Serum cortisol level to screen for significant hypothalamic-pituitary-adrenal axis suppression in patients receiving multiple steroid injections.

BACKGROUND: Morning serum cortisol level (mSCL) is a practical screening tool for hypothalamic-pituitary-adrenal (HPA) axis suppression and has been used to assess for duration of cortisol deficiency after epidural and peripheral glucocorticoid injections. More evidence is needed to establish the utility of mSCL in patients undergoing repeat injections with increasing cumulative glucocorticoid equivalent dose (CGED) that could place them at higher risk of HPA axis suppression. OBJECTIVES: To estimate the prevalence of spine injection candidates with significant HPA axis suppression (sigAS), to understand the correlation between 12 months of CGED and the presence of sigAS based on the timing of mSCL collection after the most recent glucocorticoid injection (within 6 weeks or between 6 weeks and 12 months), and to investigate demographic and clinical factors relating to sigAS. METHODS: Retrospective chart review of patients scheduled for spine injection who had an associated mSCL and documented histories of prior glucocorticoid injections. The steroid name, dose, type, and procedure location were recorded for each injection that occurred within 12 months before mSCL. CGED was calculated from standard glucocorticoid equivalent conversion factors. RESULTS: SigAS was present in 7.8% to 22% of the analysis cohorts. There was no association found between CGED and sigAS regardless of timing of mSCL. There was a trend toward lower mSCL and sigAS with increasing CGED. There were no significant relationships found between sigAS and overall demographic or clinical factors. CONCLUSIONS: A 3-fold reduction in the rate of sigAS was noted 6 weeks after the most recent steroid injection. Using mSCL provides a template to investigate the impact of CGED and the best timing for mSCL collection in order to define a more practical guideline to identify patients at higher risk of sigAS earlier and plan for future spine injections.

Association between early life antibiotic exposure and development of early childhood atopic dermatitis.

Background: Atopic dermatitis (AD) is a chronic, inflammatory skin disease commonly onset during infancy. Objective: We examine the association between pre-and postnatal antibiotic exposure and the development of AD. Methods: A retrospective, observational study analyzed 4106 infants at the University of Florida from June 2011 to April 2017. Results: Antibiotic exposure during the first year of life was associated with a lower risk of AD. The association was strongest for exposure during the first month of life. There were no significant differences in the rates of AD in infants with or without exposure to antibiotics in months 2 through 12, when examined by month. Antibiotic exposure during week 2 of life was associated with lower risk of AD, with weeks 1, 3, and 4 demonstrating a similar trend. Limitations: Retrospective data collection from a single center, use of electronic medical record, patient compliance with prescribed medication, and variable follow-up. Conclusions: Early life exposures, such as antibiotics, may lead to long-term changes in immunity. Murine models of atopic dermatitis demonstrate a "critical window" for the development of immune tolerance to cutaneous microbes. Our findings suggest that there may also be a "critical window" for immune tolerance in human infants, influenced by antibiotic exposure.

Association between atopic dermatitis and race from infancy to early childhood: a retrospective cohort study.

BACKGROUND: Atopic dermatitis (AD) is a common pediatric skin condition with significant morbidity. It is unclear what factors contribute to racial differences in disease prevalence. METHODS: A single-site, retrospective cohort study of infants born from June 1, 2011, to April 30, 2017, was performed. RESULTS: Of the 4016 infants included, 39.2% (n = 1574) were Black, 38.5% (n = 1543) White (non-Hispanic), 7.1% (n = 286) Hispanic, 5.3% (n = 213) Asian, 6.5% (n = 262) "other" race, 3.4% (n = 135) multiracial, and 0.1% (n = 3) not reported. Prevalence of AD differed by race, with 37.0% (n = 583) of Black, 25.8% (n = 55) of Asian, 24.1% (n = 69) of Hispanic, 23.0% (n = 31) of multiracial, 19.1% (n = 50) of "other" race, and 17.9% (n = 276) of White patients diagnosed (P < 0.0001). Delivery mode, NICU stay, and gestational age were all significantly associated with race. In modeling AD with logistic regression, race was significantly associated with the development of AD (P < 0.0001, OR Black = 2.6 [2.2-3.2], OR Asian = 1.6 [1.1-2.2], OR Hispanic = 1.4 [1.0-1.9], OR multiracial 1.4 [0.91-2.2], OR "other" 0.97 [0.67-1.4], and OR White 1.0). CONCLUSIONS: Racial differences in rates of AD arise early in life. Diagnosis is associated with race rather than delivery mode, insurance type, and gestational age. Further investigation into these disparities and interventions to mitigate them should focus on infancy and early childhood.

