A Digital Cognitive-Physical Intervention for Attention-Deficit/Hyperactivity Disorder: Randomized Controlled Trial.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Pharmacotherapy has been the primary treatment for ADHD, supplemented by behavioral interventions. Digital and exercise interventions are promising nonpharmacologic approaches for enhancing the physical and psychological health of children with ADHD. However, the combined impact of digital and exercise therapies remains unclear. OBJECTIVE: The aim of this study was to determine whether BrainFit, a novel digital intervention combining gamified cognitive and exercise training, is efficacious in reducing ADHD symptoms and executive function (EF) among school-aged children with ADHD. METHODS: This 4-week prospective randomized controlled trial included 90 children (6-12 years old) who visited the ADHD outpatient clinic and met the diagnostic criteria for ADHD. The participants were randomized (1:1) to the BrainFit intervention (n=44) or a waitlist control (n=46) between March and August 2022. The intervention consisted of 12 30-minute sessions delivered on an iPad over 4 weeks with 3 sessions per week (Monday, Wednesday, and Friday after school) under the supervision of trained staff. The primary outcomes were parent-rated symptoms of attention and hyperactivity assessed according to the Swanson, Nolan, and Pelham questionnaire (SNAP-IV) rating scale and EF skills assessed by the Behavior Rating Inventory of Executive Function (BRIEF) scale, evaluated pre and post intervention. Intention-to-treat analysis was performed on 80 children after attrition. A nonparametric resampling-based permutation test was used for hypothesis testing of intervention effects. RESULTS: Among the 145 children who met the inclusion criteria, 90 consented and were randomized; ultimately, 80 (88.9%) children completed the study and were included in the analysis. The participants' average age was 8.4 (SD 1.3) years, including 63 (78.8%) male participants. The most common ADHD subtype was hyperactive/impulsive (54/80, 68%) and 23 (29%) children had severe symptoms. At the endpoint of the study, the BrainFit intervention group had a significantly larger improvement in total ADHD symptoms (SNAP-IV total score) as compared to those in the control group (ß=-12.203, 95% CI -17.882 to -6.523; P<.001), owing to lower scores on the subscales Inattention (ß=-3.966, 95% CI -6.285 to -1.647; P<.001), Hyperactivity/Impulsivity (ß=-5.735, 95% CI -8.334 to -3.137; P<.001), and Oppositional Defiant Disorder (ß=-2.995, 95% CI -4.857 to -1.132; P=.002). The intervention was associated with significant reduction in the Metacognition Index (ß=-6.312, 95% CI -10.973 to -1.650; P=.006) and Global Executive Composite (ß=-5.952, 95% CI -10.214 to -1.690; P=.003) on the BRIEF. No severe intervention-related adverse events were reported. CONCLUSIONS: This novel digital cognitive-physical intervention was efficacious in school-age children with ADHD. A larger multicenter effectiveness trial with longer follow-up is warranted to confirm these findings and to assess the durability of treatment effects. TRIAL REGISTRATION: Chinese Clinical Trial Register ChiCTR2300070521; https://www.chictr.org.cn/showproj.html?proj=177806.

Prospective Pilot Investigation: Presurgical Depressive Symptom Severity and Anesthesia Response in Women Undergoing Surgery for Gynecologic Mass Removal.

BACKGROUND: Anesthesia depth has been associated with mortality. The association between anesthesia depth and presurgery physical and health status, however, is currently debated. Depression is one comorbid condition that warrants investigation given its association to reduced frontal lobe activity and high prevalence in known surgery samples (e.g., gynecologic mass removal). PURPOSE: This pilot study examined the hypothesis that severity of acute depressive symptoms would associate with greater sensitivity to anesthesia as measured by a frontal lobe electroencephalogram (EEG)-based monitor during the anesthesia induction phase among women undergoing gynecologic mass removal. METHOD: This was a prospective and surgery anesthesia-controlled pilot investigation with 31 women undergoing surgery for removal of pelvic/gynecologic masses. Participants completed the Millon Behavioral Medicine Diagnostic (MBMD) inventory to assess depressive-related symptomatology. A Bispectral Index Score (BIS™) monitor (Aspect Medical Systems Inc., MA) was placed on the left frontal region to measure change in response from a set pre-anesthesia baseline point throughout the induction phase (6.5 min of the anesthetic). BIS™ change was calculated using a modified "area under the curve with respect to ground" formula. RESULTS: Greater sensitivity to anesthesia during induction was significantly associated with higher MBMD future pessimism scores and marginally associated with higher MBMD depression scores. Depressive personality, anxiety severity, tumor type, age, medication use, and comorbidity scores were not found to be predictors of BIS score change. CONCLUSION: These pilot findings suggest that preoperative psychological health and anesthesia response are not independent. Acute presurgery depression and anesthesia response warrant closer empirical examination.

