Synthetic Marijuana: Assessment of Usage, Motivation and Associated Risks in Adolescent Substance Users.

Objectives: Use of Synthetic and designer products, including synthetic marijuana (SM), among adolescents poses a major risk to public health. Little is known about the motivating factors of synthetic substance use in adolescents. This study examined the motivations, predictors, perceived risks and benefits, and differences with SM versus natural marijuana among adolescents. Methods: Between April 2016 and May 2018, a convenience sample of adolescents receiving substance use treatment from a local counseling center completed an anonymous survey to assess the use of natural and synthetic marijuana use, the Strengths and Difficulties Questionnaire to assess levels of current psychiatric symptoms and the Community Assessment of Psychic Experiences-Positive Scale to assess symptoms of psychosis. Results: A total of 80 adolescents (age range of 14-18 years; 71% male; 53% Caucasian) completed the study. Of these, 39 (49%) reported natural marijuana use (natural marijuana users) and 41 (51%) reported both synthetic and natural marijuana use (dual users). The most commonly reported reasons for using SM were its low cost and reduced risk of detection. Participants who were familiar with SM and reported a desire to avoid detection on drug tests were likelier to use SM (all P < .05). Dual users reported more benefits and risks associated with SM use when compared to natural marijuana users (P ⩽ .05). The use of SM also heightened the perceived medical risks of natural marijuana, including seizures and respiratory issues (P < .05), compared with natural marijuana users. While dual users self-reported more conduct (P = .009) and externalizing problems (P = .024) when compared to natural marijuana users, there were no group differences in psychotic symptoms, nor correlations with the frequency of synthetic or natural marijuana use and psychotic symptoms except that persecutory ideation correlated with the frequency of natural marijuana use during the past 12 months (rp = 0.28, P = .04). Conclusions: These results suggest that reports of cost savings, and lack of detection on urine drug screens are common reasons for SM use in adolescents despite being aware of the risks of using SM. Perceived benefits of using synthetics and other novel substances appear diverse, and merit further exploration as a better understanding of what motivates adolescents to use specific novel substances may guide prevention and treatment efforts.

From Consensus Statement to Pills to Pixels: New Innovations in Attention-Deficit/Hyperactivity Disorder Care.

Objectives: This review aims to present recent innovations and advancements in attention-deficit/hyperactivity disorder (ADHD) care, encompassing international consensus statement, new medication formulations, digital therapeutics, and neurostimulation devices. Methods: A comprehensive literature search of relevant articles published in the past five years was conducted, emphasizing the evidence base, efficacy, safety, and practical implications of these advancements. Results: The World Federation of ADHD Consensus Statement offers an updated diagnostic and treatment framework rooted in global scientific evidence. There are several newer ADHD medication formulations, including a nonstimulant (Viloxazine extended release) and the first transdermal amphetamine patch approved to treat ADHD. These options offer some unique benefits to personalize treatment based on symptom profile, lifestyle, preferences, and response. Digital tools offer additional means to restructure environments for individuals with ADHD, reducing impairment and reliance on others. In addition, digital therapeutics enhance access, affordability, personalization, and feasibility of ADHD care, complementing or augmenting existing interventions. Trigeminal nerve stimulation emerges as a well-tolerated nonpharmacological, device-based treatment for pediatric ADHD, with initial trials indicating effect sizes comparable to nonstimulant medications. Conclusions: These innovations in ADHD care represent clinically significant new treatment options and opportunities for personalized care. Health care professionals should integrate these developments into clinical practice, mindful of individual patient and family needs and preferences. Future research should assess long-term outcomes, cost-effectiveness, and acceptability of these innovations.

Treatment Utilization Pattern of Preschool Children With Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: The aim of this study was to identify patterns of ADHD care, including factors that guide selection and sequencing of treatments in a large nationwide sample of preschool-aged youth over the past 6 years. METHOD: A retrospective cohort study utilizing a large electronic health record (TriNetX) of nearly 24,000 children ages 3 to 6 diagnosed with ADHD. RESULTS: One in three preschoolers with ADHD were prescribed psychotropic medication, most commonly methylphenidate and guanfacine. One in 10 had at least one psychotherapy billing code during the entire assessment with most youth starting medication before psychotherapy. Rates of most treatments, including polypharmacy, increased with comorbid psychiatric disorders or sleep problems and over the course of the coronavirus pandemic. CONCLUSION: Rates of treatment have increased over time but are still largely inconsistent with published care guidelines that advise therapy before medication. Clinicians appear to prioritize psychiatric comorbidity and sleep problems when selecting treatments.

