Long-term cortisol secretion in attention deficit hyperactivity disorder: roles of sex, comorbidity, and symptom presentation.

Low activity of the hypothalamic-pituitary-adrenal axis (HPAA) has been found in children with attention deficit hyperactivity disorder (ADHD). The condition may be related to the reduced attention regulation capacity and/or to comorbid oppositional defiant or conduct disorder (ODD/CD). Sex differences are probable but not sufficiently studied. We analyzed the HPAA activity and sympathetic nervous system reactivity (SR) in children with ADHD while accounting for ADHD symptom presentation, comorbidity, and sex differences. The sample comprised 205 children, 98 (61 boys, 37 girls) with ADHD and 107 (48 boys, 59 girls) healthy controls. DSM-5 phenotypic symptom presentation and comorbid ODD/CD were assessed using clinical interviews. Hair cortisol concentration (HCC) was used to assess the long-term, cumulative activity of the HPAA. SR was assessed via skin conductance response (SCR). For control purposes, comorbid internalizing symptoms and indicators of adverse childhood experiences (ACE) were assessed. Children were medication naive. Boys presenting with predominantly inattentive symptoms (ADHD-I) showed lower HCC than healthy boys. Girls presenting with combined symptoms (ADHD-C) showed higher HCC than did healthy girls (p's < 0.05, sex-by-group interaction, F (2,194) = 4.09, p = 0.018). Boys with ADHD plus ODD/CD showed a blunted SR (p < 0.001, sex-by-group interaction, F (2,172) = 3.08, p = 0.048). Adjustment for ACE indicators led to non-significant differences in HCC but did not affect differences in SR. HCC constitutes an easily assessable, reliable, and valid marker of phenotypic ADHD-related features (i.e. symptom presentation and comorbidity). It indicates more homogenous subgroups of ADHD and might point to specifically involved pathophysiological processes.

Baseline Dietary Restraint Predicts Negative Treatment Outcomes after 12 Months in Children and Adolescents with Obesity Participating in a Lifestyle Intervention.

OBJECTIVE: Current lifestyle interventions for children and adolescents with obesity often exclude patients with an eating pathology, leaving the impact of eating pathologies on treatment outcomes largely unconsidered. We investigated the predictive value of disordered eating symptoms on BMI z-score reduction in a sample of 111 German children and adolescents with overweight (90th percentile ≤ BMI < 97th percentile) and obesity (BMI > 97th percentile) aged 7-15 years in an outpatient lifestyle intervention program. METHODS: We defined a BMI z-score reduction of more than 5% after 12 months as a successful outcome. Disordered eating symptoms (i.e., dietary restraint, emotional eating, external eating, and binge eating) were assessed at baseline with the Eating Pattern Inventory (EPI-C) and the "bulimia" scale of the Eating Disorder Inventory (EDI-2). Covariates were: baseline z-BMI, age, gender, and maternal education level. RESULTS: Multiple regression analysis revealed that dietary restraint significantly predicted change in BMI z-scores between baseline and T1. Higher levels of dietary restraint were associated with a lower BMI z-score reduction between T0 and T1. To compare non-completers with completers on the 4 eating behavior scales, we used MANCOVA. At baseline, children who subsequently dropped out of the program prematurely showed significantly higher dietary restraint scores than children who completed the intervention, irrespectively of their gender, age, and BMI z-score at baseline and their mother's education level. DISCUSSION: Our results provide further evidence that the analysis of treatment processes in lifestyle intervention programs for children and adolescents with overweight and obesity should take into account a broader multidimensional approach including eating and dietary habits.

Predicting weight loss and maintenance in overweight/obese pediatric patients.

BACKGROUND: Pediatric lifestyle interventions have positive short-term effects on obese patients. Studies on long-term effects are still scarce in Europe. We investigated long-term weight patterns and sociodemographic predictors of a weight change in a large Central European (Germany, Austria and Switzerland) overweight pediatric cohort. METHODS: The APV (Adiposity Patients Verlaufsbeobachtung) database was retrospectively analyzed; 157 specialized childhood obesity centers contributed standardized data of 29,181 patients [body mass index (BMI) ≥ 90th percentile; 5-25 years old] presenting between 2000 and 2012. BMI standard deviation scores (BMI-SDS) were analyzed in a 2-year follow-up and grouped according to BMI-SDS changes. Multiple logistic regression analyses were conducted to assess associations between sociodemographic factors and weight patterns. RESULTS: 2-year follow-up data were available in 3,135 patients (54.6% female). Five distinct weight trajectories 'rapid weight loss' (n = 735, 23.4%), 'delayed success' (n = 697, 22.2%), 'cycling weight' (n = 43, 1.4%), 'initial weight loss' and 'weight rebound' (n = 383, 12.2%) and 'no weight loss throughout' (n = 1,277, 40.7%) best characterized long-term BMI-SDS changes. Younger and male patients were more likely to reduce weight and maintain weight loss. CONCLUSIONS: Our results suggest that an intervention before the onset of puberty seems promising for long-term weight maintenance in overweight children. Thus, new concepts are needed to improve long-term treatment success in patients with lower success rates.