Rural Latinos' mental wellbeing: a mixed-methods pilot study of family, environment and social isolation factors.

Upon immigration to the rural areas in the US, Latino families may experience cultural, geographic, linguistic and social isolation, which can detrimentally affect their wellbeing by acting as chronic stressors. Using a community engagement approach, this is a pilot mixed-method study with an embedded design using concurrent qualitative and quantitative data. The purpose of this study is to evaluate family and social environments in terms of protective factors and modifiable risks associated with mental well-being in Latino immigrants living in rural areas of Florida. Latino immigrant mother and adolescent dyads were interviewed by using in-depth ethnographic semistructured interviews and subsequent quantitative assessments, including a demographic questionnaire and three structured instruments: the Family Environment Scale Real Form, the SF-12v2™ Health Survey and the short version (eight items) of PROMIS Health Organization Social Isolation. This mixed-method pilot study highlighted how family, rural, and social environments can protect or impair wellbeing in rural Latino immigrant mother and adolescent dyads.

A pilot study evaluating presurgery neuroanatomical biomarkers for postoperative cognitive decline after total knee arthroplasty in older adults.

BACKGROUND: Total knee arthroplasty improves quality of life but is associated with postoperative cognitive dysfunction in older adults. This prospective longitudinal pilot study with a parallel control group tested the hypotheses that (1) nondemented adults would exhibit primary memory and executive difficulties after total knee arthroplasty, and (2) reduced preoperative hippocampus/entorhinal volume would predict postoperative memory change, whereas preoperative leukoaraiosis and lacunae volumes would predict postoperative executive dysfunction. METHODS: Surgery (n = 40) and age-education-matched controls with osteoarthritis (n = 15) completed pre- and postoperative (3 weeks, 3 months, and 1 yr) memory and cognitive testing. Hypothesized brain regions of interest were measured in patients completing preoperative magnetic resonance scans (surgery, n = 31; control, n = 12). Analyses used reliable change methods to identify the frequency of cognitive change at each time point. RESULTS: The incidence of postoperative memory difficulties was shown with delay test indices (i.e., story memory test: 3 weeks = 17%, 3 months = 25%, 1 yr = 9%). Postoperative executive difficulty with measures of inhibitory function (i.e., Stroop Color Word: 3 weeks = 21%, 3 months = 22%, 1 yr = 9%). Hierarchical regression analysis assessing the predictive interaction of group (surgery, control) and preoperative neuroanatomical structures on decline showed that greater preoperative volumes of leukoaraiosis/lacunae were significantly contributed to postoperative executive (inhibitory) declines. CONCLUSIONS: This pilot study suggests that executive and memory declines occur in nondemented adults undergoing orthopedic surgery. Severity of preoperative cerebrovascular disease may be relevant for understanding executive decline, in particular.

An assessment of faculty and dental student decision-making in ethics.

This study reports and compares dental student and dental faculty scores to national norms for the Defining Issues Test 2, a measure of ethical decision-making competency. The findings showed that dental students and faculty tend to make decisions that promote self-interest, paralleling the ethical orientation of business professionals. Differences associated with gender, language, and norms from previous studies were observed. The findings underscore the importance of raising dental faculty and student awareness of their own ethical decision-making approaches. More importantly, the findings highlight the need to ensure that dental faculty have both the knowledge and skills to train dental students about the central role that ethical decision-making must play in patient care.