Characterization of behavioral changes in T-maze alternation from dopamine D1 agonists with different receptor coupling mechanisms.

RATIONALE: Dopamine D1 receptor agonists have been shown to improve working memory, but often have a non-monotonic (inverted-U) dose-response curve. One hypothesis is that this may reflect dose-dependent differential engagement of D1 signaling pathways, a mechanism termed functional selectivity or signaling bias. OBJECTIVES AND METHODS: To test this hypothesis, we compared two D1 ligands with different signaling biases in a rodent T-maze alternation task. Both tested ligands (2-methyldihydrexidine and CY208243) have high intrinsic activity at cAMP signaling, but the former also has markedly higher intrinsic activity at D1-mediated recruitment of ß-arrestin. The spatial working memory was assessed via the alternation behavior in the T-maze where the alternate choice rate quantified the quality of the memory and the duration prior to making a choice represented the decision latency. RESULTS: Both D1 drugs changed the alternate rate and the choice latency in a dose-dependent manner, albeit with important differences. 2-Methyldihydrexidine was somewhat less potent but caused a more homogeneous improvement than CY208243 in spatial working memory. The maximum changes in the alternate rate and the choice latency tended to occur at different doses for both drugs. CONCLUSIONS: These data suggest that D1 signaling bias in these two pathways (cAMP vs ß-arrestin) has complex effects on cognitive processes as assessed by T-maze alternation. Understanding these mechanisms should allow the identification or discovery of D1 agonists that can provide superior cognitive enhancement.

Single and Combined Effects of Multiple Intensities of Behavioral Modification and Methylphenidate for Children with ADHD in the Home Setting.

Behavioral treatment, stimulants, and their combination are the recommended treatments for childhood attention-deficit/hyperactivity disorder (ADHD). The current study utilizes within-subjects manipulations of multiple doses of methylphenidate (placebo, 0.15, 0.30, and 0.60 mg/kg/dose t.i.d.) and intensities of behavioral modification (no, low, and high intensity) in the summer treatment program (STP) and home settings. Outcomes are evaluated in the home setting. Participants were 153 children (ages 5-12) diagnosed with ADHD. In alignment with experimental conditions implemented during the STP day, parents implemented behavioral modification levels in three-week intervals, child medication status varied daily, and the orders were randomized. Parents provided daily reports of child behavior, impairment, and symptoms and self-reported parenting stress and self-efficacy. At the end of the study, parents reported treatment preferences. Stimulant medication led to significant improvements across all outcome variables with higher doses resulting in greater improvement. Behavioral treatment significantly improved child individualized goal attainment, symptoms, and impairment in the home setting and parenting stress and self-efficacy. Effect sizes indicate that behavioral treatment combined with a low-medium dose (0.15 or 0.30 mg/kg/dose) of medication results in equivalent or superior outcomes compared to a higher dose (0.60 mg/kg/dose) of medication alone. This pattern was seen across outcomes. Parents overwhelmingly reported preferring treatment with a behavioral component as a first-choice treatment (99%). Results underscore the need to consider dosing as well as parent preference when utilizing combined treatment approaches. This study provides further evidence that combining behavioral treatment and stimulant medication may reduce the stimulant dose needed for beneficial effects.

Effects of a Primary Care-Based Engagement Intervention for Improving Use of ADHD Treatments.

INTRODUCTION: Uptake of attention deficit hyperactivity disorder (ADHD) treatments is low in primary care. A quasi-experimental study assessed the impact of a primary care-based engagement intervention to improve ADHD treatment use. METHOD: Families of children with ADHD from four pediatric clinics were invited to participate in a two-stage intervention. The first step was an assessment battery to assess functioning and identify goals, followed by an in-office engagement session run by primary care staff. RESULTS: Of the 636 invited families, 184 (28.9%) completed ratings, with 95 (51%) families completing the engagement session. ADHD office visits varied based on the number of steps completed (0-2). ADHD prescriptions decreased over time in families completing neither step but increased for children previously unmedicated whose parents completed either step. Families completing both steps had the highest rates of nonmedication ADHD treatments. DISCUSSION: A brief two-step engagement intervention was associated with increased uptake of ADHD treatments.

