with ADHD + CP scored higher on the Conners ADHDct symptom-scales than those with ADHDonly. Our finding that ADHD + CP can represent a familial distinct subtype possibly with a distinct genetic etiology is consistent with a high risk for cosegregation. Further, ADHD + CP can be a more severe disorder than ADHDonly with symptoms stable from childhood through adolescence. The findings provide partial support for the ICD-10 distinction between hyperkinetic disorder (F90.0) and hyperkinetic conduct disorder (F90.1).

Inhibitory deficits in attention-deficit/hyperactivity disorder are independent of basic processing efficiency and IQ.

BACKGROUND: A substantial proportion of children with attention-deficit/hyperactivity disorder (ADHD) show deficits on inhibitory control tests. However, questions remain about (i) the extent of these deficits across different inhibitory domains, (ii) their relationship to deficits in non-executive processes and (iii) whether they extend into adolescence. METHODS: Seventy-seven children and adolescents with ADHD and 50 non-ADHD controls completed three inhibitory tasks, a simple two choice RT task (2CR) and an IQ assessment. RESULTS: ADHD was moderately associated with deficits on all tasks (effect sizes d=0.5-0.9). Deficits were equally marked in childhood and adolescence. Inhibitory deficits were not associated with IQ and, although reduced substantially, remained significant after performance on a simple reaction time task was controlled for statistically. DISCUSSION: In highlighting the significant, but limited, role of inhibitory deficits in ADHD, these results are consistent with recent accounts that emphasize the neuropsychological heterogeneity of this condition.

Very low frequency EEG oscillations and the resting brain in young adults: a preliminary study of localisation, stability and association with symptoms of inattention.

BACKGROUND: Spontaneous very low frequency oscillations (VLFO: <0.2 Hz) in functional magnetic-resonance imaging are proposed to identify a default-mode network of resting brain activity. Activity in this network has been related to lapses of attention during goal-directed tasks and may provide a basis for ADHD. This study assessed the relation between scalp-recorded EEG VLFO at rest and ADHD. METHODS: 13 young adults with high- and 11 with low self-ratings of ADHD participated. Direct current EEG was recorded during a five minute rest session and was retested after approximately 1 week. RESULTS: A consistent and temporally stable pattern of VLFOs was observed across specific scalp regions in low-ADHD participants. High-ADHD participants had less VLFO power across these locations, especially where inattention self-ratings were high. Inattention was not related to VLFO power in other locations. DISCUSSION: Initial evidence is provided for a pattern of VLFOs at rest which is associated with inattention symptoms.

Teachers' emotional expression about disruptive boys.

OBJECTIVES: To assess teachers' emotional expression about pupils using the Five Minute Speech Sample (FMSS) and coding procedures for parental expressed emotion (EE). To compare EE for disruptive and non-disruptive pupils. METHOD: Twenty-one teachers provided speech samples for both a disruptive and a non-disruptive pupil in their class selected using standard behaviour rating scales. RESULTS: Teachers' emotional expression was reliably measured using EE codings. Teachers displayed no emotional overinvolvement (EOI) and made few critical comments. High EE, characterized by criticism and a lack of positive comments, was associated with children's behavioural difficulties. Multiple regression suggested that conduct problems rather than hyperactivity were associated with high EE. DISCUSSION: Results support the application of certain elements of the EE construct to teachers' emotional expression about pupils. However, there was an absence of EOI and a lack of association between relationship and other EE categories. The absence of this association suggests that EE might be most usefully considered as a measure of teachers' emotional response to pupils, rather than the emotional quality of the teacher-pupil relationship.

Trainee nursery teachers' perceptions of disruptive behaviour disorders; the effect of sex of child on judgements of typicality and severity.

BACKGROUND: Adults' perceptions of children with disruptive behaviour disorders (DBDs), which usually interfere with socialization and referral of children to mental health services, might differ according to the child's sex. Given the importance of (a) the interactions between these children and their educators, and (b) early identification and referral, the impact of the child's sex on adults' perceptions is an important factor to consider. AIM: To examine the role of gender-related expectations in the identification and referral of childhood DBDs by trainee nursery teachers. SAMPLE: One hundred and fifty-eight female trainee nursery teachers (mean age = 20 years) at the Department of Early Childhood Education in Athens. METHOD: Trainee nursery teachers' perceptions of male and female children with DBDs were explored using a Greek version of the Parental Account of the Causes of Childhood Problems Questionnaire. Eighty-one participants answered questions about a set of disruptive behaviours ascribed to a boy and 77 about the same behaviour ascribed to a girl. RESULTS: DBDs ascribed to girls were considered to be no more severe or of greater concern than those ascribed to boys. Judgements of severity were related to concern in the same way for boys and girls. However, DBDs were regarded as less typical for girls than boys. CONCLUSIONS: The child's sex affected trainee teachers' judgements of typicality, but not severity, of children's behaviour problems. The implications of this finding for socialization practices and referral attitudes are discussed.

Assessing expressed emotion in mothers of preschool AD/HD children: psychometric properties of a modified speech sample.