Proof of concept: digital clock drawing behaviors prior to transcatheter aortic valve replacement may predict length of hospital stay and cost of care.

AIMS: Reduced pre-operative cognitive functioning in older adults is a risk factor for postoperative complications, but it is unknown if preoperative digitally-acquired clock drawing test (CDT) cognitive screening variables, which allow for more nuanced examination of patient performance, may predict lengthier hospital stay and greater cost of hospital care. This issue is particularly relevant for older adults undergoing transcatheter aortic valve replacement (TAVR), as this surgical procedure is chosen for intermediate-risk older adults needing aortic replacement. This proof of concept research explored if specific latency and graphomotor variables indicative of planning from digitally-acquired command and copy clock drawing would predict post-TAVR duration and cost of hospitalization, over and above age, education, American Society of Anesthesiologists (ASA) physical status classification score, and frailty. METHODS: Form January 2018 to December 2019, 162 out of 190 individuals electing TAVR completed digital clock drawing as part of a hospital wide cognitive screening program. Separate hierarchical regressions were computed for the command and copy conditions of the CDT and assessed how a-priori selected clock drawing metrics (total time to completion, ideal digit placement difference, and hour hand distance from center; included within the same block) incrementally predicted outcome, as measured by R2 change significance values. RESULTS: Above and beyond age, education, ASA physical status classification score, and frailty, only digitally-acquired CDT copy performance explained significant variance for length of hospital stay (9.5%) and cost of care (8.9%). CONCLUSIONS: Digital variables from clock copy condition provided predictive value over common demographic and comorbidity variables. We hypothesize this is due to the sensitivity of the copy condition to executive dysfunction, as has been shown in previous studies for subtypes of cognitive impairment. Individuals undergoing TAVR procedures are often frail and executively compromised due to their cerebrovascular disease. We encourage additional research on the value of digitally-acquired clock drawing within different surgery types. Type of cognitive impairment and the value of digitally-acquired CDT command and copy parameters in other surgeries remain unknown.

Preclinical Research Reporting in Shock: Room for Improvement.

ABSTRACT: The ARRIVE (Animals in Research: Reporting In Vivo Experiments) guidelines were endorsed by the Shock Society in 2012, but to date there has been no systematic evaluation of research reporting quality for Shock. We systematically assessed 100 randomly selected animal-based research articles published between 2014 and 2018 for reporting quality and statistical practice, compared with 40 pre-ARRIVE studies. More than half of surveyed papers omitted verifiable ethical oversight information and basic animal descriptive information. Few papers reported best-practice methods, such as sample size justification (10%), randomization (43%), randomization method (7%), blinding (23%). Only one paper reported effect sizes to interpret study results. Most troubling was inadequate reporting of welfare-related information (anesthesia, analgesia, humane endpoints, euthanasia). Almost a decade after ARRIVE endorsement, our findings show that reporting deficiencies have persisted with little sign of correction. There is a clear need for investigators to increase transparency of research methods reporting, and drastically improve skills in experimental design. Improvement in standards and greater attention paid to reporting will lead to improvement in reproducibility, replicability, and research quality. It is incumbent upon the research community to improve reporting practices; accurate and transparent reporting is integral to producing rigorous and ethical science.

Duration of neonatal intensive care unit exposure associated with decreased risk of atopic dermatitis.

BACKGROUND/OBJECTIVES: Premature infants have lower rates of atopic dermatitis (AD) compared with full-term infants, though little is known about the factors contributing to this association. We explored the infant and environmental factors that may contribute to the association between prematurity and atopic dermatitis, including mode of delivery, birthweight, gestation, and duration of stay in the neonatal intensive care unit (NICU). METHODS: This was a single-center retrospective study. Independent samples t tests or chi-square tests were used to compare groups on continuous and categorical variables, respectively. Logistic regression then examined the association of the predictor variables with AD. RESULTS: Four thousand sixteen mother-infant dyads were included. Infants had a higher risk of developing AD if they were delivered vaginally (P = .013), did not stay in the NICU (P < .001), had a longer gestation (P = .001), or had a higher birthweight (P = .002). In modeling atopic dermatitis with the predictor variables, only NICU length of stay remained significantly associated with a lower risk of AD (P = .004). CONCLUSION: Infants had a lower risk of developing AD if they had a longer stay in the NICU.

