Ending Developmental-Behavioral Pediatrics Faculty Requirement for Pediatric Residency Programs-Desperate Times Do Not Justify Desperate Actions.

This Viewpoint discusses the issues at stake and potential adverse consequences of the Accreditation Council for Graduate Medial Education's proposal to remove the requirement for pediatric training programs to have board-certified developmental-behavioral pediatrician faculty members.

Pharmacologic Management of Cognitive Disengagement Syndrome (CDS) and Implications for Attention-Deficit/Hyperactivity Disorder (ADHD) Treatment: Emerging Treatments and Recommendations for Future Research.

Although the study of cognitive disengagement syndrome (CDS; previously called sluggish cognitive tempo) first emerged in the 1980s, very little is known about treating CDS or its impact on evidence-based interventions for attention-deficit/hyperactivity disorder (ADHD) with which it frequently co-occurs. The objective of this leading article was to investigate the existing evidence on medication treatment and CDS, including studies that have examined CDS response to medication and CDS as a moderator of ADHD treatment response. A total of seven studies were identified. At present, the limited existing literature suggests that psychostimulants such as methylphenidate and lisdexamfetamine, as well as atomoxetine, may improve CDS symptoms, although replication and research on related medications is needed. However, there are indications that CDS symptoms may predict a reduced response to methylphenidate in children with ADHD. Although untested, research on the neurobiological, neuropsychological, and behavioral correlates of CDS point to a possible benefit of other ADHD medications (e.g., guanfacine), medications that treat narcolepsy (e.g., modafinil), and medications traditionally used to treat depression and anxiety (e.g., viloxazine, bupropion, fluvoxamine), some of which have also recently been used in ADHD management. The article concludes with recommendations for future research on pharmacologic treatment and CDS.

Understanding Barriers and Facilitators of Attention-Deficit/Hyperactivity Disorder Treatment Initiation and Adherence in Black and Latinx Children.

OBJECTIVE: Despite evidence that consistent treatment is important for Attention-Deficit/Hyperactivity Disorder (ADHD) management, ADHD treatment initiation and adherence remains suboptimal in minoritized children. The goal of this study was to explore barriers and facilitators to ADHD treatment initiation/adherence for minoritized children to further inform development of our family navigation intervention. METHODS: Using a virtual platform, we completed 7 focus group sessions (total n.ß=.ß26) and 6 individual interviews with representatives from 4 stakeholder groups: experienced caregivers of children with ADHD, caregivers of children newly diagnosed with ADHD, family navigators, and clinicians who care for children with ADHD. All caregivers identified as Black and/or Latinx. Separate sessions were conducted for each stakeholder group and caregivers had the option to attend an English or Spanish session. Using a thematic analysis strategy, barriers and facilitators to ADHD treatment initiation and/or adherence were coded in focus group/interview data and themes were identified across groups. RESULTS: The primary barriers to ADHD treatment initiation and/or adherence identified for minoritized children were lack of support from school/healthcare/family members, cultural barriers, limited resources, limited access, and treatmentconcerns, with variability in endorsement across participants. Reported facilitators included caretakers having experience with ADHD, strong support, access to resources, andwitnessing their child...s functional improvement with treatment. CONCLUSIONS: Caregiver experience with and knowledge about ADHD, support, and access to resources facilitate ADHD treatment in minoritized children. The results from this study have the potential to improve ADHD treatment initiation/adherence and outcomes for minoritized children through the development of culturally tailored, multipronged interventions.

Report of a Work Group on Sluggish Cognitive Tempo: Key Research Directions and a Consensus Change in Terminology to Cognitive Disengagement Syndrome.

OBJECTIVE: The aim of this work was 2-fold: (1) to evaluate current knowledge and identify key directions in the study of sluggish cognitive tempo (SCT); and (2) to arrive at a consensus change in terminology for the construct that reflects the current science and may be more acceptable to researchers, clinicians, caregivers, and patients. METHOD: An international Work Group was convened that, in early 2021, compiled an online archive of all research studies on SCT and summarized the current state of knowledge, noted methodological issues, and highlighted future directions, and met virtually on 10 occasions in 2021 to discuss these topics and terminology. RESULTS: Major progress has been made over the last decade in advancing our understanding of SCT across the following domains of inquiry: construct measurement and stability; genetic, environmental, pathophysiologic, and neuropsychological correlates; comorbid conditions; functional impairments; and psychosocial and medication interventions. Findings across these domains are summarized, and potential avenues to pursue in the next generation of SCT-related research are proposed. Following repeated discussions on terminology, the Work Group selected "cognitive disengagement syndrome" (CDS) to replace "SCT" as the name for this construct. This term was deemed to best satisfy considerations that should apply when selecting terms for a condition or syndrome, as it does not overlap with established terms for other constructs, is not offensive, and reflects the current state of the science. CONCLUSION: It is evident that CDS (SCT) has reached the threshold of recognition as a distinct syndrome. Much work remains to further clarify its nature (eg, transdiagnostic factor, separate disorder, diagnostic specifier), etiologies, demographic factors, relations to other psychopathologies, and linkages to specific domains of functional impairment. Investigators are needed with interests and expertise spanning basic, clinical, and translational research to advance our understanding and to improve the lives of individuals with this unique syndrome.