OBJECTIVE: To examine the reliability and validity of a modified coding measure of expressed emotion (Preschool Five Minute Speech Sample [PFMSS]), suitable for parents of preschool AD/HD children. DESIGN: Mothers of preschool AD/HD children identified through a three-stage screening programme were compared with mothers of non-AD/HD children on the PFMSS. METHOD: Mothers of 80 AD/HD and 20 non-AD/HD children participated in the PFMSS. They had 10 mins of play interaction with their child and completed the Feelings on Parenting scales from the Family Impact Questionnaire. RESULTS: With the exception of emotional over-involvement, the PFMSS demonstrated acceptable code-recode and inter-rater reliability, and adequate test-retest reliability. It also demonstrated acceptable validity, being associated with less affection and greater maternal direction during play interaction and discriminated between the parents of preschool AD/HD and non-AD/HD children. CONCLUSION: This study shows that in a revised form, the Five Minute Speech Sample can provide a useful measure of expressed emotion during the preschool period.

Parent-based therapies for preschool attention-deficit/hyperactivity disorder: a randomized, controlled trial with a community sample.

OBJECTIVE: To evaluate two different parent-based therapies for preschool attention-deficit/hyperactivity disorder (ADHD) in a community sample. METHOD: Three-year-old children displaying a preschool equivalent of ADHD (n = 78) were randomly assigned to either a parent training (PT; n = 30), a parent counseling and support (PCO&S; n = 28), or a waiting-list control group (n = 20). The PT group received coaching in child management techniques. The PC&S group received nondirective support and counseling. Measures of child symptoms and mothers' well-being were taken before and after intervention and at 15 weeks follow-up. RESULTS: ADHD symptoms were reduced (F2,74 = 11.64; p < .0001) and mothers' sense of well-being was increased by PT relative to both other groups (F2,74 = 10.32; p < .005). Fifty-three percent of children in the PT group displayed clinically significant improvement (chi 2 = 4.08; p = .048). CONCLUSIONS: PT is a valuable treatment for preschool ADHD. PC&S had little effect on children's behavior. Constructive training in parenting strategies is an important element in the success of parent-based interventions. Psychostimulants are not a necessary component of effective treatment for many children with preschool ADHD.

Mental health of elderly Asians in Britain: a comparison of Hindus from nuclear and extended families of differing cultural identities.

OBJECTIVE: To compare the psychological adjustment of grandmothers from nuclear and extended families within British Hindu communities, and to investigate the influence of cultural identity. DESIGN: Interviews were carried out with Hindu grandmothers, mothers and granddaughters living in both nuclear and extended families. SETTING: The sample was drawn from the total population of Asian Hindu girls aged between 13 and 17 years at four comprehensive schools in the London Borough of Redbridge. PARTICIPANTS++: The final sample consisted of 36 and 34 sets of individuals in extended and nuclear families, respectively. MEASURES: Questionnaire measures were obtained of the following variables: cultural integrity, traditionalism, religious participation, ethnic identity, anxiety, depression, self-esteem. RESULTS: Grandmothers were better adjusted in extended families than in nuclear families. This adjustment was in part mediated by the level of traditional belief within the family. Elders whose granddaughters had an exclusively 'Indian' or 'Hindu' ethnic identity were better adjusted than those whose granddaughters included a 'British' ethnic identity. CONCLUSIONS: This study confirmed findings from earlier studies that grandmothers in extended families were significantly better adjusted in comparison to those from nuclear families. Ethnic identity of the adolescent, independent of its salience and commitment to the adolescent, had a significant relationship to the grandmother's mental health.

The effect of extended family living on the mental health of three generations within two Asian communities.

BACKGROUND: A study by Shah & Sonuga-Barke (1995) identified a relationship between family structure and the mental health of Pakistani Muslim mothers and their children. Children in extended families fared better, but their mothers fared worse than their nuclear family counterparts. The present study replicates and extends this study by exploring the impact of nuclear and extended family living on the mental health of three generations (children, mothers and grandmothers) in British Hindu as well as Muslim communities. METHOD: 44 Muslim and 42 Hindu families participated in the study. The mental health of mothers and grandmothers and the behavioural problems of children (aged 5-11) were examined. Both mothers and grandmothers completed the Hospital Anxiety and Depression Scale. The children's behavioural adjustment was rated by their teachers using the Rutter Scale. Other relevant variables such as acculturation levels were also measured. RESULTS: Children and grandmothers were better adjusted in extended families than nuclear families. In contrast, mothers were better adjusted in nuclear families. This interaction between family type and generation was evident in both Muslim and Hindu families and did not appear to be mediated by other variables such as acculturation. Furthermore, mothers' and childrens' adjustment was significantly correlated with grandmothers', but not mothers', mental health in extended families (although not in nuclear families). DISCUSSION: These results provide further evidence for the link between family structure and mental health in Asian communities. They also challenge some of the assumptions about maternal mental health, its effects on child adjustment and its links to systems of social support. In extended families where social support was likely to be most available mothers were at greatest risk, while their children profited and this advantage seemed to be linked to the grandmaternal presence.

Parents anticipating misbehaviour: an observational study of strategies parents use to prevent conflict with behaviour problem children.

Research on the role of parenting styles in the development of disruptive behaviour problems has focused primarily on how parents handle conflict once it has occurred. This home observational study examined strategies used by 52 mothers to prevent conflict with 3-year-olds. It was predicted that mothers of children with behaviour problems would use fewer "positive" strategies to resolve conflict, and would use reactive rather than pre-emptive strategies. Results showed frequency of positive strategies did not differ between the groups. Mothers of children with behaviour problems were less likely to use pre-emptive, and more likely to use reactive, strategies. Further analysis showed child conduct problems, rather than other characteristics, best discriminated pre-emptive from reactive strategy users. Follow-up of a subsample found that reactive strategies at age 3 predicted age 5 behaviour problems, even after controlling for age 3 behaviour problems.