Successful treatment with atomoxetine of an adolescent boy with attention deficit/hyperactivity disorder, extreme obesity, and reduced melanocortin 4 receptor function.

OBJECTIVE: Recent case reports suggest a link between reduced melanocortinergic tone and both obesity and attention deficit / hyperactivity disorder (ADHD). We present the case of a 13-year-old, male, obese MC4R mutation carrier with ADHD. CASE REPORT: The boy carries a heterozygous mutation in the melanocortin 4 receptor gene (MC4R; Met281Val), that leads to a reduced receptor function. Dominant mutations of this type represent major gene effects for obesity. He participated in a lifestyle intervention program for obesity and received treatment with the selective norepinephrine re-uptake inhibitor atomoxetine for 31 months. The boy markedly reduced his BMI from 47.2 to 29.6 kg/m². CONCLUSION: Atomoxetine proved to efficiently reduce weight in a severely obese MC4R mutation carrier with ADHD. We briefly discuss possible mechanisms for our observation, including evidence for the functional connectivity between melanocortinergic, dopaminergic, and norepinephrinergic brain circuitries.

Links between psychopathological symptoms and disordered eating behaviors in overweight/obese youths.

OBJECTIVE: Among overweight and obese youths, rates of depression, anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD) are elevated. We analyze whether these emotional and behavioral problems are associated with specifically disordered eating pattern. METHOD: Participants in the study were 128 overweight and obese children/adolescents (BMI: m = 29.3, s = 4.5; BMI-SDS: m = 2.5, s = 0.4) between 8 and 15 years. Structured psychiatric assessments were conducted adopting a multimethod, multiinformant approach. RESULTS: Children/adolescents with ODD symptoms showed increased eating in response to external cues and binge eating. ADHD symptoms were not associated with disordered eating behaviors. Children/adolescents with symptoms of depression and anxiety showed emotional and binge eating. In particular, overweight girls with symptoms of depression showed restrained eating. DISCUSSION: Our results point to specific eating problems in overweight/obese children with ODD and depression/anxiety symptoms. The findings could help to tailor interventions to optimally meet the specific needs of overweight children with emotional and behavioral problems.

Do common variants separate between obese melanocortin-4 receptor gene mutation carriers and non-carriers? The impact of cryptic relatedness.

BACKGROUND/AIMS: Genome-wide association studies revealed associations of single nucleotide polymorphisms (SNPs) flanking MC4R with body mass index variability and obesity. We genotyped 28 SNPs, covering MC4R, and searched for haplotypes discriminating between obese mutation carriers and non-carriers. METHODS: We analyzed all three-marker haplotype combinations of the 28 SNPs to discriminate between obese mutation carriers and non-carriers - overall and in functional categories for 25 different MC4R mutations: (a) 'like wild type', (b) 'partial loss of function', and (c) 'complete loss of function'. We checked for the possible impact of 'cryptic relatedness' by sensitivity analyses including only 1 randomly selected patient per mutation. RESULTS: Overall analyses revealed a haplotype of 3 SNPs downstream of the MC4R discriminating between obese mutation carriers and obese non-carriers. However, sensitivity analyses showed that the finding is most likely due to cryptic relatedness. CONCLUSION: Given a mutation prevalence of 1-5%, the sample size of 62 obese mutation carriers with overall 25 different MC4R mutations represents a unique feature of our study. Taking MC4R as an example, we demonstrate the impact of cryptic relatedness when trying to link non-coding SNPs to functionally relevant mutations. Hence, a thorough mutation screen can currently not be guided by SNP genotyping.

Conditions of long-term success in a lifestyle intervention for overweight and obese youths.