Neural Predictors of Improvement With Cognitive Behavioral Therapy for Adolescents With Depression: An Examination of Reward Responsiveness and Emotion Regulation.

Earlier depression onsets are associated with more debilitating courses and poorer life quality, highlighting the importance of effective early intervention. Many youths fail to improve with evidence-based treatments for depression, likely due in part to heterogeneity within the disorder. Multi-method assessment of individual differences in positive and negative emotion processing could improve predictions of treatment outcomes. The current study examined self-report and neurophysiological measures of reward responsiveness and emotion regulation as predictors of response to cognitive-behavioral therapy (CBT). Adolescents (14-18 years) with depression (N = 70) completed monetary reward and emotion regulation tasks while electroencephalogram (EEG) was recorded, and self-report measures of reward responsiveness, emotion regulation, and depressive symptoms at intake. Adolescents then completed a 16-session group CBT program, with depressive symptoms and clinician-rated improvement assessed across treatment. Lower reward positivity amplitudes, reflecting reduced neural reward responsiveness, predicted lower depressive symptoms with treatment. Larger late positive potential residuals during reappraisal, potentially reflecting difficulty with emotion regulation, predicted greater clinician-rated improvement. Self-report measures were not significant predictors. Results support the clinical utility of EEG measures, with impairments in positive and negative emotion processing predicting greater change with interventions that target these processes.

Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them.

OBJECTIVE: Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking. METHOD: The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis. RESULTS: Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses. CONCLUSION: Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

Systematic Review and Meta-analysis: Pharmacological and Nonpharmacological Interventions for Persistent Nonepisodic Irritability.

OBJECTIVE: This meta-analysis examined the efficacy of available pharmacological and nonpharmacological interventions for irritability among youth with autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), disruptive behavior disorders (DBD), disruptive mood dysregulation disorder (DMDD), and/or severe mood dysregulation (SMD). METHOD: Literature searches were conducted in October 2020, resulting in 564 abstracts being reviewed to identify relevant papers, with 387 articles being reviewed in full. A random effects model was used for the meta-analysis, with subgroup meta-regressions run to assess effects of study design, intervention type, medication class, and clinical population. RESULTS: A total of 101 studies were included (80 pharmacological, 13 nonpharmacological, 8 combined). Despite high heterogeneity in effects (I2 = 94.3%), pooled posttreatment effect size for decreasing irritability was large (Hedges' g = 1.62). Large effects were found for pharmacological (g = 1.85) and nonpharmacological (g = 1.11) interventions; moderate effects were found for combined interventions relative to monotherapy interventions (g = 0.69). Antipsychotic medications provided the largest effect for reducing irritability relative to all other medication classes and nonpharmacological interventions. A large effect was found for youth with ASD (g = 1.89), whereas a medium effect was found for youth with ADHD/DMDD/DBD/SMD (g = 0.64). CONCLUSION: This meta-analysis provides a comprehensive review of interventions targeting persistent nonepisodic irritability among youth with various psychiatric disorders. Strong evidence was found for medium-to-large effects across study design, intervention type, and clinical populations, with the largest effects for pharmacological interventions, particularly antipsychotic medications and combined pharmacological interventions, and interventions for youth with ASD.

Editorial: Can Too Much Positive Emotion Be Bad for You?

There has been increasing focus on the assessment and treatment of irritability over the past decade in recognition of the impairment produced by abnormally persistent or excessive displays of negative emotions. However, emotional dysregulation may not be valence specific, and the impact of excessive or abnormally persistent displays of positive affect has received little attention. In their review in this issue of the Journal, Vogel et al.1 argue that it should receive more attention. They do an admirable job synthesizing the developmental and clinical literature to support the potential value of assessing the capacity to regulate positive affect in an attempt to determine if too much of good thing can in fact be bad for you.

Adolescent Suicide Risk Screening: A Secondary Analysis of the SHIELD Randomized Clinical Trial.