Child Protective Custody Placement for Children with Developmental Disorders.

OBJECTIVE: The purpose of this study was to determine whether children with developmental disorders (DDs) in protective custody are more likely to experience specific placement types and stay in care longer than their typically developing peers. Furthermore, in the DD-only group, we examined whether the likelihood of each placement type differed by specific DD diagnosis. METHODS: This observational retrospective study used child welfare administrative data linked to electronic health records in a large Ohio county. Participants were aged 5 to 20 years (N = 2787). DD diagnoses were determined using problem list and encounter diagnosis codes. RESULTS: Children with versus without DD were less likely to be in kinship placement (adjusted odds ratio [aOR], 0.79; 95% confidence interval [CI]: 0.66-0.94) and more likely to be in congregate care (aOR, 1.26; 95% CI: 1.04-1.53) and nonrelative foster care (aOR, 1.20; 95% CI: 1.00-1.45). A likelihood of independent living placement did not differ for those with and without DD. Those with versus without DD had longer lengths of stay in protective custody ( p ≤ 0.001), but the number of placement changes did not differ after accounting for length of stay. The pattern of results differed somewhat by individual DD diagnosis. CONCLUSION: Compared with their typically developing peers, children with DD are less likely to be in kinship care and tend to have longer lengths of stay in protective custody. If replicated, these findings suggest the need to identify and address mechanisms to support children with DD across placement settings and to better understand factors prolonging their protective custody stay.

Breastfeeding Initiation and Continuation Among Women with Substance and Tobacco Use During Pregnancy: Findings from the Pregnancy Risk Assessment Monitoring System 2016-2018.

Background and Aims: Substance and tobacco use is associated with poor maternal and child health outcomes. Although these have each been linked to lower breastfeeding rates when examined separately, studies have yet to examine how the combination of tobacco and other substance use influences breastfeeding initiation and continuation. The aim of this study was to examine how the combination of smoking tobacco and use of illicit substances influences the odds of breastfeeding initiation and continuation. Materials and Methods: This retrospective cohort study (n = 15,634) used survey data from the 2016-2018 Centers for Disease Control and Prevention (CDC) Pregnancy Risk Assessment Monitoring System from eight US states to examine the association of tobacco and illicit substance use with breastfeeding initiation and continuation (≥6 weeks). The odds of breastfeeding initiation and continuation for individuals with and without prenatal tobacco and illicit substance use, adjusting for maternal and infant characteristics, were estimated using weighted, multivariable logistic regression models. Results: The combination of prenatal tobacco and illicit substance use was associated with a 42% reduction in the odds of initiating breastfeeding (adjusted odds ratio [aOR] 0.58 [95% confidence interval, CI 0.39-0.87]) and a 39% reduction in the odds of breastfeeding for at least 6 weeks (aOR 0.61 [95% CI 0.41-0.92]) when compared with those without tobacco and substance use. Conclusion: The odds of breastfeeding initiation and continuation are significantly lower among individuals with both prenatal tobacco and illicit substance use. Future studies are needed to identify barriers to breastfeeding within this population, to inform patient-centered interventions aimed at overcoming these barriers.

Factors Associated With Bullying Victimization and Bullying Perpetration in Children and Adolescents With ADHD: 2016 to 2017 National Survey of Children's Health.

OBJECTIVE: To identify characteristics associated with bullying involvement in pediatric ADHD. METHODS: Data from the 2016 to 2017 National Survey of Children's Health for children aged 6 to 17 years with ADHD were evaluated to assess the association between parent-reported bullying victimization or perpetration and the following potential predictors: demographic characteristics, family factors, school factors, and child conditions/behaviors. RESULTS: Among children with ADHD, 46.9% were bullying victims and 16.2% were perpetrators. Factors associated with victimization included having family financial strain, developmental delay or intellectual disability, friendship difficulties, and school reports about problems. Factors linked to perpetration included being male, receiving government assistance, lack of school engagement, school reports about problems, and having difficulties with friendships, staying calm, and arguing. CONCLUSIONS: Children with ADHD frequently were bullying victims and sometimes bullying perpetrators. Factors related to family financial strain, developmental disabilities, emotional regulation, peer relationships, and school functioning may help to identify risk for bullying and opportunities for anti-bullying interventions.