OBJECTIVE: Childhood lifestyle interventions usually involve the families. However, knowledge of family characteristics that promote or constrain a child's weight-reduction outcome is limited. Candidates for such factors might be family characteristics that have proven to be associated with social adjustment (development) in childhood. Thus, we analyzed whether family adversity, maternal depression, and attachment insecurity predict long-term success in children's weight reduction. PATIENTS AND METHODS: Participants in the study were 111 parent-child dyads with overweight and obese children/adolescents (BMI mean: 29.07 [SD: 4.7] [range: 21.4-44.9]; BMI SD score mean: 2.43 [SD: 0.44] [range: 1.31-3.54]) aged between 7 and 15 years. The families took part in a best-practice lifestyle intervention of 1 year's duration. A longitudinal analysis with 3 assessment waves (baseline, conclusion, 1-year follow-up) was conducted. RESULTS: Hierarchical regression analyses revealed that long-term success (at least 5% weight reduction by the 1-year follow-up) versus failure (dropping out or less weight reduction) was significantly predicted by the set of psychosocial variables (family adversity, maternal depression, and attachment insecurity) when we controlled for familial obesity, preintervention overweight, age, and gender of the index child and parental educational level. Maternal depression proved to be the best predictor. Maintenance of weight reduction between the conclusion of the program and the 1-year-follow-up was also predicted by the set of psychosocial variables. Maternal insecure-anxious attachment attitudes best predicted this criterion. CONCLUSIONS: Although cross-validation is required, our results are the first evidence for proximal and distal family characteristics linked to long-term weight-reduction outcomes. The results suggest a need to create tailored intervention modules that address the difficulties of these families.

Course of depressive symptoms in overweight youth participating in a lifestyle intervention: associations with weight reduction.

OBJECTIVE: The study investigates whether preintervention depressive symptoms predict weight loss and whether an increase in depressive symptoms during a group-based lifestyle intervention of 1 year's duration is associated with failure in weight reduction while controlling for the influence of psychosocial risks. METHOD: Participants were 136 overweight and obese children and adolescents between 7 and 15 years, who had been referred for weight reduction treatment by local pediatric practices. Depressive symptoms in the child/adolescent were screened by a German version of the Children's Depression Inventory, in accordance with DSM-IV criteria, at baseline and conclusion of the program. Family adversity was assessed using the Psychosocial Risk Index at baseline. Preintervention maternal depression was assessed using the Center for Epidemiological Studies Depression Scale. RESULTS: Preintervention depressive symptoms in the child/adolescent did not predict reduction in body mass index-standard deviation score. High number of psychosocial risks predicted an increase in depressive symptoms. Independently of this association, failure to reduce weight within the 1-year duration of the program was significantly associated with an increase in depressive symptoms. CONCLUSION: It is necessary to identify cases at risk to offer further and more specific support.

[Conditions for success in a lifestyle intervention weight-reduction programme for overweight or obese children and adolescents]. / Bedingungen für den Erfolg übergewichtiger und adipöser Kinder in einem ambulanten Programm zur Gewichtsreduktion durch Veränderungen des Lebensstils.

OBJECTIVE: To analyze whether caregiver and family characteristics predict success in a family-based lifestyle intervention programme for overweight or obese children and adolescents. METHOD: Participants were 136 overweight or obese children and adolescents (7-15 years) who attended a family-based weight-reduction programme. BMI and BMI standard deviation scores (BMI-SDS) of the index child, BMI of family members, family adversity characteristics, and depression and attachment attitudes of the primary caregiver were assessed. 116 participants finished the 12-month programme: 100 (85.3%) showed a decrease of the BMI-SDS, 79 (68.1%) a more than 5% reduction of the BMI-SDS. These "successful" children were compared to 56 "unsuccessful" ones (dropouts and children with a BMI-SDS reduction of 5% or less). RESULTS: Failure to reduce weight considerably (≤ 5% reduction of BMI-SDS, or dropout) occurred more frequently in older children and in cases with obese sibling(s), maternal depression, and maternal avoidant attachment attitude. In a logistic regression analysis, maternal depression as well as attachment attitude, and the age of the index child explained common variance, while the presence of obese sibling(s) explained unique variance in non-responding. CONCLUSION: Our data suggest that special support should be provided to adolescents with obese sibling(s) and to adolescents with mothers suffering from depression and exhibiting an avoidant attachment style, so as to meet the specific needs of all participating families and to prevent the discouraging experience of failure in weight-control interventions. The efficacy of these modules must be tested in further studies.

Association between inhibitory control capacity and body weight in overweight and obese children and adolescents: dependence on age and inhibitory control component.

It has been assumed that overweight individuals show weak inhibitory control capacity leading to a failure to resist external cues for palatable food and that this deficit underlies the recently reported empirical association between obesity and attention deficit/hyperactivity disorder (ADHD). In childhood and adolescence, empirical research on this issue is scarce. Here, the hypothesis is tested that high body weight is associated with weak inhibitory control performance and that this association is moderated by age. The sample included 177 overweight and obese children and adolescents (BMI: M = 29.2, SD = 4.33; BMI-SDS: M = 2.45, SD = 0.43) between 8 and 15 years. Inhibitory control was assessed by a Go/No-Go task and an Interference Task. A principal component analysis yielded two components: impulsivity (fast but invalid responses) and inattention (highly variable reaction times). While controlling for age, gender, and maternal education level, we found that more obese children/adolescents showed more inattention. As indicated by a significant interaction effect, exclusively at younger ages, high impulsivity was associated with high body weight. The results thus confirm a link between low inhibitory control capacity and high body weight and might point to a developmental period with heightened significance of impulsivity for weight gain.