Genotype is correlated with but does not predict virulence of Vibrio vulnificus biotype 1 in subcutaneously inoculated, iron dextran-treated mice.

Vibrio vulnificus is the leading cause of reported deaths from infections related to consumption of seafood in the United States. Affected predisposed individuals frequently die rapidly from sepsis. Otherwise healthy people can experience severe wound infection, which can lead to sepsis and death. A question is why, with so many people consuming contaminated raw oysters, the incidence of severe V. vulnificus disease is low. Molecular typing systems have shown associations of V. vulnificus genotypes and the environmental or clinical source of the strains, suggesting that different genotypes possess different virulence potentials. We examined 69 V. vulnificus biotype 1 strains that were genotyped by several methods and evaluated them for virulence in a subcutaneously inoculated iron dextran-treated mouse model. By examining the relationships between skin infection, systemic liver infection, and presumptive death (a decrease in body temperature), we determined that liver infection is predicated on severe skin infection and that death requires significant liver infection. Although most strains caused severe skin infection, not every strain caused systemic infection and death. Strains with polymorphisms at multiple loci (rrn, vcg, housekeeping genes, and repetitive DNA) designated profile 2 were more likely to cause lethal systemic infection with more severe indicators of virulence than were profile 1 strains with different polymorphisms at these loci. However, some profile 1 strains were lethal and some profile 2 strains did not cause systemic infection. Therefore, current genotyping schemes cannot strictly predict the virulence of V. vulnificus strains and further investigation is needed to identify virulence genes as markers of virulence.

Nutrition Support Therapies on the Medication Administration Record: Impacts on Staff Perception of Nutrition Care.

BACKGROUND: It has been reported that many hospitals in the United States have fragmented and ineffective ordering, administration, documentation, and evaluation/monitoring of nutrition therapies. This paper reports on a project to investigate if perceived hospital staff awareness and documentation of nutrition support therapies (NSTs) improves by including them as part of the medication administration record (MAR). METHODS: Surveys were conducted with nursing staff, physicians, and dietitians before and after adding NSTs to the MAR to evaluate the perceived impact on the outcome of interest. The outcomes of interest include nurses' perception of ease of finding information, awareness of an order, and ability to assess administration and documentation and dietitian, nurse, and physician staff perceptions of impact of intervention on aspects of the nutrition care process. RESULTS: After adding NST to the MAR, nursing staff perceived improvement in knowing that their patient had an oral nutritional supplement (ONS) order (P = .01), when and how much product was last administered (P = .01), and documentation of the type of product consumed (P = .01) and volume of product consumed (P = .01). The majority of dietitian and nurses surveyed reported perceived improvement in placing and finding ONS orders, in administration of ONS, in ability to evaluate patient nutrition status, and in ONS intake and a positive impact on clinical practice. CONCLUSION: Inclusion of NST in the MAR presents an innovative solution to enhance staff awareness of ordered therapies and perception of improved documentation of nutrition interventions for hospitalized patients.

Executive functioning at ages 5 and 7 years in children with prenatal cocaine exposure.

This prospective longitudinal study evaluated the effect of prenatal cocaine exposure (PCE) on executive functioning in 5- and 7-year-old children. In total, 154 pregnant cocaine users, identified by urine toxicology and structured interviews, were matched to 154 nonusers. Children were assessed by certified masked evaluators, and caregivers were interviewed by experienced staff during home visits. In approximately 90% of the surviving sample tested at ages 5 and 7 years, structural equation modeling demonstrated that an increased head circumference at birth (adjusted for gestation) significantly predicted better performance on executive functioning, and that PCE was indirectly related to executive functioning through its significant negative effect on head circumference at birth. At age 5 years, quality of environment also predicted executive functioning, and the R(2) for the total model was 0.24. At 7 years, caregiver functioning predicted quality of environment, which in turn was positively related to executive functioning, and girls had better executive functioning. The total model at age 7 years accounted for 30% of the variance in executive functioning.

