Disease course and psychosocial outcome for children and adolescents with anti-N-methyl-D-aspartate receptor encephalitis.

OBJECTIVES: Explore psychosocial outcome and impact of persisting deficits on quality of life (QoL) and global functioning after anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) in children and adolescents. METHODS: Four female patients (age 7-16y) and their caregivers participated in the study. Information was collected from the medical records and the caregivers via a questionnaire. Both the patients and their caregivers were interviewed by means of the structured clinical interview for DSM-5 disorders, junior version (SCID-5 junior). CGAS and mRS scores were defined and the Pediatric Quality of Life Inventory (PedsQL) was used to assess quality of life of patients and caregivers. RESULTS AND CONCLUSION: After the acute phase of the disease patients go through a post-acute phase in which several persisting physical, cognitive and psychiatric symptoms gradually resolve during the following months to a year. In long-term follow up these symptoms partly resolved, but deficits persisted on several domains. Psychiatric symptoms, fatigue and mild cognitive deficits were present in three out of four patients at current assessment. In three patients their academic trajectory was altered. These deficits can have an impact on the quality of life and the global functioning of the patients and caregivers.

A longitudinal study of autism spectrum disorder characteristics in adolescents with restrictive type anorexia nervosa during and after underweight.

OBJECTIVES: This prospective, longitudinal study aims to compare the prevalence of autism spectrum disorder (ASD) characteristics in adolescents with anorexia nervosa (AN) during and after underweight in order to help unravel the complex link between both conditions. METHODS: 24 adolescents with AN completed the youth self-report, autism spectrum quotient (AQ) or autism spectrum quotient adolescent version (AQ - adolescent) and a questionnaire designed by the researchers during a state of underweight and after weight recovery. RESULTS: AQ total score and several AQ subscale scores at the time of underweight are significantly higher than after weight recovery with medium to large effect sizes. Linear modelling cannot prove a significant effect of weight gain, internalizing problems or medication use on AQ score, but it does show an association between AQ during underweight and AQ after weight recovery. CONCLUSIONS: The results highlight the complexity of the link between AN and ASD characteristics. Although a clear change in AQ score is seen in part of the participants, this effect cannot be generalized and a link with weight change cannot be demonstrated. It seems likely that ASD characteristics in AN are a combination of trait and state: underweight and starvation might exacerbate potentially present traits. Part of our results may indicate the existence of subgroups based on AQ score during underweight. Our study supports the theory that more ASD characteristics at T1 may result in a poorer outcome and a higher need for specified and intensive treatment.

Emotion Regulation as a Transdiagnostic Risk Factor for (Non)Clinical Adolescents' Internalizing and Externalizing Psychopathology: Investigating the Intervening Role of Psychological Need Experiences.

This study investigated emotion regulation (i.e., emotional integration, suppression and dysregulation) as a transdiagnostic process underlying adolescents' internalizing and externalizing symptoms. Basic psychological need experiences were investigated as a possible underlying mechanism explaining this association. A heterogeneous sample of non-clinical and clinically-referred adolescents reported upon emotion regulation, basic psychological needs (i.e., need satisfaction and frustration), and both internalizing and externalizing problems. Results indicated that dysfunctional emotion regulation was positively linked to internalizing as well as externalizing problems. Need frustration was a partial mediator in this relation between emotion regulation and psychopathology. The findings suggest that both emotion regulation and basic psychological needs may play a transdiagnostic role in adolescents' internalizing and externalizing symptoms.

Adolescent Attachment: A Social Relations Perspective on Family Relations.

While attachment at an early age is almost exclusively determined by parental behavior, variation in the quality of attachment in adolescence seems strong to be influenced by the complex interplay between the adolescent's internal working model and its environment. To unravel the different sources of variance in adolescent attachment relationships we applied the Social Relations Model. Two parents and two adolescents from 70 relatively well-functioning families reported on their attachment relationships within a family context. In this study, attachment was conceptualized by two different dimensions of attachment, namely anxiety (for being abandoned) and avoidance (of intimacy). Our findings suggest adolescents experience little attachment anxiety throughout adolescence, but they report significantly more attachment avoidance toward their parents. The variance in the quality of adolescents' attachment relationships was mainly determined by characteristics of the adolescent and the unique adjustments they make to the attachment figure.