Predictors of Stimulant Medication Continuity in Children with Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: The objective of this study was to examine the simultaneous impact of patient-related and parent-related factors, medication-related factors, and health care system-related factors on attention-deficit/hyperactivity disorder (ADHD) medication continuity. METHOD: Stimulant-naïve children (N = 144, M age = 8 yrs, 71% male) with ADHD completed a methylphenidate (MPH) trial and were followed for 1 year after trial completion and return to community care. Multivariable analysis investigated predictors of (1) having at least 1 filled ADHD prescription after return to community care versus none and (2) having more days covered with medicine after return to community care. Predictors included race; age; sex; income; baseline ADHD symptom severity; MPH trial experience; child and parent mental health conditions; and parent beliefs about ADHD, ADHD medications, and therapeutic alliance. RESULTS: One hundred twenty-one children (84%) had at least 1 filled ADHD medication prescription (mean = 178 d covered by medication) in the year after return to community care. Multivariable models found that a weaker perceived clinician-family working alliance predicted not filling any ADHD prescriptions. Among those who filled ≥1 prescription, factors linked to fewer days of ADHD medication coverage included child sociodemographic factors (non-White race, older age, being female, and lower income), lower parent beliefs that the child's ADHD affects their lives, and higher parent beliefs that medication is harmful, while child oppositional defiant disorder and parental ADHD predicted having more days of medication coverage. CONCLUSION: Child demographic factors, parent beliefs, and medication-related factors are associated with continuation of ADHD medication. These findings may facilitate the development of effective strategies to improve ADHD medication continuity for children from diverse groups.

Substance Use and Utilization of Prenatal and Postpartum Care.

OBJECTIVES: Prenatal and postpartum care for women with substance use is important due to increased risk of poor health outcomes. The influence of substance use on perinatal care utilization is not well characterized, especially postpartum care. The objective of this study was to examine the effect of substance use during pregnancy on prenatal and postpartum care utilization in a nationally representative sample and to identify maternal characteristics associated with inadequate prenatal and postpartum care among women with substance use. METHODS: Pregnancy Risk Assessment Monitoring System data (2016-2018) from 8 states were used for this study. Logistic regression models adjusted for complex survey weights and confounder variables were used to estimate the odds of not receiving adequate prenatal care and postpartum care. Weighted Rao-Scott chi-square tests were used to examine maternal characteristics associated with care utilization among women who reported substance use during pregnancy. RESULTS: The study included 15,131 women, with 5.3% who reported illicit substance use during pregnancy. In multivariable models, substance use was associated with an increase in the odds of not receiving adequate prenatal care (OR 1.69, CI 1.32, 2.17) and not receiving postpartum care (OR: 1.47, CI 1.10, 1.95). Among women who reported substance use, depression and smoking status were associated with not receiving adequate prenatal or postpartum care. CONCLUSIONS: Substance use during pregnancy is independently associated with disparities in prenatal and postpartum care access. Future studies are needed to identify how barriers lead to care inequalities and importantly, to identify strategies to improve care utilization.

Comparison of Attention-Deficit Hyperactivity Disorder in Typically Developing Children and Children with Down Syndrome.

OBJECTIVE: This study aimed to evaluate attention-deficit hyperactivity disorder (ADHD) symptom patterns among children with Down syndrome (DS) with or without ADHD and typically developing (TD) children with ADHD. METHODS: Parents and teachers rated symptoms of inattention, hyperactivity, and general behavioral concerns for 22 children with DS and comorbid diagnoses of ADHD (DS + ADHD), 66 gender-matched and age-matched children with DS with no diagnosis of ADHD (DS - ADHD), and 66 gender-matched and age-matched TD children with ADHD (TD + ADHD). Children with DS were recruited from the community. TD children with ADHD were recruited from a specialty clinic evaluating for ADHD. RESULTS: Parents tended to report higher scores of inattention and hyperactivity for TD children with ADHD compared with children with DS and no ADHD. Although mean ADHD symptom summary scores were not significantly different in DS + ADHD and DS - ADHD, specific parent-report items (e.g., distractibility and being "on the go") did tend to differentiate these groups. By contrast, teachers tended to report higher inattention and hyperactivity scores for DS + ADHD compared with both DS - ADHD and TD + ADHD. Specific teacher-reported items tending to differentiate DS + ADHD and DS - ADHD included difficulties following through on tasks, avoiding tasks, leaving one's seat, and excessive talking. CONCLUSION: Variability in response patterns between parent and teacher reports for children with and without DS highlights the need to evaluate ADHD symptoms across environments. Our findings also suggest specific items that may particularly be helpful in distinguishing children with DS who do and do not have ADHD, although replication is needed.

"My mom calls it Annaland": A Qualitative Study of Phenomenology, Daily Life Impacts, and Treatment Considerations of Sluggish Cognitive Tempo.