Psychometric properties of teacher SKAMP ratings from a community sample.

This study examines the basic psychometric properties of the Swanson, Kotkin, Agler, M-Flynn, and Pelham Scale (SKAMP), a measure intended to assess functional impairment related to attention deficit hyperactivity disorder, in a sample of 1,205 elementary students. Reliability, factor structure, and convergent, discriminant and predictive validity are evaluated. Results provide support for two separate but related subscales, Attention and Deportment, and provide evidence that the SKAMP predicts school functioning above and beyond symptoms alone. Boys, African American children, and children living in poverty are rated as having higher impairment scores than girls, Caucasian children, and more advantaged peers. Norm-referenced data are provided by gender, race, and parental concern level. This study supports the reliability and validity of the SKAMP in a large, diverse community sample and broadens its clinical utility.

Parent and teacher SNAP-IV ratings of attention deficit hyperactivity disorder symptoms: psychometric properties and normative ratings from a school district sample.

To examine Swanson, Nolan, and Pelham-IV (SNAP-IV) psychometric properties, parent (N = 1,613) and teacher (N = 1,205) data were collected from a random elementary school student sample in a longitudinal attention deficit hyperactivity disorder (ADHD) detection study. SNAP-IV reliability was acceptable. Factor structure indicated two ADHD factors and an oppositional defiant disorder (ODD) factor. Parent and teacher scores varied by gender and poverty status (d = .49-.56) but not age; only teacher scores varied by race (d = .25-.55). Screening and diagnostic utility was evaluated with likelihood ratios (LRs) and posttest probabilities. Parent SNAP-IV scores above 1.2 increased probability of concern (LR > 10) and above 1.8, of ADHD diagnosis (LR > 3). Teacher hyperactivity/impulsivity scores above 1.2 and inattention scores above 1.8 increased probabilities of concern only (LR = 4.2 and >5, respectively). Higher teacher scores for African American children and race differences in measurement models require future study.

Predicting caregiver-reported behavior problems in cocaine-exposed children at 3 years.

Predictors of caregiver-reported behavior problems for 3-year-olds with prenatal cocaine exposure (PCE) and matched controls were examined using structural equation modeling. We tested whether PCE had a direct effect on child behavior problems in a model that included other prenatal drug exposure, child sex, caregiver depression, and the quality of the child's home environment. The sample (N = 256) was drawn from a longitudinal, prospective study of children of (predominantly crack) cocaine-using women and controls matched on race, socioeconomic status, parity, and pregnancy risk. Child Behavior Problems was modeled as a latent variable composed of the 48-item Conners' Parent Report Scale Conduct Problem and Impulsive-Hyperactive scales and the Eyberg Child Behavior Inventory Intensity scale. Caregiver depression was the only significant predictor of Child Behavior Problems. Mean levels of caregiver self-reported depression and reported child behavior problems did not differ between groups. Mean depression scores were well above the recommended clinical cutoff while mean child behavior problems scores were within normal limits. The model explained 21% of the variance in caregiver-reported child behavior problems in our sample of rural African American, low SES youngsters. Non-maternal caregivers of cocaine-exposed children had significantly lower mean depression scores and mean child behavior problems ratings for 2 of 3 scales used in the study compared to biological mothers of children with PCE and controls. For all groups, much larger proportions of children were rated as having clinically significant behavior problems than would be expected based on the prevalence of behavior problems in the general population.

Willingness to use ADHD Self-Management: Mixed Methods Study of Perceptions by Adolescents and Parents.

