UK adult ADHD services in crisis.

The UK's services for adult attention-deficit hyperactivity disorder (ADHD) are in crisis, with demand outstripping capacity and waiting times reaching unprecedented lengths. Recognition of and treatments for ADHD have expanded over the past two decades, increasing clinical demand. This issue has been exacerbated by the COVID-19 pandemic. Despite an increase in specialist services, resource allocation has not kept pace, leading to extended waiting times. Underfunding has encouraged growth in independent providers, leading to fragmentation of service provision. Treatment delays carry a human and financial cost, imposing a burden on health, social care and the criminal justice system. A rethink of service procurement and delivery is needed, with multiple solutions on the table, including increasing funding, improving system efficiency, altering the service provision model and clinical prioritisation. However, the success of these solutions hinges on fiscal capacity and workforce issues.

George Wallett, 1775-1845: entrepreneur and asylum doctor.

George Wallett (1775-1845) is generally known only as Haslam's successor at Bethlem who resigned under the cloud of corruption. However, his life proves to have been more eventful. He trained as a lawyer and doctor, enlisted in the army three times and bottled Malvern's first soda water. After bankruptcy, he managed Pembroke House Asylum as it opened, held two jobs in Bethlem and then operated Surrey House Asylum in Battersea. He moved on to help set up the Suffolk and Dorset asylums, and designed the Leicestershire asylum. He finally designed and opened Northampton Asylum, where being a Catholic ended his career.

The case of Dr Pownall - mad doctor, sane patient and insane murderer.

Dr Pownall was a surgeon, asylum proprietor and one-time mayor of Calne who had bouts of insanity. He had two serious bouts of violence when insane, and later murdered a servant, Louisa Cook, after his discharge from Northwoods Asylum as recovered. He was tried for murder and ended up in Broadmoor, where he died in 1882. There are extensive contemporary public accounts of the case, but detailed examination of the roles of the local chief magistrate, Purnell Barnsby Purnell, and Pownall's brother-in-law and asylum doctor, Dr Ogilvie, reveals severe tensions that adversely influenced events. Everyone defended themselves, and few lessons were learned about cooperation.

Anxiety Disorders in Adults with Autism Spectrum Disorder: A Population-Based Study.

Anxiety is common in children with ASD; however, the burden of specific anxiety disorders for adults with ASD is under-researched. Using the Stockholm Youth Cohort, we compared anxiety disorder diagnoses among autistic adults (n = 4049), with or without intellectual disability, and population controls (n = 217,645). We conducted additional sibling analyses. Anxiety disorders were diagnosed in 20.1% of adults with ASD compared with 8.7% of controls (RR = 2.62 [95% CI 2.47-2.79]), with greatest risk for autistic people without intellectual disability. Rates of almost all individual anxiety disorders were raised, notably obsessive-compulsive disorder and phobic anxiety disorders. Anxiety disorders were more common in full siblings and half-siblings of people with ASD. The implications of this are explored.

Association of Autistic Traits With Depression From Childhood to Age 18 Years.

Importance: Population-based studies following trajectories of depression in autism spectrum disorders (ASD) from childhood into early adulthood are rare. The role of genetic confounding and of potential environmental intermediaries, such as bullying, in any associations is unclear. Objectives: To compare trajectories of depressive symptoms from ages 10 to 18 years for children with or without ASD and autistic traits, to assess associations between ASD and autistic traits and an International Statistical Classification of Diseases, 10th Revision (ICD-10) depression diagnosis at age 18 years, and to explore the importance of genetic confounding and bullying. Design, Setting, and Participants: Longitudinal study of participants in the Avon Longitudinal Study of Parents and Children birth cohort in Bristol, United Kingdom, followed up through age 18 years. Data analysis was conducted from January to November 2017. Main Outcomes and Measures: Depressive symptoms were assessed using the Short Mood and Feelings Questionnaire (SMFQ) at 6 time points between ages 10 and 18 years. An ICD-10 depression diagnosis at age 18 years was established using the Clinical Interview Schedule-Revised. Exposures were ASD diagnosis and 4 dichotomized autistic traits (social communication, coherence, repetitive behavior, and sociability). An autism polygenic risk score was derived using the Psychiatric Genomics Consortium autism discovery genome-wide association study summary data. Bullying was assessed at ages 8, 10, and 13 years. Results: The maximum sample with complete data was 6091 for the trajectory analysis (48.8% male) and 3168 for analysis of depression diagnosis at age 18 years (44.4% male). Children with ASD and autistic traits had higher average SMFQ depressive symptom scores than the general population at age 10 years (eg, for social communication 5.55 [95% CI, 5.16-5.95] vs 3.73 [95% CI, 3.61-3.85], for ASD 7.31 [95% CI, 6.22-8.40] vs 3.94 [95% CI, 3.83-4.05], remaining elevated in an upward trajectory until age 18 years (eg, for social communication 7.65 [95% CI, 6.92-8.37] vs 6.50 [95% CI, 6.29-6.71], for ASD 7.66 [95% CI, 5.96-9.35] vs 6.62 [95% CI, 6.43-6.81]). Social communication impairments were associated with depression at age 18 years (adjusted relative risk, 1.68; 95% CI, 1.05-2.70), and bullying explained a substantial proportion of this risk. There was no evidence of confounding by the autism polygenic risk score. Analysis in larger samples using multiple imputation led to similar but more precise results. Conclusions and Relevance: Children with ASD and ASD traits have higher depressive symptom scores than the general population by age 10 years, which persist to age 18 years, particularly in the context of bullying. Social communication impairments are an important autistic trait in relation to depression. Bullying, as an environmental intermediary, could be a target for interventions.

