A risk calculator to predict adult attention-deficit/hyperactivity disorder: generation and external validation in three birth cohorts and one clinical sample.

AIM: Few personalised medicine investigations have been conducted for mental health. We aimed to generate and validate a risk tool that predicts adult attention-deficit/hyperactivity disorder (ADHD). METHODS: Using logistic regression models, we generated a risk tool in a representative population cohort (ALSPAC - UK, 5113 participants, followed from birth to age 17) using childhood clinical and sociodemographic data with internal validation. Predictors included sex, socioeconomic status, single-parent family, ADHD symptoms, comorbid disruptive disorders, childhood maltreatment, ADHD symptoms, depressive symptoms, mother's depression and intelligence quotient. The outcome was defined as a categorical diagnosis of ADHD in young adulthood without requiring age at onset criteria. We also tested Machine Learning approaches for developing the risk models: Random Forest, Stochastic Gradient Boosting and Artificial Neural Network. The risk tool was externally validated in the E-Risk cohort (UK, 2040 participants, birth to age 18), the 1993 Pelotas Birth Cohort (Brazil, 3911 participants, birth to age 18) and the MTA clinical sample (USA, 476 children with ADHD and 241 controls followed for 16 years from a minimum of 8 and a maximum of 26 years old). RESULTS: The overall prevalence of adult ADHD ranged from 8.1 to 12% in the population-based samples, and was 28.6% in the clinical sample. The internal performance of the model in the generating sample was good, with an area under the curve (AUC) for predicting adult ADHD of 0.82 (95% confidence interval (CI) 0.79-0.83). Calibration plots showed good agreement between predicted and observed event frequencies from 0 to 60% probability. In the UK birth cohort test sample, the AUC was 0.75 (95% CI 0.71-0.78). In the Brazilian birth cohort test sample, the AUC was significantly lower -0.57 (95% CI 0.54-0.60). In the clinical trial test sample, the AUC was 0.76 (95% CI 0.73-0.80). The risk model did not predict adult anxiety or major depressive disorder. Machine Learning approaches did not outperform logistic regression models. An open-source and free risk calculator was generated for clinical use and is available online at https://ufrgs.br/prodah/adhd-calculator/. CONCLUSIONS: The risk tool based on childhood characteristics specifically predicts adult ADHD in European and North-American population-based and clinical samples with comparable discrimination to commonly used clinical tools in internal medicine and higher than most previous attempts for mental and neurological disorders. However, its use in middle-income settings requires caution.

The biopsychosocial burden of genital herpes: evidence-based and other approaches to care.

Genital herpes, an incurable disease, is increasing in epidemic proportions in the United States (Eng & Butler, 1997). Updated information on the epidemiology and psychosocial aspects of genital herpes is necessary to understand the biopsychosocial burden of living with the disease. Data from both qualitative and quantitative research are used to support evidence-based and other approaches to care.

How a regression artifact makes ICFs/MR look ineffective.

Based on a simple matched-control group quasi-experiment, Conroy (1996) concluded that small ICFs for persons with mental retardation have negative quality-of-life impacts. Our analysis of Conroy's design suggests, in contrast, that the reported effect is a pure regression artifact. The flaw in Conroy's design is selecting a control group on the basis of pretest matching. Although selecting a subsample of controls by matching on static characteristics such as age or gender can reduce the confounding influence of these variables, selection on the basis of pretest scores leads invariably to a large, spurious effect. The literature on this issue dates back a century, with warnings against pretest matching by Galton, Thorndike, McNemar, Stanley, Campbell, Cronbach, and Cook. We reviewed this historical literature and then used a Monte Carlo experiment to estimate the spurious effect that Conroy would observe from pretest matching alone. The magnitude of the artifact is as large as the quality-of-life reduction that Conroy attributed to the effects of living in an ICF. We discussed the methodological logic involved in matching and the broader policy issues raised by this evaluation.

Analog classroom assessment of Adderall in children with ADHD.

OBJECTIVE: This was a randomized, double-blind, crossover study of 30 children with attention-deficit/hyperactivity disorder (ADHD) that evaluated the time course effects of four doses of Adderall (5, 10, 15, and 20 mg), an inactive control (placebo), and a positive control (clinical dose of methylphenidate). METHOD: For each treatment condition, a capsule was administered in the morning and assessments were performed in an analog classroom setting every 1.5 hours across the day. Subjective (teacher ratings of deportment and attention) and objective (scores on math tests) measures were obtained for each classroom session, and these measures were used to evaluate time-response and dose response effects of Adderall. RESULTS: For doses of Adderall greater than 5 mg, significant time course effects were observed. Rapid improvements on teacher ratings and math performance were observed by 1.5 hours after administration, and these effects dissipated by the end of the day. The specific pattern of time course effects depended on dose: the time of peak effects and the duration of action increased with dose of Adderall. CONCLUSIONS: This documentation of efficacy in a controlled study supports the addition of Adderall to the armamentarium of psychotropic medications for the treatment of ADHD. The differences in time-response patterns of Adderall and methylphenidate may help tailor treatment to meet specific clinical needs of different children with ADHD.