Little is known about perceptions surrounding self-management for attention deficit hyperactivity disorder (ADHD), although such interventions appear commonly used and are considered essential components of the chronic care model. Our research is part of a mixed methods study that followed students at high and low risk for ADHD over 11 years. During the final study years, area-representative samples of 148 adolescents (54.8% participation; 97 ADHD high-risk group; 51 low-risk peers) and 161 parents (59.4% participation; 108 parents of high-risk adolescent; 53 parents of low-risk peer) completed a cross-sectional survey on community-identified self-management interventions for ADHD (activity outlets, sleep regulation, dietary restriction, homework help, family rules, and prayer). Respondents also answered open-ended questions addressing undesirable self-management effects, which were analyzed using grounded theory methods. High-risk adolescents expressed significantly lower willingness towards all self-management interventions than did adult respondents, except for increased activity outlets. They also reported lower receptivity towards sleep regulation and dietary restriction than did their low-risk peer group. No gender or race differences in self-management willingness were found, except for higher receptivity to prayer in African American respondents. Cost, perceived ineffectiveness, disruptions to routines, causation of interpersonal conflicts, and reduced future self-reliance were seen as potential undesirable effects. Findings suggest that activity-based ADHD interventions appear particularly acceptable across all demographic and risk groups, unlike sleep regulation and dietary approaches. Further research on self-care effectiveness is needed to incorporate adolescents' viewpoints about ADHD self-management, as interventions may be acceptable to adults, but resisted by adolescents.

Use and persistence of pharmacotherapy for elementary school students with attention-deficit/hyperactivity disorder.

OBJECTIVE: The aim of this study was to describe rates of attention-deficit/hyperactivity disorder (ADHD) medication treatment and relevant school services use during a 2-year period, and to examine independent predictors of these interventions. METHOD: Parent and child interviews (n = 266) and follow-up 12-month telephone surveys (n = 220) were conducted among a high-risk sample, selected from a districtwide, stratified, random sample of elementary-school students screened for ADHD risk. Medication treatment status and school services use were assessed from multiple sources, and their predictors were identified by logistic regression modeling, adjusting for sociodemographic and parental characteristics, as well as clinical-need variables. RESULTS: Approximately one third (35%) of the children received ADHD medications during a 2-year period, and of those treated at Time 2, approximately one third (36%) were no longer on medications at Time 3. Boys were more than twice as likely to receive ADHD medication as girls. Approximately one quarter (28%) of the children accessed school services and continued their use over 2 years. African-American youths were more likely to receive school services than were Caucasian children. CONCLUSIONS: In this elementary school-district high-risk sample, care for ADHD was remarkable for underuse and attrition of medication treatment, as well as poor linkage to relevant school services. Interventions to improve ADHD care should include supports to access and sustain medication treatment, as well as link with school services, especially for girls.

Relative ability of biologic specimens and interviews to detect prenatal cocaine use.

For this study, we recruited women admitted to our labor and delivery service, enrolling all consenting patients with a history of prenatal cocaine use and the next admission with no recorded use. During the immediate postpartum period, experienced researchers conducted private, structured interviews to obtain details of prenatal cocaine use and to identify a priori exclusion criteria (other illicit drug use, high alcohol use and chronic illnesses and medications). Specific protocols were used to collect amniotic fluid, cord blood, infant urine, meconium and maternal hair. All specimens were analyzed blind with respect to exposure using gas chromatography/mass spectrometry. Of 115 subjects, 46 had one or more biologic specimens positive for cocaine metabolites and five admitted prenatal use, but had negative specimens. Of these 51 identified as users by any method, 38 admitted, 32 were positive for urine, 28 for hair and 25 for meconium. Of the 38 admitters, 87% had positive specimens; of the 77 denying use, 17% were positive. Urine was most frequently positive in identified users, 67% overall and 62% of users who denied. Hair was next, positive in 65% of all users and 50% of users who denied. Of the 13 subjects who denied use but were positive on at least one specimen, four were identified solely by urine, two only by hair and one only by meconium. Self-report identified five users with all negative specimens. Although no one method identified all users, the single method that maximally identified users was detailed history taken by experienced interviewers.

Childhood ADHD Symptoms: Association with Parental Social Networks and Mental Health Service Use during Adolescence.