Autistic Traits and Suicidal Thoughts, Plans, and Self-Harm in Late Adolescence: Population-Based Cohort Study.

OBJECTIVE: To examine the hypothesis that autism spectrum disorders (ASD) diagnosis and traits in childhood are associated with suicidal thoughts, plans and self-harm at 16 years, and that any observed associations are explained by depression at 12 years. METHOD: We examined associations between ASD diagnosis and 4 dichotomized ASD traits (social communication, pragmatic language, repetitive behavior, and sociability) with suicidal and nonsuicidal self-harm, suicidal thoughts, and suicidal plans at age 16 years in 5,031 members of the United Kingdom-based birth cohort study the Avon Longitudinal Study of Parents and Children. We assessed whether any associations were explained by depressive symptoms in early adolescence measured by the Short Moods and Feelings Questionnaire at 12 years. RESULTS: Children with impaired social communication had a higher risk of self-harm with suicidal intent (relative risk [RR] = 2.14, 95% CI = 1.28-3.58), suicidal thoughts (RR = 1.42, 95% CI = 1.06-1.91), and suicidal plans (RR = 1.95, 95% CI = 1.09-3.47) by age 16 years as compared to those without. There was no evidence for an association between ASD diagnosis and outcomes, although these analyses were imprecise because of small numbers. There was also no evidence of an association between other autism traits and the outcomes. Approximately 32% of the total estimated association between social communication impairment and self-harm was explained by depressive symptoms at 12 years. CONCLUSION: Social communication impairments are an important autistic trait in relation to suicidality. Early identification and management of depression may be a preventative mechanism, and future research identifying other potentially modifiable mechanisms may lead to interventions against suicidal behavior in this high-risk group.

Association Between Autism Spectrum Disorders With or Without Intellectual Disability and Depression in Young Adulthood.

Importance: Depression is a frequently occurring mental disorder and may be common in adults with autism spectrum disorders (ASD), but there is a lack of longitudinal population-based studies examining this association. Whether any increased risk of depression in ASD has a shared familial basis and whether it differs by co-occurring intellectual disability is not well known. Objectives: To examine whether individuals with ASD are more likely to be diagnosed as having depression in adulthood than the general population and their nonautistic siblings and to investigate whether these risks differ by the presence or absence of intellectual disability. Design, Setting, and Participants: Population-based cohort study with a nested sibling comparison. The Stockholm Youth Cohort is a total population record linkage study that includes all children and young people (age range, 0-17 years) who were ever resident in Stockholm County, Sweden, between January 2001 and December 2011 (n = 735 096). Data analysis was conducted between January 5 and November 30, 2017, in Stockholm County, Sweden. Main Outcomes and Measures: Clinical diagnosis of depressive disorders was identified using the Stockholm County Adult Psychiatric Outpatient Register and the Swedish National Patient Register. Results: Participants were 223 842 individuals followed up to age 27 years by 2011, of whom 4073 had diagnosed ASD (mean [SD] age, 21.5 [2.7] years; 65.9% male; 2927 without intellectual disability and 1146 with intellectual disability) and 219 769 had no ASD (mean [SD] age, 22.1 [2.8] years; 50.9% male). By age 27 years, 19.8% (n = 808) of individuals diagnosed having ASD had a diagnosis of depression compared with 6.0% (n = 13 114) of the general population (adjusted relative risk [RR], 3.64; 95% CI, 3.41-3.88). The risk of a depression diagnosis was higher in ASD without intellectual disability (adjusted RR, 4.28; 95% CI, 4.00-4.58) than in ASD with intellectual disability (adjusted RR, 1.81; 95% CI, 1.51-2.17). Nonautistic full-siblings (adjusted RR, 1.37; 95% CI, 1.23-1.53) and half-siblings (adjusted RR, 1.42; 95% CI, 1.23-1.64) of individuals with ASD also had a higher risk of depression than the general population. Compared with their nonautistic full-siblings, individuals with ASD had more than a 2-fold risk of a depression diagnosis (adjusted odds ratio, 2.50; 95% CI, 1.91-3.27) in young adulthood. Conclusions and Relevance: According to this study's results, ASD, particularly ASD without intellectual disability, is associated with depression by young adulthood compared with the general population. It appears that this association is unlikely to be explained by shared familial liability. Future research to identify modifiable pathways between ASD and depression may assist in the development of preventive interventions.