Psychometric Properties of the Vanderbilt ADHD Diagnostic Rating Scale Completed by Juvenile Corrections Staff.

Objective: This research tests the psychometric performance of the Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS) completed by juvenile corrections (JC) staff. Method: With institutional review board (IRB) approval and appropriate consents/assents, data were collected from case managers (n = 18), teachers (n = 9), youth (n = 261), and an administrative database. Separate psychometric analyses were conducted for case managers and teachers. Results: For both respondent groups, 2-week retest reliability and internal consistency were high for all four VADTRS subscales, and confirmatory factor analysis suggested fit with previously reported VADTRS subscale structure. Significant correlations of VADTRS with respective Revised Behavior Problem Checklist subscale scores indicated good concurrent validity. Discriminative validity was strong for ADHD, but not for conduct subscales. Interrater agreement was poor, similar as reported in other settings. Conclusion: Acceptable VADTRS psychometric performance among two JC staff groups supports guideline-consistent practice of obtaining standardized rating scale information from JC staff to enhance the quality of ADHD treatment.

Feasibility and Rationale for Incorporating Frailty and Cognitive Screening Protocols in a Preoperative Anesthesia Clinic.

BACKGROUND: Advanced age, frailty, low education level, and impaired cognition are generally reported to be associated with postoperative cognitive complications. To translate research findings into hospital-wide preoperative assessment clinical practice, we examined the feasibility of implementing a preoperative frailty and cognitive assessment for all older adults electing surgical procedures in a tertiary medical center. We examined associations among age, education, frailty, and comorbidity with the clock and 3-word memory scores, estimated the prevalence of mild to major cognitive impairment in the presurgical sample, and examined factors related to hospital length of stay. METHODS: Medical staff screened adults ≥65 years of age for frailty, general cognition (via the clock-drawing test command and copy, 3-word memory test), and obtained years of education. Feasibility was studied in 2 phases: (1) a pilot phase involving 4 advanced nurse practitioners and (2) a 2-month implementation phase involving all preoperative staff. We tracked sources of missing data, investigated associations of study variables with measures of cognition, and used 2 approaches to estimate the likelihood of dementia in our sample (ie, using extant data and logistic regression modeling and using Mini-Cog cut scores). We explored which protocol variables related to hospital length of stay. RESULTS: The final implementation phase sample included 678 patients. Clock and 3-word memory scores were significantly associated with age, frailty, and education. Education, clock scores, and 3-word scores were not significantly different by surgery type. Likelihood of preoperative cognitive impairment was approximately 20%, with no difference by surgery type. Length of stay was significantly associated with preoperative comorbidity and performance on the clock copy condition. CONCLUSIONS: Frailty and cognitive screening protocols are feasible and provide information for perioperative care planning. Challenges to clinical adaptation include staff training, missing data, and additional administration time. These challenges appear minimal relative to the benefits of identifying frailty and cognitive impairment in a group at risk for negative postoperative cognitive outcome.

Proof of principle: Preoperative cognitive reserve and brain integrity predicts intra-individual variability in processed EEG (Bispectral Index Monitor) during general anesthesia.

