Screening for attention-deficit/hyperactivity disorder (ADHD): can high-risk children be identified in first grade?

AIM: Recent studies have demonstrated the beneficial long-term effects of an indicated parent support programme for acting out behaviour in pre-school children with attention-deficit/hyperactivity disorder (ADHD) traits. In this study we wanted to assess different thresholds for screening with the Conners scale for hyperactive-inattentive behaviours in first grade for ADHD in grade four. METHOD: The study population consisted of 422 first graders (6- to 7-year-olds) in one municipality in Stockholm County who were screened with Conners 10-item scale and followed up by ADHD assessment in grade four. Sensitivity, specificity, likelihood ratios, and positive predictive value (PPV) of the screening by parents and teachers in first grade for being diagnosed with ADHD in fourth grade were calculated. RESULTS: The prevalence of pervasive and situational ADHD was 5.7% and 5.9% respectively. A score ≥ 10 on the Conners scale in first grade in teachers' reports identified 63% [95% confidence interval (CI): 43-79] of children diagnosed with pervasive ADHD in grade four (P < 0.001) with a PPV of 29% and a positive likelihood ratio (LR+) of 6.72. Parental reports of a score ≥ 10 yielded a lower sensitivity (29%; 95% CI: 15-49), PPV of 20% and LR+ of 4.24 for pervasive ADHD. The best predictor was a combination of parent and teacher scores ≥ 10 with a PPV of 50% and LR+ of 16.63. Associations with situational ADHD were weak with LR+ of 1.81 and 2.49, respectively, for teachers' and parental scores ≥ 10. CONCLUSIONS: This study indicates a strong association between a teacher's report of a score ≥ 10 on the Conners scale in first grade and pervasive ADHD in grade four, while parental reports were less predictive.

Long-term follow-up of children breast-fed by mothers using oral contraceptives.

In a long-term follow-up study 48 breast-fed children, whose mothers had used oral contraceptives containing 50 micrograms of ethinylestradiol while lactating, were compared to a matched control group whose mothers had not used any hormonal contraceptives during lactation. In spite of a very large number of data collected from several different sources of information, no effect could be demonstrated of the ingested steroid, neither upon the panorama of diseases nor upon intellectual or psychological behaviour of the infants and children up to 8 years of age. The mothers who used oral contraceptives lactated a significantly shorter period of time than the controls, but no differences were found in weight gain and height increase in the children between cases and controls.

PIP: When lactating women use hormonal contraceptives, small amounts of the steroids are transferred to the breast milk; these steroids can also be detected in infants' plasma after breastfeeding. In a long-term follow-up study 48 breast-fed children, whose mothers had used oral contraceptives (OCs) containing .50 microgram of ethinylestradiol while lactating, were compared to a matched control group whose mothers had not used hormonal contraceptives during lactation. The only significant difference between cases and controls was a shorter lactating period for the women who had used OCs. However, the study demonstrated no effect of the steroid ingested during the suckling period, neither upon the panorama of diseases nor upon intellectual or psychological behavior of the infants and children up to 8 years of age. The study looked at the 1st, 2nd, and 3rd consecutive illnesses of the children who became diseased as well as the age at debut and degree of difficulty; no significant differences were found between cases and controls. Nor were there any differences between the 2 groups according to a special control of 4-year old children or at school start. Also, no differences were found in weight gain and height increase between cases and controls. Admittedly, the present study includes a limited number of cases and controls. However, for each child a very large number of data was collected from several different sources of information and sets of data are complete for all cases and controls. The time period of observation in this prospective study is now 8 years; the study will be continued beyond puberty.

Early and late discharge after hospital birth. Health of mother and infant in the postpartum period.

Early discharge, defined as hospital leave 24-48 hours after birth, was introduced at Falun Hospital in 1984. 164 women interested in participating in an evaluative study of the program were randomly allocated in late pregnancy to an Experimental group (EG) offered early discharge, and a Control group (CG) offered the regular postpartum care in hospital. After medical and other withdrawals 24 h after the birth, 50 women remained in EG and 54 in CG. Infant morbidity and number of prescribed medicaments during the first 6 months after the birth were lower in EG than in CG, but the difference was not statistically significant. EG mothers made fewer visits to the Child Health Centre nurse than did CG mothers (p less than 0.05). No significant difference in puerperal complications was demonstrated, but the intake of sedatives by EG mothers was smaller than that of CG mothers during the first puerperal week (p less than 0.01).

Assessment of speech and language skills in children.