Si bien el apego en los primeros años de vida está casi exclusivamente determinado por la conducta de los padres, la variación de la calidad del apego en la adolescencia parece significativamente influenciada por la interacción compleja entre el modelo de funcionamiento interno del adolescente y su entorno. Para descifrar las diferentes fuentes de varianza en las relaciones de apego de los adolescentes, aplicamos el modelo de relaciones sociales. Dos padres y dos adolescentes de 70 familias con un funcionamiento relativamente bueno informaron sobre sus relaciones de apego dentro de un contexto familiar. En este estudio, el apego se conceptualizó mediante dos aspectos diferentes del apego, por ejemplo, la ansiedad (por ser abandonado) y la evitación (de la intimidad). Nuestros resultados sugieren que los adolescentes sufren poca ansiedad por el apego durante la adolescencia, pero informan una evitación del apego más significativa hacia sus padres. La varianza en la calidad de las relaciones de apego de los adolescentes estuvo determinada principalmente por las características del adolescente y por las adaptaciones únicas que hace a la figura de apego.

Studying Motivation in ADHD: The Role of Internal Motives and the Relevance of Self Determination Theory.

OBJECTIVE: Motivation is what moves us to act, what engages us in goal-directed behavior. The Self Determination Theory (SDT) is a motivational framework conceptualizing motivation-or internal motives-as a continuum of motivation qualities fueled by satisfaction of the three basic psychological needs Autonomy, Relatedness, and Competence. ADHD has been associated with motivational alterations that contribute to academic difficulties. However, ADHD theories and research are mainly focused on the effects of reinforcement on behavior, with little attention for the broader definition of motivation, that is, internal motives. Therefore, the main objective here was to introduce the SDT as theoretical framework within which we can develop relevant research questions about motivation in the field of ADHD. METHOD: To this end, we (i) present the SDT as a comprehensive motivational framework, and (ii) describe current motivation-related ADHD theories and research. RESULTS: Based on this, we suggest how SDT can be used as a guiding framework in generating relevant research questions that can help broaden our understanding of the role motivation plays in individuals with ADHD. CONCLUSION: We conclude that ADHD research on motivation would benefit from (i) including internal motives as potential key mediators in the relation between environmental factors and behavior/symptoms; (ii) studying potential negative effects of external reinforcers intrinsic motivation, affect, and well-being. Finally, we conclude that this framework carries value for further development of clinical interventions for those with ADHD.

I won't obey!: Psychologically Controlling Parenting and (Non)-Clinical Adolescents' Responses to Rule-setting.

OBJECTIVES: This study examined associations between maternal psychologically controlling parenting and adolescents' responses to rule-setting as well as the link between both study variables and adolescents' internalizing and externalizing problems. METHOD: Both clinical and nonclinical adolescents reported upon maternal psychological control, responses to rule-setting (i.e., oppositional defiance, submissive compliance, negotiation, and accommodation) and both adolescents and mothers reported upon adolescents' problems. RESULTS: Perceived psychological control related positively to adolescents' oppositional defiance and submissive compliance and negatively to negotiation and accommodation. Further, an integrated path model indicated that psychological control related to externalizing problems via oppositional defiance and internalizing problems via submissive compliance. CONCLUSIONS: Psychological control relates to different types of problem behaviors via diverse responses to maternal rule-setting. The discussion emphasizes the importance of future prevention and intervention programs to focus on both parenting and on adolescents' active contribution to their socialization process.

The Impact of Idle Time in the Classroom: Differential Effects on Children With ADHD.

OBJECTIVE: Studies have identified an exacerbation of ADHD deficits under specific laboratory conditions. Less is known about the significance of such contextual factors in relation to everyday functioning in naturalistic settings. METHOD: This study investigated the differential impact of classroom "idle time"--periods when students are not actively engaged or waiting for a task--on the behavior of 31 children with ADHD (25 boys and 6 girls; aged 6-12 years) and 31 sex- and age-matched typically developing classmates, who were simultaneously observed in their normal classroom during two school days. RESULTS: Both groups experienced the same amount of idle time (12% of the time). During idle time, however, levels of hyperactivity and noisiness increased significantly more in children with ADHD than in their classmates (p < .05). CONCLUSION: Findings highlight the differential susceptibility of ADHD children to classroom idle time. Classroom interventions might consider targeting specifically these periods to reduce disruptive behavior in these children.