OBJECTIVE: This study examines the associations of childhood attention-deficit/hyperactivity disorder (ADHD) risk status with subsequent parental social network characteristics and caregiver strain in adolescence; and examines predictors of adolescent mental health service use. METHODS: Baseline ADHD screening identified children at high risk (n = 207) and low risk (n = 167) for ADHD. At eight-year follow-up, parents reported their social network characteristics, caregiver strain, adolescents' psychopathology and mental health service utilization, whereas adolescents self-reported their emotional status and ADHD stigma perceptions. Analyses were conducted using ANOVAs and nested logistic regression modeling. RESULTS: Parents of youth with childhood ADHD reported support networks consisting of fewer spouses but more healthcare professionals, and lower levels of support than control parents. Caregiver strain increased with adolescent age and psychopathology. Increased parental network support, youth ADHD symptoms, and caregiver strain, but lower youth stigma perceptions were independently associated with increased service use. CONCLUSIONS: Raising children with ADHD appears to significantly impact parental social network experiences. Reduced spousal support and overall lower network support levels may contribute to high caregiver strain commonly reported among parents of ADHD youth. Parental social network experiences influence adolescent ADHD service use. With advances in social networking technology, further research is needed to elucidate ways to enhance caregiver support during ADHD care.

Child temperament, ADHD, and caregiver strain: exploring relationships in an epidemiological sample.

OBJECTIVE: To investigate the relationship between child-reported dimensions of temperament and attention-deficit/ hyperactivity disorder (ADHD), as well as other indicators of child psychopathology, including disruptive disorders, depression, and anxiety. It also examined whether difficult child temperament scores independently predicted caregiver strain. METHOD: A school-district-wide, two-phase screening design (response rate 70% for phase 2) identified elementary school children at high risk for ADHD. Two hundred high-risk children and their parents completed standardized instruments to assess child temperament, diagnoses of disruptive disorders, children's symptoms of anxiety and depression, and caregiver strain. Relationships were examined using analysis of variance, correlations, and multivariate prediction models, adjusting for child sociodemographic characteristics and psychopathology. All estimates were weighted for sampling design and differential participation. RESULTS: Combined subtype ADHD was associated with lower scores on task orientation and higher scores on general activity level. Depressive symptoms correlated significantly with all but one difficult temperament dimension, in a pattern consistent with clinical symptoms of depression. Child temperament did not vary by ADHD treatment status. Among these high-risk children, maternal caregiver strain experiences were increased by male gender, inattention symptoms, and oppositional defiant disorder, but not by difficult temperament scores. CONCLUSION: This study provides support for Graham and Stevenson's hypothesis of continuity between specific temperament traits and certain child psychiatric disorders, namely ADHD and depressive disorders.

Social networks, caregiver strain, and utilization of mental health services among elementary school students at high risk for ADHD.

OBJECTIVE: This study explores whether parental support networks vary by sociodemographic factors among children at high risk for attention-deficit/hyperactivity disorder (ADHD) and whether network characteristics influence the receipt of mental health treatment for the child. METHOD: A school district-wide, two-phase screening study design was used to identify 266 children at high risk for ADHD. Parents completed standardized instruments assessing network structure and function, DSM-IV diagnoses of disruptive disorders, caregiver strain, and treatment receipt, and children self-reported internalizing symptoms. Relationships were examined with analysis of variance and multivariate prediction, adjusting for sociodemographic characteristics, psychopathology, and parental strain. RESULTS: Network characteristics varied by race and socioeconomic status (SES), but not by child gender. African-American and disadvantaged parents reported smaller network sizes, but more frequent contact and higher levels of support than their white and high-SES counterparts. High levels of instrumental support lowered the odds of ADHD treatment during the 12 months before (OR =.7, p <.001) and after (OR =.7, p <.001) the network assessment interview. In contrast, parental strain increased the likelihood of ADHD treatment during both periods. CONCLUSIONS: Clinicians should anticipate high levels of caregiver strain and low levels of instrumental support among their patients' parents and address the potential high need for respite care in treatment plans.

Cocaine exposure and developmental outcome from birth to 6 months.