A speech and language assessment procedure was developed to study different aspects of speech and language skills in children 6.5 years old who had needed intensive care in the neonatal period. It was required that the procedure could be carried out at one examination session and that it should characterize a broad spectrum of language skills and permit detection of deviations in language development. The assessment comprises three parts. Part A is an evaluation of the child's spontaneous speech during a 10- to 15-minute conversation between the child and the assessor. Eight different variables are assessed, and an overview of the child's conversational behaviour is obtained. Part B is an assessment of speech and language skills. A set procedure is used to assess auditory discrimination, interaction between auditory and speech motor capacity, different comprehension functions, vocabulary and word fluency. Some motor tasks are included to elucidate the relationship between speech and non-linguistic fine motor activity. Part C is an interview with the parents. A control group of 40 children was tested. The assessment protocol is now being applied for follow-up examination of children who have needed neonatal intensive care at Uppsala University Hospital, Sweden.

The importance of the Child Health Services to the health of children: summary of the state-of-the-art document from the Sigtuna conference on Child Health Services with a view to the future.

In September 1999, a state-of-the-art conference was held in Sigtuna outside Stockholm, Sweden. The subject of the conference was the future of the Child Health Services. The approximately 40 participants included researchers from all professions with a link to child healthcare. The conference was prepared by a working committee consisting of Claes Sundelin (chairman), Uppsala, Sven Bremberg, Huddinge, Gisela Dahlqvist, Umeå, Kerstin Hedberg Nyqvist, Uppsala, Anders Håkansson, Malmö, Gunilla Lindmark, Uppsala, Birgitta Wickberg, Göteborg and Maria Nyström Peck (secretary), Stockholm. The state-of-the-art report has recently been published by the National Council for Medical Research and is briefly summarized below.

Growing up in Uppsala: the "new morbidity" in the adolescent period. A longitudinal epidemiological study based on school data and some external sources.

The study comprised all 1805 children, most born in 1967, who were in grade 9 of the compulsory school in Uppsala in the spring of 1983 (cross-sectional population) and all 1723 children born in 1967 and resident in Uppsala at ages 10 and 15 years (longitudinal population). The aims were (1) to describe and analyse a normal population of 9th graders in social, medical, educational and psychological respects, (2) to assess relationships between risk level at 10 years, school-identified difficulties at 15 years and psychosocial problems up to age 18, (3) to assess relationships between intervention in school at 15 years and psychosocial problems up to 18 years. Ten-year data had been collected through teacher interviews and analysis of school health records in grade 3. Fifteen-year data were collected through interviews with school health staff and analysis of school health records in grade 9. School marks were gathered at the end of grade 9. Psychosocial problems up to 18 years were assessed on the basis of all registered contacts with official institutions outside school (authorities for care of the handicapped, Department of Child Psychiatry, social agencies, legal authorities). CROSS-SECTIONAL POPULATION. Children older than the grade norm and children of lower social class manifested a more problematic school adjustment and had lower mean marks than younger children and those of higher social classes. Twenty-five per cent of the population had entries in official registers up to age 18, indicating psychosocial problems. Social conditions were related both to the learning process and to psychological health. Educational and psychological problems were mutually correlated. Social problems increased the risk of a number of medical conditions. There were certain relationships between medical and educational problems as well as between medical and psychological problems. LONGITUDINAL POPULATION. Both 10- and 15-year data, particularly the latter, contributed independently to the prediction of psychosocial problems up to age 18. There was a considerably increased risk of psychosocial problems if there had been numerous school difficulties at age 15. Children who had been offered intervention in school at 15 years did not escape psychosocial problems up to 18 years more frequently than children without interventions. In fact, the contrary was the case: with more interventions, the frequencies of psychosocial problems up to age 18 increased.

Characteristics of school children who are choosy eaters.

Choosiness, manifested in refusal of foods, eating little, and disinterest in food, was studied with regard to prevalence, stability, sociodemographic characteristics, health problems, weight, and associated problem behaviors in a sample of 240 Swedish primary school children. Questionnaires were used, and data on sociodemographic variables, health problems, weight, and height were collected from child health-care and school health records. Choosiness was present in one third of the children, but only 8% showed choosy behavior both at home and in school. The choosy children had no more health problems than others, nor were they significantly thinner. Choosiness was not related to gender, social class, or ethnic background. The choosy children had modestly elevated levels of externalizing, hyperactive, and internalizing behavior. The choosy children with a history of refusal to eat in infancy or preschool age had more pronounced choosy behavior and had more problem behaviors than the other choosy children. Choosiness can not easily be categorized within an eating disorders or main problem syndromes of childhood frame of reference.