The impact of instructional context on classroom on-task behavior: a matched comparison of children with ADHD and non-ADHD classmates.

Classroom inattentiveness is an important reason for clinical referral of children with ADHD and a strong predictor of their educational achievement. This study investigates classroom on-task behavior of Flemish children with ADHD withdrawn from medication as a function of instructional context. Thirty-one pairs of children (one with ADHD and one age- and sex-matched control; 25 boys and 6 girls 6 to 12years of age) were observed in their classroom environment during two consecutive school days. On-task behavior (time on-task and on-task span) of ADHD and non-ADHD individuals was compared in different class contexts (i.e., different class structures and academic content types). Individualized teacher supervision was simultaneously assessed. Generalized estimation equation analyses showed that children with ADHD were significantly less on-task than controls during individual work and whole class group teaching, but not during small group work, and had significantly shorter on-task span during academic tasks (mathematics, language, and sciences) and instructional transitions between tasks, but not during music and arts. These effects persisted even after controlling for the higher levels of teacher supervision observed for ADHD pupils (7%) across all contexts (vs. 4% in controls). Findings suggest that despite receiving more overall teacher supervision, children with ADHD displayed lower levels of on-task behavior in settings that place high self-regulatory, information processing, and motivational demands on them. This finding may have initial implications for classroom interventions in this population.

Differences in posttraumatic stress reactions between witnesses and direct victims of motor vehicle accidents.

The present study describes posttraumatic stress reactions in young witnesses of motor vehicle accidents (MVAs). This study investigated (a) whether witnesses of MVAs report fewer trauma symptoms than direct victims, but more than adolescents who were never exposed to an MVA; and (b) whether individual differences in sex, negative appraisal, avoidant coping, and social support account for variability in trauma symptoms beyond status as a witness as compared to a victim. Self-report data came from a community-based sample of 3,007 adolescents with an average age of 14.6 years and comprising 53% boys. Compared to direct victims of an MVA in which someone was injured, witnesses of MVAs with injury reported significantly less internalizing symptoms, such as symptoms of posttraumatic stress (d = 0.25), fear (d = 0.21), and depression (d = 0.17). Compared to adolescents who were never exposed to an MVA with injury, witnesses reported significantly more externalizing symptoms (d = 0.24). In multiple regression analyses the significant difference between witnesses and victims disappeared when sex, other stressful events, appraisals, and coping were added to the model. These findings suggest that adolescent witnesses, as well as direct victims, may be at risk for posttraumatic reactions.

Altered circadian profiles in attention-deficit/hyperactivity disorder: an integrative review and theoretical framework for future studies.

Disruptions in the sleep-wake cycle and the circadian system have been found in a wide range of psychiatric disorders and are generally correlated with clinical severity and diminished quality of life. Emerging evidence suggests similar disturbances may be found in attention-deficit/hyperactivity disorder (ADHD). Here we review the available literature on across the day fluctuations in ADHD-related processes in terms of; (i) time of day effects on behavior and activity; (ii) morningness-eveningness chronotypology; (iii) sleep/wake rhythms; and (iv) rhythmicity in neuroendocrine and neurophysiological responsiveness. On this basis, we propose a neurobiological framework to guide future study, which sees circadian effects in ADHD, along with other aspects of ADHD arousal-related deficits (e.g., cognitive energetic deficits), as being the result of dysregulated locus coeruleus function. Based on this perspective specific recommendations for future research are presented.

Time-of-day effects in arousal: disrupted diurnal cortisol profiles in children with ADHD.