The theoretical framework for many of the early studies of prenatal cocaine exposure has been rooted in the basic concepts of teratology/developmental toxicology. Few have published longitudinal analyses of the complex interplay between the relative effects of prenatal cocaine exposure and perinatal and environmental factors on development. The purpose of this paper was to use structural equation modeling to describe the direct and indirect effects of prenatal drug exposure on developmental outcome from birth to age 6 months. Key variables considered for study include prenatal drug exposure, perinatal medical characteristics, maternal/caregiver/family characteristics, the home environment, and neurobehavioral outcomes. We prospectively enrolled 154 predominantly crack-using women. A priori exclusion criteria included: <18 years old, major illnesses diagnosed prior to pregnancy, chronic use of legal drugs, and any use of illicit drugs other than cocaine and marijuana. From the pool of noncocaine users, 154 subjects were matched to users on pregnancy risk, parity, race, and socioeconomic status. At the end of each trimester, experienced staff conducted private interviews prompting memory of amount and timing of past drug use. Urine specimens were collected at two unanticipated times; positive screens were confirmed by gas chromatography/mass spectroscopy. Measures analyzed include medical (birth) and developmental (birth, 1 month, 6 months) assessments, all performed by blinded evaluators, as well as caregiver characteristics and environmental factors (birth, 1 month). A series of four theoretical models was tested, one for each time point (birth, 1 month, 6 months) and a longitudinal model spanning birth to 6 months. Key findings include direct effects of prenatal cocaine exposure on development at birth in the birth model and on development at birth and 6 months in the longitudinal model. In addition, indirect effects of prenatal cocaine exposure were identified on development at birth, 1 month, and 6 months, mediated through the prenatal use of alcohol and tobacco and the birth head circumference. Implications of these and other findings, including the advantages and limitations of structural equation modeling, are discussed.

Use of complementary and alternative medicine for symptoms of attention-deficit hyperactivity disorder.

OBJECTIVE: Attention-deficit hyperactivity disorder (ADHD) is a common childhood psychiatric condition for which evidence-based treatments have been established. This study describes use of complementary and alternative medicine among children with ADHD or at risk of having ADHD and explores possible predictors of use of such treatments. METHODS: A sample of 1,615 parents of elementary school students in a public school district were interviewed in a telephone screening survey of ADHD symptoms and use of traditional and nontraditional ADHD treatment. A total of 822 parents had a child with a diagnosis of ADHD, had a child in whom ADHD was suspected, or had a child about whose emotions or behavior the parents or school staff had general concerns. RESULTS: Use of complementary and alternative medicine was significantly higher among children who had received a diagnosis of ADHD (12 percent) or in whom ADHD was suspected (7 percent) than among those about whom parents or school staff had general concerns (3 percent). Faith healing had been used for 4 percent of the 822 children. Nontraditional treatments were more likely to have been used among children with a diagnosis or a suspected diagnosis of ADHD and those whose parents used the Internet as a source of information than among other children. CONCLUSIONS: Providers should inquire about nontraditional interventions and educate families about evidence-based approaches when treating children with ADHD.

Barriers to detection, help-seeking, and service use for children with ADHD symptoms.

This study describes 4 help-seeking steps among children at high risk for attention deficit hyperactivity disorder (ADHD), and identifies barriers to ADHD symptom detection and treatment. Using a district-wide stratified random sample of 1615 elementary school students screened for ADHD risk, predictors of 4 help-seeking steps among a high-risk group (n = 389) and parent-identified barriers to care among children with unmet need for ADHD care (n = 91) were assessed. Study findings indicate that although 88% of children were recognized as having a problem, only 39% had been evaluated, 32% received an ADHD diagnosis, and 23% received current treatment. Older children and those with more severe behavior problems were more likely to be perceived by their parents as having a problem. Additionally, gender and ethnic disparities in the subsequent help-seeking process emerged. Boys had over 5 times the odds than girls of receiving an evaluation, an ADHD diagnosis, and treatment. Compared to African American youth, Caucasian children had twice the odds of taking these help-seeking steps. For those children with unmet need for ADHD care, poverty predicted lower treatment rates and was associated with the most pervasive barriers. The gap between parental problem recognition and seeking services suggests that thresholds for parental recognition of a child behavior problem and for seeking ADHD services may be different. Future research examining the help-seeking process for ADHD should include a qualitative component to explore the potential mechanisms for gender and ethnic differences.