Toward complete miniaturisation of flow injection analysis systems: microfluidic enhancement of chemiluminescent detection.

Conventional flow injection systems for aquatic environmental analysis typically comprise large laboratory benchscale equipment, which place considerable constraints for portable field use. Here, we demonstrate the use of an integrated acoustically driven microfluidic mixing scheme to enhance detection of a chemiluminescent species tris(2,2'-bipyridyl)dichlororuthenium(II) hexahydrate-a common chemiluminescent reagent widely used for the analysis of a wide range of compounds such as illicit drugs, pharmaceuticals, and pesticides-such that rapid in-line quantification can be carried out with sufficient on-chip sensitivity. Specifically, we employ surface acoustic waves (SAWs) to drive intense chaotic streaming within a 100 µL chamber cast in polydimethoxylsiloxane (PDMS) atop a microfluidic chip consisting of a single crystal piezoelectric material. By optimizing the power, duration, and orientation of the SAW input, we show that the mixing intensity of the sample and reagent fed into the chamber can be increased by one to two orders of magnitude, leading to a similar enhancement in the detection sensitivity of the chemiluminescent species and thus achieving a theoretical limit of detection of 0.02 ppb (0.2 nM) of l-proline-a decade improvement over the industry gold-standard and two orders of magnitude more sensitive than that achievable with conventional systems-simply using a portable photodetector and without requiring sample preconcentration. This on-chip microfluidic mixing strategy, together with the integrated miniature photodetector and the possibility for chip-scale microfluidic actuation, then alludes to the attractive possibility of a completely miniaturized platform for portable field-use microanalytical systems.

Parental socioeconomic status and risk of offspring autism spectrum disorders in a Swedish population-based study.

OBJECTIVE: Epidemiological studies in the United States consistently find autism spectrum disorders (ASD) to be overrepresented in high socioeconomic status (SES) families. These findings starkly contrast with SES gradients of many health conditions, and may result from SES inequalities in access to services. We hypothesized that prenatal measures of low, not high, parental SES would be associated with an increased risk of offspring ASD, once biases in case ascertainment are minimized. METHOD: We tested this hypothesis in a population-based study in Sweden, a country that has free universal healthcare, routine screening for developmental problems, and thorough protocols for diagnoses of ASD. In a case-control study nested in a total population cohort of children aged 0 to 17 years living in Stockholm County between 2001 and 2007 (N = 589,114), we matched ASD cases (n = 4,709) by age and sex to 10 randomly selected controls. We retrieved parental SES measures collected at time of birth by record linkage. RESULTS: Children of families with lower income, and of parents with manual occupations (OR = 1.4, 95% CI = 1.3-1.6) were at higher risk of ASD. No important relationships with parental education were observed. These associations were present after accounting for parental ages, migration status, parity, psychiatric service use, maternal smoking during pregnancy, and birth characteristics; and regardless of comorbid intellectual disability. CONCLUSIONS: Lower, not higher, socioeconomic status was associated with an increased risk of ASD. Studies finding the opposite may be underestimating the burden of ASD in lower SES groups.

Detection of s-triazine pesticides in natural waters by modified large-volume direct injection HPLC.