Does inhibitory control capacity in overweight and obese children and adolescents predict success in a weight-reduction program?

It has been assumed that inhibitory control capacity might influence the success of overweight or obese subjects in reducing weight. However, empirical research on this association is scarce. The present study, therefore, examines whether success in an outpatient weight-reduction program for children and adolescents can be predicted by pre-intervention inhibitory control capacity. The study sample consisted of 111 overweight and obese children and adolescents (7.5-15 years) who attended an outpatient weight-reduction program of 1 year's duration. Inhibitory control was assessed by two computerized neuropsychological procedures, a Go-NoGo and an interference task. Principal component analysis revealed "impulsivity" (fast but less valid reactions) and "inattention" (slow and highly variable reaction times) component. Those who succeeded in the intervention (losing more than 5% of BMI-SDS; n = 63) scored significantly higher in the first component than those who failed, while controlling for pre-intervention BMI-SDS, age, gender, and maternal education level. The association was moderated by age. Although in younger children no effect was found, in adolescents high "impulsivity" predicted success. Our result supports the scant evidence for a role of inhibitory control. However, further studies are required to substantiate that weak inhibitory control, and thus high reactivity to external cues, entails a better outcome in behavior modification interventions.

Treating childhood obesity: family background variables and the child's success in a weight-control intervention.

OBJECTIVE: To analyze whether caregiver and family characteristics predict success in a family-based lifestyle intervention program for children and adolescents. METHOD: Participants were 111 overweight and obese children (7-15 years) who attended a family-based weight-reduction program. Body mass index (BMI) and BMI standard deviation scores (BMI-SDS) of index child, and BMI of family members, family adversity characteristics, depression, and attachment attitudes of the primary caregiver were assessed. RESULTS: Risk of nonresponse (

[The development of the personality in childhood epilepsy with complex-partial seizures]. / Zur Persönlichkeitsentwicklung bei im Kindesalter beginnenden Epilepsien mit komplex-fokalen Anfällen.

The study presented addresses the association between severity and course of childhood epilepsy with complex-partial seizures and subsequent personality development. Participants in the study were 84 patients first seen when they were 8 years on average. A follow-up examination was conducted about 13 years thereafter. At the first examination about half of the patients showed a psychiatric disorder, another quarter showed developmental delays and 35% were mentally retarded. It could be demonstrated that a high frequency of complex-partial seizures was related to depressive symptoms. However, additional generalized seizures did not further contribute to the severity of psychiatric problems. Patients who continued to show seizures reported less life satisfaction, a more passive attitude and higher emotional instability at follow-up in comparison to patients with a complete remission of epilepsy.

Negative emotionality, attachment quality, and behavior problems in early childhood.

Negative emotionality, as well as attachment security and disorganization, are seen as major contributors to social adjustment and maladjustment in childhood. However, relatively little is known about whether infant negative emotionality and attachment quality operate together to affect developing behavior problems. The present study thus aims to contribute to this question. Participants were 64 healthy firstborn children and their primary caregivers. Negative emotionality was assessed at the infant ages of 4, 8, and 12 months using laboratory routines. At 18 months, the Strange Situation procedure was conducted to assess infant attachment security and disorganization, and at 30 months, the child's behavior problems were assessed within a structured clinical interview. Attachment security and attachment disorganization were significantly associated with subsequent behavior problems. There was no significant relation between infant negative emotionality and behavior problems. However, there were indications of a stronger association between attachment disorganization and behavior problems in infants high in negative emotionality. The results underpin the importance of attachment quality as well as negative emotionality in social adjustment. Disorganized attachment precedes poor adjustment, especially in infants high in negative emotionality.

[Sleeping problems and attachment quality in toddlers]. / Schlafstörungen und Bindungsqualität im Kleinkindalter.

The study presented addresses the association between 18-months-olds' attachment quality and subsequent sleeping problems at 30 months. The sample consisted in 62 healthy, firstborn children and their primary caregivers. Attachment quality was assessed using Ainsworths' Strange Situation Procedure. Sleeping disorders were diagnosed conducting a standardized psychiatric interview with the mothers. Securely attached toddlers showed sleeping problems more often than insecurely-avoidant attached ones. Attachment disorganization was not related to sleeping problems. Analyzing the impact of self-stimulation behavior (i.e. thumb or pacifier sucking) it could be demonstrated that all 30-months-olds who showed self-stimulating behavior were insecurely-avoidant attached to their primary caregiver. Thus, insecure-avoidant toddlers might incline to suppress attachment behavior and negative emotions when being separated from parent in the evening and night hours.