OBJECTIVE: To evaluate the effectiveness of adolescent suicide risk screening to increase initiation of mental health services via a secondary analysis using data from the SHIELD (Screening in High Schools to Identify, Evaluate and Lower Depression) randomized clinical trial, which evaluated school-based screening for major depressive disorder (MDD). STUDY DESIGN: Students in 14 Pennsylvania high schools were randomized by grade to either the usual school practice of targeted referral for behavior raising a concern for suicide risk or universal screening using the Patient Health Questionnaire-9 (PHQ-9), with any response >0 to item 9 regarding suicide risk considered positive. Students identified in either arm were referred to the Student Assistance Program (SAP), which is mandated in all Pennsylvania schools. The SAP determined follow-up. Study groups were compared using mixed-effects logistic regression. RESULTS: The participants comprised 12 909 students, with 6473 (50.1%) randomized to universal screening. The study group was 46% female and 43% Hispanic or non-Hispanic Black. Adolescents in the universal screening arm had 7.1-fold greater odds (95% CI, 5.7-8.8) of being identified as at risk for suicide, 7.8-fold greater odds (95% CI, 4.6-13.1) of follow-up needs, and 4.0-fold greater odds (95% CI, 2.0-7.9) of initiating mental health treatment. CONCLUSIONS: Although the PHQ-9 is a MDD screening tool, its use in universal screening increased identification and treatment initiation for adolescents at risk for suicide. This confirms the value of universal screening and suggests that a suicide-specific risk assessment would have even greater impact on treatment initiation for identified youth. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03716869.

School Year and Suicidal Behaviors Among Youth: Insight From a National Dataset.

Objective: To compare suicidal behaviors that occur during the school year with those during school break and to examine demographic characteristics and comorbidities of the suicidal behaviors by time period.Methods: This retrospective cross-sectional analysis of a nationwide US sample included 74,385 inpatients (aged 10-18 years) who were admitted to the hospital with primary ICD-9 codes of suicidal ideation or suicide and self-inflicted injury including poisoning between January and December 2014. For this study, the sample was further subgrouped based on school year (September to May) and school break (June to August).Results: Suicidal behaviors were higher during the school year (average of 6,761/month) compared to school break (average of 4,512/month). Prevalence of suicidal behaviors was highest in October for both hospitalization and primary diagnosis of mood disorder. Among the school year cohort, the rate of suicidal behaviors was higher in youth with mood disorders (91.6% vs 90%). During school break, the suicidal behavior rate was higher for youth with disruptive behavior disorders (34.6% vs 31.5%) and comorbid alcohol (7.9% vs 5.7%) and other substance use disorders (21.7% vs 18.4%).Conclusions: Suicidal behaviors were higher (1.5 times) during the school year compared to school break. Given the finding that suicidal behaviors are higher among students with mood disorders during the school year, schools should implement universal depression and suicide screening. Youth with disruptive behavior disorders and substance use disorders are at higher risk for suicidal behaviors during school break, thus increased outreach and monitoring during extended breaks seems warranted for these high-risk youth during unstructured times.

Analysis of Daily Sleep Diary Measures From Multilayer Extended-Release Methylphenidate (PRC-063) Studies in Children and Adults With ADHD.

OBJECTIVE: To compare the effect of a once-daily extended-release methylphenidate formulation (PRC-063) versus placebo on sleep, measured via daily electronic diary in two clinical trials in pediatric (6-12 years) and adult (≥18 years) patients with attention deficit hyperactivity disorder (ADHD). METHOD: A diary was completed by adult patients or parents/caregivers of pediatric patients during two randomized, double-blind, placebo-controlled laboratory classroom studies. Following dose optimization of PRC-063, patients were randomized to 1 week of double-blind treatment with PRC-063 or placebo before attending a full-day laboratory classroom session. RESULTS: In the studies, 148 pediatric patients and 239 adult patients were randomized to either PRC-063 or placebo. When compared with the diaries of placebo patients, the sleep diaries in both pediatric and adult patients showed no statistical difference in total sleep time, efficiency, or latency. CONCLUSION: PRC-063 did not impact subjective measures of sleep versus placebo in pediatric and adult patients with ADHD.

Updates in Pharmacologic Strategies for Emotional Dysregulation in Attention Deficit Hyperactivity Disorder.