There is a need for simple and inexpensive methods to quantify potentially harmful persistent pesticides often found in our water-ways and water distribution systems. This paper presents a simple, relatively inexpensive method for the detection of a group of commonly used pesticides (atrazine, simazine and hexazinone) in natural waters using large-volume direct injection high performance liquid chromatography (HPLC) utilizing a monolithic column and a single wavelength ultraviolet-visible light (UV-vis) detector. The best results for this system were obtained with a mobile phase made up of acetonitrile and water in a 30:70 ratio, a flow rate of 2.0 mL min(-1), and a detector wavelength of 230 nm. Using this method, we achieved retention times of less than three minutes, and detection limits of 5.7 microg L(-1) for atrazine, 4.7 microg L(-1) for simazine and 4.0 microg L(-1) for hexazinone. The performance of this method was validated with an inter-laboratory trial against a National Association of Testing Authorities (NATA) accredited liquid chromatography-mass spectrometry/mass spectrometry (LC-MS/MS) method commonly used in commercial laboratories.

Donepezil for dementia in people with Down syndrome.

BACKGROUND: Alzheimer's dementia (AD) is the most common form of dementia in people with Down Syndrome [DS]. Acetylcholine is a chemical found in the brain that has an important role in memory, attention, reason and language. Donepezil a reversible inhibitor of acetylcholinesterase, which is thought to maintain levels of acetylcholine, and is reported to have some benefits for people with AD in the general population. It is important to note that people with DS tend to present with AD at a much younger age than the normal population as well as having subtle differences in physiology (e.g. metabolism and heart rate) and may therefore have different requirements from the general population. OBJECTIVES: To determine the effectiveness and safety of donepezil for people with DS who develop AD. SEARCH STRATEGY: CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, BIOSIS, SCI, SSCI and the NRR were searched up to October 2008. We contacted the manufacturers of donepezil as well as experts in the field, to ask about reports of unpublished or ongoing trials. SELECTION CRITERIA: Randomised controlled trials of participants with DS and AD in which treatment with donepezil was administered compared with a placebo group. DATA COLLECTION AND ANALYSIS: Data were extracted from the published reports of the one relevant study identified. MAIN RESULTS: The one study included in this review is a small (n=30) randomised controlled trial lasting 24 weeks. It was followed-up by an open label study with a crossover design.No significant differences were found on any four validated outcomes including global functioning and three measures of cognitive abilities and behavioural problems. 6 out of 16 carers (37%) of participants on donepezil and 2 out of 15 (13%) on placebo reported improvement. No data were available for day to day skills, institutionalisation, reduction in carers' stress or economic outcomes. Half the intervention group and 20% of the placebo group reported adverse events; two participants left because of adverse events. AUTHORS' CONCLUSIONS: To date there is only one small randomised controlled study on the effect of donepezil. This shows, at best, a modest, non statistically significant trend in favour of people with Down syndrome and Alzheimer's dementia who are able to tolerate donepezil (this drug is currently only dispensed in relatively large doses and is contraindicated for those with cardiac and respiratory problems).This study does not provide good evidence on which to base practice. Findings in an open-label follow up to this study suggest possible benefit in some individuals. Further, larger randomised controlled studies with longer-term follow up are required.

Galantamine for dementia in people with Down syndrome.

BACKGROUND: Alzheimer's dementia (AD) is the most common form of dementia in people with Down Syndrome (DS). Acetylcholine is a chemical found in the brain that has an important role in memory, attention, reason and language. Galantamine both inhibits the activity of acetylcholinesterase and increases the level of acetylcholine. Galantamine can improve cognitive function and slow the decline of AD in the general population over time. It is important to note that people with DS tend to present with AD at a much younger age than the normal population as well as having subtle differences in physiology (e.g. metabolism and heart rate) and may therefore have different requirements from the general population. OBJECTIVES: To determine the effectiveness and safety of galantamine for people with DS who develop AD. SEARCH STRATEGY: CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, BIOSIS, SCI, SSCI and the NRR were searched up to October 2008. We contacted the manufacturers of galantamine as well as experts in the field, to ask about reports of unpublished or ongoing trials. SELECTION CRITERIA: Randomised controlled trials of participants with DS and AD in which treatment with galantamine was administered compared with a placebo group. DATA COLLECTION AND ANALYSIS: No study was identified which met inclusion criteria for this review. MAIN RESULTS: No study was identified which met inclusion criteria for this review. AUTHORS' CONCLUSIONS: As there are no included trials, recommendations cannot be made about galantamine for AD in DS. Well-designed, adequately powered studies are required.

Memantine for dementia in people with Down syndrome.