BACKGROUND: Fluctuations in attention-deficit hyperactivity disorder (ADHD) symptoms related to regulatory deficits in arousal states are themselves characterized by circadian rhythms. Although cortisol is an important circadian arousal-related marker, studies focusing on across-the-day cortisol variations in ADHD are scarce. There is no study with multiple measurements to take into account interday and intraday variability. METHODS: Salivary cortisol was sampled five times a day (awakening, 30 min after awakening, noon, 4 p.m., 8 p.m.) across five consecutive days in 33 children with ADHD (22 with and 11 without oppositional defiant disorder; ODD) and 33 class- and sex-matched controls (aged 6-12). The cortisol awakening response (increase from awakening to 30 min after awakening) and the diurnal cortisol profile (across-the-day variations) were compared for ADHD with ODD (ADHD + ODD) and without ODD (ADHD) subgroups and the control group. RESULTS: The cortisol awakening response was not significantly different between groups. However, longitudinal analyses to evaluate cortisol profiles across the day revealed a significant Group × Time effect (p < .001). More specifically, compared to each other, the ADHD subgroup showed a flatter slope with relative morning hypo-arousal and evening hyperarousal, whereas the ADHD + ODD subgroup showed a steeper slope with relative morning hyperarousal and evening hypo-arousal (p < .001). CONCLUSIONS: Findings support time-related arousal disruptions in children with ADHD associated with the presence or absence of ODD comorbidity. We recommend research on cortisol in larger samples for a better understanding of arousal mechanisms involved in ADHD not only with and without ODD but also with other comorbidities which may have implications for timing of arousal-based treatments.

The traumatic impact of motor vehicle accidents in high school students.

OBJECTIVES: To obtain the year prevalence of nonfatal motor vehicle accidents (MVAs) in adolescents, to describe trauma symptoms (posttraumatic stress, depression, anxiety, dissociation), and to test a theoretical model of traumatic events. METHODS: A community-based sample of 3,007 adolescents (mean age: 14.6 years) completed questionnaires regarding MVAs, appraisals, coping, support, and trauma symptoms. RESULTS: Three percent of the adolescents reported being injured in a MVA during the past year. Of the adolescents who reported a MVA in their life (22.4%), 11.0% reported significant posttraumatic stress or other trauma symptoms. Structural equation modeling revealed that negative appraisals mediated the relation between trauma symptoms and MVA severity. Avoidant coping partially mediated the relation between appraisal and trauma symptoms. Social support was associated with less negative appraisals and with more avoidant coping. CONCLUSIONS: Results suggest the need for a better registration of young traffic victims to optimize screening for psychological problems.

Diurnal variations in arousal: a naturalistic heart rate study in children with ADHD.

Previous studies suggest an altered circadian regulation of arousal in children with attention-deficit hyperactivity disorder (ADHD) as measured by activity, circadian preference, and sleep-wake patterns. Although heart rate is an important measure to evaluate arousal profiles, to date it is unknown whether 24-h heart rate patterns differentiate between children with and without ADHD. In this study, 24-h heart rate data were collected in 30 non-medicated children with ADHD (aged 6-11) and 30 sex-, class-, and age-matched normal controls in their naturalistic home and school setting, during 5 days. Simultaneously, 24-h activity patterns were registered. Confounding effects of demographic variables (e.g., age, sex, BMI, pubertal stage) and comorbid internalizing and externalizing problems on heart rate levels were additionally assessed. Longitudinal analysis showed that heart rate levels were overall higher in the ADHD group (p < 0.01)--with the largest effects during afternoon and night--in a model controlling for age. Other factors did not significantly contribute to variations in heart rate levels. Compared to controls, children with ADHD showed higher activity levels during daytime (especially early afternoon), but not during nighttime (p < 0.05). Post hoc analyses showed that environmental effects might influence daytime variations. Findings suggest an autonomic imbalance in children with ADHD as compared to controls, with higher heart rate levels in the ADHD group. Nighttime tachycardia in this group could not be explained by nighttime activity levels or comorbid externalizing/internalizing problems. Further research on autonomic functioning in ADHD is recommended because of the major impact of higher resting heart rate on health outcomes.

ADHD and delay aversion: the influence of non-temporal stimulation on choice for delayed rewards.