Emotional dysregulation (ED) manifesting as irritability or aggression produces appreciable impairment in children with attention deficit hyperactivity disorder and a main reason why they present for treatment. Central nervous system (CNS) stimulants seem to be a safe and tolerable treatment of most youth with these presentations. Optimization of CNS stimulants dose in combination with psychosocial interventions led to reductions in ED. Randomized controlled trials support that addition of risperidone further reduces aggression when these treatments are not sufficient. There is evidence for the efficacy of divalproex, molindone and selective serotonin reuptake inhibitor improve these outcomes when used as adjunct to CNS stimulants.

Associations among ADHD symptoms, ODD symptoms, and borderline personality features: A network analysis.

Attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are common childhood syndromes that exhibit a high degree of comorbidity. Both ADHD and ODD symptoms in childhood predict higher levels of borderline personality features (BPF) later in development. Yet ADHD, ODD, and BPF each consist of a heterogeneous group of symptoms, and symptom-level associations between these groups remain unclear. The present study examined symptom-level associations, as well as sex differences in symptom-level associations, among ADHD, ODD, and BPF using network analysis. Caregivers of 962 children between the ages of 5 and 12 completed rating scales of ADHD, ODD, and BPF. Assessment of Bridge Expected Influence indicated a number of bridge symptoms linking ADHD to ODD; these bridge symptoms were primarily from the hyperactive-impulsive (rather than the inattentive) dimension of ADHD (e.g., blurts out answers, leaves seat, runs excessively). A smaller number of bridge symptoms were identified linking ADHD and ODD to BPF, and these bridge symptoms were different for girls versus boys. Overall, several ADHD hyperactive-impulsive symptoms were related to the BPF item gets in trouble for doing things without thinking, and the ODD item touchy/easily annoyed was related to the BPF item goes back and forth between different feelings. Moreover, whereas we observed stronger links between ODD antagonistic symptoms (e.g., blames others) and BPF among girls, we observed stronger links between ODD oppositional symptoms (e.g., defies/refuses to comply) and BPF among boys. Taken together, results provide a more nuanced, symptom-level understanding of the overlap among ADHD, ODD, and BPF.

The effect of stimulant medication on the learning of academic curricula in children with ADHD: A randomized crossover study.

OBJECTIVE: Evaluate whether stimulant medication improves acquisition of academic material in children with attention deficit hyperactivity disorder (ADHD) receiving small-group, content-area instruction in a classroom setting. METHOD: Participants were 173 children between the ages of 7 and 12 years old (77% male, 86% Hispanic) who met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for ADHD and were participating in a therapeutic summer camp. The design was a triple-masked, within-subject, AB/BA crossover trial. Children completed two consecutive phases of daily, 25-min instruction in both (a) subject-area content (science, social studies) and (b) vocabulary. Each phase was a standard instructional unit lasting for 3 weeks. Teachers and aides taught the material to small groups in a summer classroom setting. Each child was randomized to be medicated with daily osmotic-release oral system methylphenidate (OROS-MPH) during either the first or second of the instructional phases, receiving placebo during the other. RESULTS: Medication had large, salutary, statistically significant effects on children's academic seatwork productivity and classroom behavior on every single day of the instructional period. However, there was no detectable effect of medication on learning the material taught during instruction: Children learned the same amount of subject-area and vocabulary content whether they were taking OROS-MPH or placebo during the instructional period. CONCLUSIONS: Acute effects of OROS-MPH on daily academic seatwork productivity and classroom behavior did not translate into improved learning of new academic material taught via small-group, evidence-based instruction. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Corrigendum: A Mini-Review of Pharmacological and Psychosocial Interventions for Reducing Irritability Among Youth With ADHD.

[This corrects the article DOI: 10.3389/fpsyt.2022.794044.].

A Mini-Review of Pharmacological and Psychosocial Interventions for Reducing Irritability Among Youth With ADHD.