National Institute of Mental Health Collaborative Multimodal Treatment Study of Children with ADHD (the MTA). Design challenges and choices.

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first child multisite cooperative agreement treatment study of children conducted by the National Institute of Mental Health, Rockville, Md. It examines the long-term effectiveness of medication vs behavioral treatment vs both for treatment of ADHD and compares state-of-the-art treatment with routine community care. In a parallel-groups design, 576 children (age, 7-9 years) with ADHD (96 at each site) are thoroughly assessed and randomized to 4 conditions: (1) medication alone, (2) psychosocial treatment alone, (3) the combination of both, (4) or community comparison. The first 3 groups are treated for 14 months and all are reassessed periodically for 24 months. Designers met the following challenges: framing clinically relevant primary questions; defining the target population; choice, intensity, and integration and combination of treatments for fair comparisons; combining scientific controls and standardization with clinical flexibility; and implementing a controlled clinical trial in a nonclinical setting (school) controlled by others. Innovative solutions included extensive decision algorithms and manualized adaptations of treatments to specific needs.

Primary care in Cuba: a public health approach.

Cuba's primary health care model is presented. Unlike ambulatory care services, which are but one component of primary care, Cuba's model is a comprehensive public health approach that meets the World Health Organization's definition of primary care. The history of the development of Cuba's model is presented, including an update on the innovative neighborhood/home clinics. Achievements in health outcomes as a result of Cuba's model and the consequences for women's health care are discussed. Examples are presented of the effects on health care delivery of the economic hardship that Cuba has experienced since 1991 as a result of the loss of 85% of its trade with the former Soviet Union and the intensified U.S. embargo. A critique of Cuba's model concludes the article.

PIP: Cuba has been able to achieve some things that few Western countries have been able to achieve: equal access to health services for the entire population and equity in health status. After the 1959 revolution, community organizations conducted a census to obtain baseline demographic and epidemiologic data about the population, a literacy campaign, and sanitary and immunization campaigns. Polyclinics provided various social, environmental, and community health services free of charge. They were geographically distributed. Cuba instituted its neighborhood/home clinic model in 1984, a holistic, family, and neighborhood approach to comprehensive health care of the community. The family physician and nurse live in the neighborhood. Health education and health promotion are central to this model. The physicians and nurses are expected to conduct research and to present their findings at congresses or in journals. Cuba's infant mortality rate is not much higher than that of the US (1993, 9.4 vs. 8.3). Major causes of death in Cuba match those in developed countries, mainly heart disease and cancer. More than 95% of pregnant women attend their first prenatal visit during the first trimester. They receive prenatal care monthly unless they have a high-risk pregnancy when they receive prenatal care once a week. Infants receive well-baby care once a month. Sex education is available to everyone. All primary care facilities provide contraception. Nevertheless, the induced abortion rate is high, which concerns the government and health providers. Key effects of the economic hardship Cuba faces caused by the fall of the Soviet Union include food rationing, emigration, increased use of traditional herbs, lack of exchange of professional literature between the US and Cuba, and lack of enough paper to continue publications of medical and nursing journals. Cuba has prioritized health and education over economic development.

Historical and social context for birth planning in Iceland.

PIP: Iceland is a rugged subarctic island 600 miles from Norway and 500 miles from Scotland. From the mid-14th to the end of the 18th century the island was virtually isolated. Isolation and sociocultural factors interacted to delay the fertility transition in Iceland until late in the 20th century. In 1983 Iceland had the highest crude birth rate of any developed country -- 18.4/1000. Between 1890-1982, the population almost tripled, to 235,501 inhabitants. The total fertility rate is 2.2, down from 4.17 in 1960. Combined with a high birth rate was a low mortality rate of 7.0/1000 of the population and a life expectancy of 79.5 years for women and 73.9 years for men -- the highest in the world. Infant mortality is only 6.2/1000 live births. This combination of high fertility, low mortality, and low emigration caused the high population growth. By the end of the 18th century, Iceland had achieved near universal literacy, and education through university is free, but not until 1960 did a woman receive a doctorate from the University of Iceland. By 198, 2/3 of women in Iceland participated in the labor force, but their earnings were only 2/3 those of men. In 1983 a Women's Party was formed, and women now hold 15% of the seats in the Althing (Parliament). Marriage rates have declined to 5.22/1000 of the population. The unique marital pattern of Iceland contributes to the high (41%) illegitimacy rate. Icelandic couples cohabit and have a child or 2 before they marry. They therefore tend to marry late (25.5 for men, 23.3 for women). Health care, including family planning services, is free in Iceland; and there is a medical school, a school of pharmacy, and 2 nursing schools. 35% of Icelandic women 20-40 years of age use either the pill or the IUD. Over-the-counter contraceptives are also available, and an average of 358 women are sterilized each year. The abortion rate is only 10.6/1000 females 15-49 years of age. The Birth Control Act of 1975 calls for the provision of sex education and counseling, including contraception, sterilization and abortion. Nurses can assist in family planning program by observing needs, offering birth planning for couples, and carrying out research in the factors that affect family planning in Iceland.^ieng

Systematic dyskinesia examination of profoundly mentally retarded persons: cooperation and assessment.