BACKGROUND: Preoperative cognitive reserve and brain integrity may explain commonly observed intraoperative fluctuations seen on a standard anesthesia depth monitor used ubiquitously in operating rooms throughout the nation. Neurophysiological variability indicates compromised regulation and organization of neural networks. Based on theories of neuronal integrity changes that accompany aging, we assessed the relative contribution of: 1) premorbid cognitive reserve, 2) current brain integrity (gray and white matter markers of neurodegenerative disease), and 3) current cognition (specifically domains of processing speed/working memory, episodic memory, and motor function) on intraoperative neurophysiological variability as measured from a common intraoperative tool, the Bispectral Index Monitor (BIS). METHODS: This sub-study included participants from a parent study of non-demented older adults electing unilateral Total Knee Arthroplasty (TKA) with the same surgeon and anesthesia protocol, who also completed a preoperative neuropsychological assessment and preoperative 3T brain magnetic resonance imaging scan. Left frontal two-channel derived EEG via the BIS was acquired preoperatively (un-medicated and awake) and continuously intraoperatively with time from tourniquet up to tourniquet down. Data analyses used correlation and regression modeling. RESULTS: Fifty-four participants met inclusion criteria for the sub-study. The mean (SD) age was 69.5 (7.4) years, 54% were male, 89% were white, and the mean (SD) American Society of Anesthesiologists score was 2.76 (0.47). We confirmed that brain integrity positively and significantly associated with each of the cognitive domains of interest. EEG intra-individual variability (squared deviation from the mean BIS value between tourniquet up and down) was significantly correlated with cognitive reserve (r = -.40, p = .003), brain integrity (r = -.37, p = .007), and a domain of processing speed/working memory (termed cognitive efficiency; r = -.31, p = .021). Hierarchical regression models that sequentially included age, propofol bolus dose, cognitive reserve, brain integrity, and cognitive efficiency found that intraoperative propofol bolus dose (p = .001), premorbid cognitive reserve (p = .008), and current brain integrity (p = .004) explained a significant portion of intraoperative intra-individual variability from the BIS monitor. CONCLUSIONS: Older adults with higher premorbid reserve and less brain disease were more stable intraoperatively on a depth of anesthesia monitor. Researchers need to replicate findings within larger cohorts and other surgery types.

Considerations for Clock Drawing Scoring Systems in Perioperative Anesthesia Settings.

The Clock Drawing Test is a cognitive screening tool gaining popularity in the perioperative setting. We compared 3 common scoring systems: (1) the Montreal Cognitive Assessment; (2) the Mini-Cog; and (3) the Libon scale. Three novice raters acquired interrater and intrarater reliability for each scoring system and then scored 738 preoperative clock drawings with each scoring system. Final scores correlated with each other but with notable discrepancies, indicating the need to attend to interrater and intrarater reliability when implementing any scoring approach in a clinical setting.

Clock Drawing Performance Slows for Older Adults After Total Knee Replacement Surgery.

BACKGROUND: Clock drawing is a neurocognitive screening tool used in preoperative settings. This study examined hypothesized changes in clock drawing to command and copy test conditions 3 weeks and 3 months after total knee arthroplasty (TKA) with general anesthesia. METHODS: Participants included 67 surgery and 66 nonsurgery individuals >60 years who completed the digital clock drawing test before TKA (or a pseudosurgery date), and 3 weeks and 3 months postsurgery. Generalized linear mixed models assessed digital clock drawing test latency (ie, total time to completion, seconds between digit placement) and graphomotor output (ie, total number of strokes, clock size). Reliable change analyses examined the percent of participants showing change beyond differences found in nonsurgery peers. RESULTS: After adjusting for age, education, and baseline cognition, both digital clock drawing test latency measures were significantly different for surgery and nonsurgery groups, where the surgery group performed slower on both command and copy test conditions. Reliable change analyses 3 weeks after surgery found that total time to completion was slower among 25% of command and 21% of copy constructions in the surgery group. At 3 months, 18% of surgery participants were slower than nonsurgery peers. Neither graphomotor measure significantly changed over time. CONCLUSIONS: Clock drawing construction slowed for nearly one-quarter of patients after TKA surgery, whereas nonsurgery peers showed the expected practice effect, ie, speed increased from baseline to follow-up time points. Future research should investigate the neurobiological basis for these changes after TKA.

The Impact of an Infant Oral Health Program on Dental Students' Knowledge and Attitudes.

The high prevalence of early childhood caries and many general dentists' reluctance to treat young children and pregnant women demand new educational programs to foster delivery of oral health services. The aim of this study was to evaluate the impact of an Infant Oral Health Program (IOHP) at the University of Florida College of Dentistry on dental students' knowledge about and willingness to provide dental care for infants, children up to three years of age, and pregnant women. A total of 233 dental students in the first through fourth years and recent graduates completed a survey that assessed the educational outcomes of the IOHP; only the fourth-year students had received IOHP training. The results showed that females were more likely than males to provide counseling to caregivers about dental and physical development (p=0.024) and to offer restorative treatment to young children (p=0.021). Older students were more likely than younger students to provide restorative treatment (p=0.013). A greater percentage of IOHP-trained students (96%) reported knowing how to use the lap examination technique compared with untrained students (71%; p<0.001). IOHP-trained students were the most uncomfortable dealing with a crying child in the dental chair (p=0.0175). The graduates and fourth-year students were significantly more likely than the other cohorts to provide preventive (p=0.001) and restorative (p<0.001) care for pregnant women. The graduates were least likely to use some form of caries risk assessment (p<0.001). These findings highlight the need for earlier and greater exposure to the IOHP and the importance of promoting awareness about risk assessment and oral disease management.