BACKGROUND: Delay aversion, the motivation to escape or avoid delay, results in preference for small immediate over large delayed rewards. Delay aversion has been proposed as one distinctive psychological process that may underlie the behavioural symptoms and cognitive deficits of attention deficit/hyperactivity disorder (ADHD). Furthermore, the delay aversion hypothesis predicts that ADHD children's preference for immediate small over large delayed rewards will be reduced when stimulation, which makes time appear to pass more quickly, is added to the delay interval. The current paper tests these predictions. METHODS: A group of children with a diagnosis of ADHD (with or without oppositional defiant disorder (ODD)), a group with a diagnosis of high-functioning autism (HFA), and a normal control group were compared on an experimental paradigm giving repeated choices between small immediate and large delayed rewards (Maudsley Index of Delay Aversion-MIDA) under two conditions (stimulation and no stimulation). RESULTS: As predicted, ADHD children displayed a stronger preference than the HFA and control children for the small immediate rewards under the no-stimulation condition. The ADHD children preferences were normalised under the stimulation condition with no differences between the groups. This pattern of results was the same whether the ADHD children had comorbid ODD or not. DISCUSSION: The findings from the MIDA are consistent with the delay aversion hypothesis of ADHD in showing that preference for small immediate rewards over large delayed rewards is a specific feature of ADHD and that this preference can be reduced by the addition of stimulation. Further research is required to better understand the emotional and motivational mechanisms underpinning delay aversion.

The impact of attention deficit hyperactivity disorders on brainstem dysfunction in nocturnal enuresis.

PURPOSE: In a specialized university setting the prevalence of attention deficit hyperactivity disorder in general and particularly the inattentive subtype attention deficit hyperactivity disorder of the predominantly inattentive subtype is highly increased. We replicated previous research findings that enuresis is associated with a brainstem deficit and investigated the impact of attention deficit hyperactivity disorder on this brainstem deficit in enuresis. MATERIALS AND METHODS: Electromyography recorded startle eye blink modification with and without attentional modulation was used to measure brainstem functioning in 158 children between 6 and 12 years old. Performance in 3 enuresis groups, including children with enuresis, enuresis plus attention deficit hyperactivity disorder of the predominantly inattentive subtype and enuresis plus attention deficit hyperactivity disorder combined, respectively, was compared with that in normally developing controls and in children with attention deficit hyperactivity disorder subtypes without enuresis. RESULTS: In an automatic attentional task the enuresis groups showed decreased brainstem inhibition compared to that in the control and attention deficit hyperactivity disorder groups (p <0.006). In a controlled attentional task children with and without enuresis who had attention deficit hyperactivity disorder of the predominantly inattentive subtype were unable to show attentional modulation in all age groups (p <0.02). CONCLUSIONS: Startle eye blink modification research reveals a brainstem inhibition deficit in children with enuresis, which could explain why they are unable to remain dry at night. When additional attention is allocated to specific trials in the task, children with attention deficit hyperactivity disorder of the predominantly inattentive subtype fail to optimize sensory gating. With respect to enuresis, this could result in an identification problem of bladder signals, leading to an inadequate or absent arousal effect in attention deficit hyperactivity disorder of the predominantly inattentive subtype.

State regulation in adult ADHD: an event-related potential study.

The state regulation hypothesis postulates that poor task performance of children with ADHD is related to poor energetical state control. The current study aimed to investigate whether such a deficit persists in adult ADHD. Event-related potentials (ERPs) were recorded during administration of a Go/No-Go task that incorporated the stressor presentation rate of stimuli. It was found that males with ADHD responded slower than control males in the slow condition, which was accompanied by smaller parietal P3s, suggesting less effort allocation. No group differences were found with respect to the response inhibition measures (errors of commission and the N2 effect). In conclusion, problems in state regulation seem to persist in male adults with ADHD.

Probing the limits of delay intolerance: preliminary young adult data from the Delay Frustration Task (DeFT).