BACKGROUND: Alzheimer's dementia (AD) is the most common form of dementia in people with Down Syndrome (DS). There is an understanding that an increase in L-glutamate contributes to the pathogenesis of cerebral ischemias and AD. Memantine acts as an antagonist of N-methyl-D-aspartate (NMDA) type receptors, which is thought to reduce abnormal activation of glutamate neurotransmission. It binds with a low affinity to the NMDA receptor and so should not prevent learning and the formation of memory. Memantine can improve cognitive function and slow the decline of AD in the general population over time, and is the subject of this review. It is important to note that people with DS tend to present with AD at a much younger age than the normal population as well as having subtle differences in physiology (e.g. metabolism and heart rate) and may therefore have different requirements from the general population. OBJECTIVES: To determine the effectiveness and safety of memantine for people with DS who develop AD. SEARCH STRATEGY: CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, BIOSIS, SCI, SSCI and the NRR were searched up to October 2008. We contacted the manufacturers of memantine, as well as experts in the field, to ask about reports of unpublished or ongoing trials. SELECTION CRITERIA: Randomised controlled trials of participants with DS and AD in which treatment with memantine was administered compared with a placebo group. DATA COLLECTION AND ANALYSIS: No study was identified which met the inclusion criteria for this review. MAIN RESULTS: No study was identified which met inclusion criteria for this review, however there is an on-going randomised controlled study being conducted in the UK and data are expected in 2009. AUTHORS' CONCLUSIONS: As there are no included trials, recommendations cannot be made about memantine for AD in DS. Well-designed, adequately powered studies are required.

Rivastigmine for dementia in people with Down syndrome.

BACKGROUND: Alzheimer's dementia (AD) is the most common form of dementia in people with Down Syndrome (DS). Acetylcholine is a chemical found in the brain that has an important role in memory, attention, reason and language. Rivastigmine is a "pseudo-irreversible" inhibitor of acetylcholinesterase, which is thought to maintain levels of acetylcholine. Rivastigmine can improve cognitive function and slow the decline of AD in the general population over time. It is important to note that people with DS tend to present with AD at a much younger age than the normal population as well as having subtle differences in physiology (e.g. metabolism and heart rate) and may therefore have different requirements from the general population. OBJECTIVES: To determine the effectiveness and safety of rivastigmine for people with DS who develop AD. SEARCH STRATEGY: CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, BIOSIS, SCI, SSCI and the NRR were searched up to October 2008. We contacted the manufacturers of rivastigmine as well as experts in the field, to ask about reports of unpublished or ongoing trials. SELECTION CRITERIA: Randomised controlled trials of participants with DS and AD in which treatment with rivastigmine was administered compared with a placebo group. DATA COLLECTION AND ANALYSIS: No study was identified which met inclusion criteria for this review. MAIN RESULTS: No study was identified which met inclusion criteria for this review. AUTHORS' CONCLUSIONS: As there are no included trials, recommendations cannot be made about rivastigmine for AD in DS. Well-designed, adequately powered studies are required.

A deterministic model for the sublayer streaks in turbulent boundary layers for application to flow control.

We present a relatively simple, deterministic, theoretical model for the sublayer streaks in a turbulent boundary layer based on an analogy with Klebanoff modes. Our approach is to generate the streamwise vortices found in the buffer layer by means of a vorticity source in the form of a fictitious body force. It is found that the strongest streaks correspond to a spanwise wavelength that lies within the range of the experimentally observed values for the statistical mean streak spacing. We also present results showing the effect of streamwise pressure gradient, Reynolds number and wall compliance on the sublayer streaks. The theoretical predictions for the effects of wall compliance on the streak characteristics agree well with experimental data. Our proposed theoretical model for the quasi-periodic bursting cycle is also described, which places the streak modelling in context. The proposed bursting process is as follows: (i) streamwise vortices generate sublayer streaks and other vortical elements generate propagating plane waves, (ii) when the streaks reach a sufficient amplitude, they interact nonlinearly with the plane waves to produce oblique waves that exhibit transient growth, and (iii) the oblique waves interact nonlinearly with the plane wave to generate streamwise vortices; these in turn generate the sublayer streaks and so the cycle is renewed.

Simultaneous reconstruction of flow and temperature cross-sections in gases using acoustic tomography.

This paper describes the use of air-coupled ultrasonic tomography for the simultaneous measurement of flow and temperature variations in gases. Air-coupled ultrasonic transducers were used to collect through-transmission data from a heated gas jet. A transducer pair was scanned in two-dimensional sections at an angle to the jet, and travel time and amplitude data recorded along various paths in counter-propagating directions. Parallel-beam tomographic reconstruction techniques allowed images to be formed of variations in either temperature or flow velocity. Results have been obtained using heated jets, where it has been shown that it is possible to separate the two variables successfully.