Developing and Testing the Short-Form Knowledge, Efficacy, and Practices Instrument for Assessing Cultural Competence.

The importance of educating dental students in cultural competence has been widely emphasized, but there is a need to assess cultural competence in a consistent and reliable way. The aims of this study were to determine latent constructs for the initial measure of cultural competence for oral health providers, the Knowledge, Efficacy, and Practices Instrument (KEPI), and to determine how well these factors related to previously identified latent constructs. Data were collected in surveys of dental students and from dental hygiene, dental assisting, and dental faculty members in 44 academic dental institutions from 2012 to 2015. There were a total of 1,786 respondents to the surveys; response rates to individual surveys ranged from 35% to 100%. There were 982 (55%) female and 804 (45%) male respondents, 286 (16%) underrepresented minority (URM) and 1,500 (84%) non-URM respondents, and 339 (19%) faculty and 1,447 (81%) student respondents. Three latent constructs were identified. Female respondents scored significantly higher on the culture-centered practice and efficacy of assessment factors, while URM respondents had significantly higher scores on all three of the KEPI factors. Measurements indicated that the long-form KEPI could be shortened by ten questions and still have three meaningful measurements. Continued research in assessing other health care providers' cultural competence is needed to expand the KEPI to measure providers' cultural competence with patients with minority sexual orientation and gender identity issues and those with physical disabilities, mental illness, and autism to advance patient-centric communication.

Wellness Among Dental Students: An Institutional Study.

The high prevalence of distress among health professionals during their education has fostered increased interest in the study of student well-being. The aim of this study was to assess the self-perceived wellness of dental students and determine the relationship between factors affecting wellness and demographic variables. An online questionnaire was distributed to 334 first-through fourth-year dental students at one U.S. dental school. The questionnaire consisted of modified versions of the Perceived Wellness Survey, Medical Outcomes Study Social Support Survey, and Mental Health Inventory and also collected demographic information. The response rate was 78% (N=261). More than 80% of the respondents reported that they were happy all, most, or a good bit of the time. These students exhibited a strong sense of self-worth, were positive about their friendships, and perceived they had good social support. Less than 20% of respondents did not view their physical health as excellent and identified a lack of self-perceived wellness. First-year and single students reported statistically less social support. Students who were parents perceived their wellness less favorably. Hispanic and Asian students were less happy regarding their mental health than white and African American students. These findings suggest that students, especially Hispanic and Asian students, may benefit from programs that promote student well-being. Academic programs that encourage students to work together and promote peer-to-peer involvement may be beneficial, especially for first-year and single students.

Relationships Among the Knowledge, Efficacy, and Practices Instrument, Color-Blind Racial Attitudes Scale, Deamonte Driver Survey, and Defining Issues Test 2.

Concordance studies indicate the degree to which instruments measure the same or similar constructs or something different. The aims of this study were to identify the factor structure of the Deamonte Driver Survey and determine the relationship between the Deamonte Driver (a measure of social class stereotyping), the Defining Issues Test 2 (DIT2; a measure of ethical sensitivity), the Color-Blind Racial Attitudes Scale (CoBRAS; a measure of racial stereotyping), and the Knowledge, Efficacy, and Practices Instrument (KEPI; a measure of cultural competence). The results showed a three-factor solution for the Deamonte Driver Survey and significant relationships between CoBRAS and DIT2 subscales and between CoBRAS and Deamonte Driver subscales. Significant relationships between the measures and exploratory variables, underrepresented minority status, age, citizenship, marital status, political stance, English as a first language, and gender were found. The lack of a significant relationship between the KEPI and Deamonte Driver, DIT2, or CoBRAS subscales suggests that the KEPI is measuring a unique construct. These findings showed how these scales contributed to the assessment of cultural competence among dental students and faculty.

Feasibility of School-Based ADHD Interventions: A Mixed-Methods Study of Perceptions of Adolescents and Adults.