Performance of 344 institutionalized mentally retarded adults was measured to assess the applicability of the Dyskinesia Identification System Condensed User Scale. A larger proportion of profoundly retarded persons cooperated with Dyskinesia Identification examination procedures than has previously been found. Performance deficits were observed on activation tasks (APA, 1979) that precede assessment of lingual abnormal involuntary movements. Intelligence quotients, neuroleptic dosage, gender, and ambulatory and visual impairments were associated with performance of activation tasks. Results suggest the difficulty of implementing standardized tardive dyskinesia assessments and that client behavior problems may threaten the valid assessment of this disorder among institutionalized profoundly retarded persons.

Birth planning in Cuba: a basic human right.

PIP: This paper reports on the development of birth planning in Cuba and strategies that are relevant to nurses in the communities of Cuba. Cuba reduced its crude birth rate by 40% from 1964-75 without formal family planning programs and resources. By 1975, Cuba had achieved the lowest birth rate in Latin America (21/1000) except Barbados (19/1000). By 1978, Cuba's crude birth rate declined to a low of 15.3/1000. The demographic transition in Cuba has been a process of equalization by: 1) community participation to ensure basic human rights for everyone, 2) increasing the status of women while providing child care centers, 3) providing equal availability of health care services including contraceptive services, sterilization, and abortion, and 4) focusing on individual birth choice, not on limiting population growth. Emphasis in Cuba for reducing fertility has been put on literacy, education, and infant mortality. The illiteracy rate in 1961 decreased from 20% to 4%. Infant mortality decreased from 38.8/1000 live births in 1970 to 22.3/1000 in 1978. 1/3 of Cuban women were participating fully in the labor force in 1978. Polyclinics have been established as preventive care medical centers throughout Cuba and health care is free. Family planning options are integrated into routine primary health care at polyclinics and assure equal access to the total Cuban population. Abortion is freely available and increased to 61/1000 in 1976. The implications for nursing are that: 1) the traditional work of nurses places them in a key position to help extend basic human rights beyond current levels, 2) nurses can initiate discussions of birth planning with women and men in a variety of settings, and 3) nurses can increase case-finding related to birth planning needs both in health care classes or within established groups in the community.^ieng

Knowledge, knowledge, who's got the knowledge? The male contraceptive career.

PIP: A pilot study was conducted to explore some initial family planning concerns of men who sought to obtain reproductive health services. In-depth contraceptive histories were obtained by interviewing 30 men attending the Men's Reproductive Health Clinic in San Francisco over the 1977-1978 period. The men ranged in age between 19-37. The average respondent was white, 27, and single, with some college. Respondents included married and divorced men, and black, Latin, and European men. The research methodology was that of comparative analysis. Preliminary study findings indicate that men perceive they are left out of family planning services and are finding out what they can do despite these circumstances. 4 areas of special concern to the men interviewed, in their search for information and services, were the following: 1) the changing social milieu which includes specifically the effect of the ecological and women's movements; 2) the degree of visibility, or the extent to which men view themselves as invisible in family planning clinics; 3) the nature of the terrain, or the characteristics of family planning clinics that make men feel unwelcome; and 4) accessibility, or the difficulty they experienced gaining contraceptive information and services. Despite the fact that men feel that they are excluded from family planning services, they strategize to handle their concerns. 3 emerging patterns men use to interact with their partners in the practice of family planning are described. These patterns are directing, encountering, and assuming. The patterns reflect how men see themselves in relation to family planning. The directing pattern is based on the man's perception of himself as an outsider, who is directing or managing the process alone. Men are usually willing to direct the process, but they are aware of the many advantages women have over men such as ready access to services, and they strategize to overcome this barrier to them. The pattern of encountering was the most common pattern among men in this study. In this instance the man becomes increasingly involved in the family planning process. This man has access to knowledge through his partner and enters a process of determining what he needs to know and, in turn, finding out how he can use what he has gained to insure a more satisfactory outcome. These men put much effort into increasing their understanding of their partner's family planning experience. The assuming pattern is based on the man's perception of himself as an outsider who makes the assumption that his partner is managing family planning alone. He is less involved than men in the other 2 patterns.^ieng