Delay intolerance/aversion is one amongst a number of candidate neuropsychological endophenotypes for ADHD. Pilot data suggest that, because of potential ceiling effects, simple choice measures of delay tolerance used for children are probably not appropriate for adolescents and adults. The Delay Frustration Task (DeFT) is a new measure of delay intolerance, designed to be used in a similar form with adolescents and adults as well as children. In it delay frustration is indexed as the number and duration of responses made on a response key during a series of unpredictable and unsignalled delay periods, which interrupt the completion of a simple computer-based tests. The aim of this study was to provide preliminary data on the applicability of the task in a sample of young adults. The DeFT was administered to 49 male and female undergraduate students selected from a normal population-base. Their mean age was 23.14 (S.D.=1.54). Three measures of delay frustration were recorded across time intervals during the response window; the number of responses, their duration and their combined product (total time button was pressed) was calculated for each second interval bin during the post-response delay period. The AARS and HADS were used as screening questionnaires for ADHD and anxiety behaviour, respectively. The results indicated that young adults with high-ADHD symptoms scores pressed the button more than those with low ADHD scores during the post-response delay condition. While both groups increased responding across time within intervals this was significantly more marked in the high-ADHD symptom group. These effects became more pronounced when anxiety was controlled. Young adults with high-ADHD symptoms appear to be more sensitive to the imposition of unscheduled and unsignalled delay during a simple maths test. DeFT may provide a useful index of delay tolerance in young adults with ADHD. Future research needs to examine DeFT performance in different age groups and in clinical and non-clinical populations.

Activity in children with ADHD during waiting situations in the classroom: a pilot study.

BACKGROUND: According to the optimal stimulation theory and the delay aversion hypothesis, children with attention deficit hyperactivity disorder (ADHD) experience difficulties when they are confronted with low levels of stimulation and delay, respectively. AIM: This study investigated the activity level of children with ADHD during waiting situations in the classroom. Three series of hypothesis were made: (1) with respect to the comparison between waiting and non-waiting intervals, (2) with respect to the effects of non-temporal stimulation, and (3) with respect to the effects of temporal stimulation on behaviour during waiting. SAMPLE AND METHOD: The activity level of 14 children with ADHD and 14 control children between the ages of 6 and 11 years was observed during two non-waiting class situations and three waiting situations: without any stimulation, in the presence of nontemporal stimulation and in the presence of temporal stimulation. RESULTS: Both groups of children obtained higher activity scores for all behavioural dimensions during waiting compared with non-waiting situations. The results further revealed additive effects of waiting and diagnostic group on behaviour. Additional nontemporal stimulation during waiting affected the behaviour of all children for most behavioural characteristics. For noisiness, additive effects were also found for diagnostic group and either non-temporal stimulation or temporal stimulation. For restlessness, a trend for an interaction effect between diagnostic group and nontemporal stimulation was found. CONCLUSION: The findings have clear implications for school observations within an assessment protocol.

STIVID: A VBSCRIPT-based program for adding visual and auditory stimuli on videotapes.

Some psychological experiments require placement of visual and auditory stimuli on predefined frames in a videotape. We introduce STIVID (STImuli on VIDeo) as a method of performing this task STIVID can add images, words, simple shapes, and audio tones to specific frames of existing video files created in AVI format. STIVID is written in Visual Basic and uses VBScripts to modify the AVI files. Three applications of this program are discussed: adding stimuli for reaction time experiments with couples watching a relational conflict, use of distractors in ADHD experiments, and placing eye masks on actors in existing videotapes to manipulate perceptibility of the target's facial expression during the mind-reading process.

Stimulation seeking and hyperactive behavior in children with ADHD: a re-analysis.

To examine the stimulation-seeking function of hyperactivity in children with ADHD, Antrop and colleagues analyzed the behavior of 30 hyperactive and 30 nonhyperactive children during a waiting situation, either with or without extra stimulation. The behavior was assessed by frequency measures. In their study it was hypothesized that children with ADHD would show a greater decrease in activity in the presence of stimulation than control children. Since confirmation for this hypothesis was only found for 2 of 25 target behaviors, the present re-analysis included other behavioral measures to assess two relationships: first, how hyperactivity varies under fixed time conditions, using measures of duration and intensity of behavior instead of frequency measures, and second, how the perceived duration of waiting time affects behavior. Analysis indicated that children with ADHD showed a greater decrease in behavior in the presence of stimulation for touching objects and movements of trunk, as reported. Further, children who underestimated the waiting period were more apt to seek additional stimulation in its absence than those who overestimated the waiting period.