Approximately a third of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) experience significant irritability; despite this, no study has reviewed whether interventions for youth with ADHD can improve irritability. This mini review sought to address this gap in the literature by discussing existing pharmacological and psychosocial interventions for irritability among children and adolescents with ADHD. A literature search was conducted in April 2021, with a total of 12 intervention articles identified (six pharmacological, one psychosocial, five combined). Studies were excluded if they did not involve an intervention, a measure of irritability, or the population was not youth with ADHD. Of these articles, two were with an ADHD only sample; seven included ADHD with comorbid disruptive behavior, disruptive mood dysregulation disorder (DMDD), or severe mood dysregulation (SMD); and three included ADHD with comorbid autism spectrum disorder (ASD). Findings suggest that central nervous system stimulants used alone or in combination with behavior therapy are effective at reducing irritability in youth with ADHD only or comorbid ADHD and DMDD/SMD. Less evidence was found for the efficacy of guanfacine and atomoxetine for youth with ADHD only or comorbid ADHD and ASD. Parent training alone or in combination with atomoxetine was found to be effective at reducing irritability in youth with comorbid ADHD and ASD. Future research assessing the efficacy of other psychosocial interventions, particularly cognitive behavioral therapy is necessary, as are randomized trials assessing intervention sequencing and intensity among youth with ADHD. Researchers are advised to utilize well-validated measures of irritability in future research.

Treatment Engagement Following a Positive Mental Health Screening Questionnaire.

INTRODUCTION: Less than half of U.S. adolescents with major depressive disorder receive treatment. Despite the U.S. Preventive Services Task Force 2016 statement supporting primary care major depressive disorder screening, there is limited data examining whether positive screens prompt treatment engagement. This study evaluated treatment engagement following a positive Patient Health Questionnaire-Adolescent Version screen and assessed the impact of demographics, clinical variables, and provider recommendations on treatment engagement. METHODS: This was a retrospective cohort study (analysis November 2021) of adolescents aged 11-18 years seen at a primary care clinic of an academic medical center from July 2017 to December 2018 and identified with a positive Patient Health Questionnaire-Adolescent Version (broadest definition score ≥10; ≥1 for Item 9 regarding suicidal thoughts; yes for unscored Items 1, 3, or 4; or very or extremely difficult for unscored Item 2). Positive screen by score ≥10 alone was also considered. The primary outcome was treatment engagement, defined as initiation of a psychotropic medication, or a behavioral health treatment session within 1 year of symptom identification. RESULTS: Of the 1,315 eligible adolescents, 23.0% had a positive Patient Health Questionnaire-Adolescent Version (n=302) by the broadest criteria; 92/302 (30.5%) engaged in treatment. Patients whose providers recommended treatment had 7.32 times the odds (95% CI=3.76, 14.2, p<0.001) of treatment engagement. For those positive by Patient Health Questionnaire-Adolescent Version ≥10 (85/302, 28.1%), 37/85 (43.5%) engaged in treatment. The influence of provider recommendations was comparable (OR=6.96, 95% CI=3.56, 13.6, p<0.001). CONCLUSIONS: Less than half of adolescents with a positive Patient Health Questionnaire-Adolescent Version at an academic primary care clinic engaged with treatment. Provider recommendation was an impactful intervention to improve mental healthcare treatment engagement.

The Impact of Irritability and Callous Unemotional Traits on Reward Positivity in Youth with ADHD and Conduct Problems.

Children with attention-deficit/hyperactivity disorder (ADHD) and conduct problems exhibit significant variability in functioning and treatment response that cannot be fully accounted for by differences in symptom severity. Reward responsivity (RR) is a potential transdiagnostic means to account for this variability. Irritability and callous-unemotional (CU) traits moderate associations between both ADHD and conduct problems with multiple realms of functioning. Both are theorized to be associated with RR, but associations in clinical samples are unknown. In 48 youth ages 5-12 with ADHD referred for treatment of conduct problems, we examined RR using a guessing task where participants select a door icon to win and lose money. Analyses focused on the reward positivity (RewP) event-related potential in response to gain and loss feedback, which reliably peaks approximately 300 ms after feedback. Frequentist and Bayesian approaches assessed main effects of ADHD, Conduct Disorder (CD) and non-irritable Oppositional Defiant Disorder (ODD) symptoms with RR, plus interactions between symptoms and affective dimensions (irritability, CU). CD and ODD were hypothesized to be associated with altered RR, with irritability and CU moderating these associations. Across models, a reliable CD x irritability interaction emerged, indicating enhanced RewP when irritability was elevated and CD symptoms were low. CU did not moderate any associations with RR, and little support was found for associations between RR and other symptom domains. As neural response to reward varied with levels of irritability and CD symptoms, RR may hold potential as a clinically-relevant biomarker in youth with ADHD and conduct problems.