OBJECTIVE: Little is known about perceptions surrounding academic interventions for ADHD that determine intervention feasibility. METHOD: As part of a longitudinal mixed-methods research project, representative school district samples of 148 adolescents (54.8%), 161 parents (59.4%), 122 teachers (50.0%), 46 health care providers (53.5%), and 92 school health professionals (65.7%) completed a cross-sectional survey. They also answered open-ended questions addressing undesirable intervention effects, which were analyzed using grounded theory methods. RESULTS: Adolescents expressed significantly lower receptivity toward academic interventions than adult respondents. Stigma emerged as a significant threat to ADHD intervention feasibility, as did perceptions that individualized interventions foster inequality. CONCLUSION: Findings suggest that adolescents' viewpoints must be included in intervention development to enhance feasibility and avoid interventions acceptable to adults, but resisted by adolescents.

Team-based learning instruction for responsible conduct of research positively impacts ethical decision-making.

Common practices for responsible conduct of research (RCR) instruction have recently been shown to have no positive impact on and possibly to undermine ethical decision-making (EDM). We show that a team-based learning (TBL) RCR curriculum results in some gains in decision ethicality, the use of more helpful metacognitive reasoning strategies in decision-making, and elimination of most negative effects of other forms of RCR instruction on social-behavioral responses. TBL supports the reasoning strategies and social mechanisms that underlie EDM and ethics instruction, and may provide a more effective method for RCR instruction than lectures and small group discussion.

Psychometric properties of the Treatment-Emergent Activation and Suicidality Assessment Profile (TEASAP) in youth with OCD.

This study evaluated the psychometric properties of the treatment-emergent activation and suicidality assessment profile (TEASAP) in a clinical sample of 56 youth aged 7-17 with obsessive-compulsive disorder (OCD) who participated in a double-blind randomized controlled trial. The 38-item TEASAP demonstrated good internal consistency for its total score (α=0.93) and adequate to good performance for its five subscale scores (α=0.65-0.92). One-week test-retest stability (N=18) was adequate (Intraclass correlation coefficient [ICC]=0.68-0.80) except for Self-Injury (ICC=0.46). Construct validity was supported by total and subscale TEASAP score relationships with related constructs, including irritability, hyperactivity, externalizing behaviors, manic symptoms, and suicidal ideation, and the absence of relationships with unrelated constructs. Predictive validity was established for the Disinhibition subscale through significant associations with subsequent activation events. Furthermore, TEASAP sensitivity to change in activation scores over time was supported by longitudinal associations of TEASAP scores with clinician ratings of activation over the course of treatment. Findings indicate that the TEASAP has acceptable psychometric properties in a clinical sample of youth with OCD and merits further study in larger samples for additional refinement of its measurement approaches.

ADHD knowledge, perceptions, and information sources: perspectives from a community sample of adolescents and their parents.

PURPOSE: The chronic illness model advocates for psychoeducation within a collaborative care model to enhance outcomes. To inform psychoeducational approaches for ADHD, this study describes parent and adolescent knowledge, perceptions, and information sources and explores how these vary by sociodemographic characteristics, ADHD risk, and past child mental health service use. METHODS: Parents and adolescents were assessed 7.7 years after initial school district screening for ADHD risk. The study sample included 374 adolescents (56% high and 44% low ADHD risk) aged, on average, 15.4 (standard deviation = 1.8) years, and 36% were African American. Survey questions assessed ADHD knowledge, perceptions, and cues to action and elicited used and preferred information sources. Multiple logistic regression was used to determine potential independent predictors of ADHD knowledge. McNemar tests compared information source utilization against preference. RESULTS: Despite relatively high self-rated ADHD familiarity, misperceptions among parents and adolescents were common, including a sugar etiology (25% and 27%, respectively) and medication overuse (85% and 67%, respectively). African American respondents expressed less ADHD awareness and greater belief in sugar etiology than Caucasians. Parents used a wide range of ADHD information sources, whereas adolescents relied on social network members and teachers/school. However, parents and adolescents expressed similar strong preferences for the Internet (49% and 51%, respectively) and doctor (40% and 27%, respectively) as ADHD information sources. CONCLUSIONS: Culturally appropriate psychoeducational strategies are needed that combine doctor-provided ADHD information with reputable Internet sources. Despite time limitations during patient visits, both parents and teens place high priority on receiving information from their doctor.