Objective: To conduct qualitative analysis of interviews to understand phenomenology, daily life impact, and treatment considerations of sluggish cognitive tempo (SCT) behaviors in children and adolescents. Method: Youth with elevated SCT symptoms (N = 15, ages 9-16 years) and their parents completed interviews focused on their perception and daily life impact of SCT behaviors. Parents were also asked about intervention targets. Results: Parents and youth had both negative and positive perceptions of SCT, with SCT fostering creativity/imagination and a break from stressors while also negatively impacting daily functioning. The domains most frequently selected by parents as SCT intervention targets were academics, emotions, mind wandering, morning routines, and self-esteem. Conclusion: Children and their parents share negative and positive views of SCT behaviors, while also detailing specific ways that SCT negatively impacts day-to-day functioning. This study offers insights into possible intervention targets as provided by youth and parents directly impacted by SCT.

Striving for Structure and Stability in Cincinnati's Family Homeless Shelters: A Community-Based Participatory Research Approach.

Experiencing homelessness negatively impacts child health, development, and emotional-behavioral functioning, but there is limited knowledge regarding specific service priorities, as articulated by families themselves, to prevent or address these adverse sequelae. Thus, to elicit the service needs perspective of families in shelter and to translate these findings into real-world action, we undertook a community-based participatory research effort using Group-Level Assessment, a focus group methodology. An action-based participatory needs assessment called a Group-Level Assessment (GLA) was conducted in collaboration with parents currently experiencing homelessness. A total of 53 parents from 3 Cincinnati homeless shelters participated by responding to 17 to 20 open-ended prompts regarding their child's medical, developmental, learning, social, and behavioral needs. Using GLA methodology, we found that the needs expressed by families residing in shelters coalesced around the following themes: job and housing stability, education and skill development, emotional support, and improving shelter life. The GLA findings were then shared with shelter and community leaders, leading to a number of policy and practice enhancements in the shelters. This study demonstrates the power of the GLA approach to affect community action as a direct result of priorities generated by families experiencing homelessness.

Racism as an Adverse Childhood Experience: An Interactive Workshop to Train Pediatricians to Address Racism in Clinical Care.

OBJECTIVE: The objective of this study was to address critical gaps in pediatric medical education by developing and evaluating an interactive educational workshop on racism as an adverse childhood experience (ACE). METHODS: A team of developmental-behavioral pediatrics professionals used a best-practice curriculum development model of Kern's 6 steps to develop the workshop curriculum. Based on a targeted needs assessment, goals and objectives to address the topics of race and racism in clinical practice were developed. A variety of educational strategies (e.g., audience polls, videos, didactic presentations, experiential activities, and peer-guided case-based discussion and practice) were used to appeal to varied learning styles. Selection of strategies was guided by self-determination theory, an adult learning model that addresses the needs of autonomy, competence, and relatedness. The workshop was implemented at 2 national pediatric meetings and evaluated using participant polls and written program evaluation. RESULTS: The workshop curriculum was well-received. Participants endorsed improvements in comfort level in talking about race/racism and demonstrated a significant change in preparation or comfort level for skills-based activities, including counseling families and offering resources to address experiences with racism, postworkshop. Participants endorsed intent to change clinical practice by discussing the issues of race and indicated a desire to receive additional training. CONCLUSION: An interactive educational workshop on racism as an ACE was effective in improving pediatric professionals' comfort level and self-rated skills. Desire for a longer educational session suggests receptivity to longitudinal approaches. Replication and refinement of the educational workshop could clarify effective components of this approach. We advocate for longitudinal training curricula that incorporate observable behavior change and skills to increase and further evaluate the impact. Health care provider education and training to implement antiracism efforts in clinical encounters with patients and families can serve as an entry point to the complex process of addressing racism at multiple levels in health care.

Psychosocial and behavioral problems of children and adolescents in the early stage of reopening schools after the COVID-19 pandemic: a national cross-sectional study in China.

This study aims to explore the psychosocial and behavioral problems of children and adolescents in the early stage of reopening schools. In this national cross-sectional study, a total of 11072 students from China were naturally divided into two groups based on their schooling status: reopened schools (RS) and home schooling (HS) group. The psychosocial and behavioral functioning were measured by Achenbach Child Behaviour Checklist (CBCL) and compared in these two groups. Multivariable logistic regression analyses were conducted to explore the independent predictors associated with the psychosocial and behavioral problems. Our results showed that the students in the RS group had more adverse behaviors than that of HS group. The RS group had the higher rates of parent-offspring conflict, prolonged homework time, increased sedentary time and sleep problems (all p < 0.001). When separate analyses were conducted in boys and girls, the RS group had the higher scores for (1) overall behavioral problems (p = 0.02 and p = 0.01), internalizing (p = 0.02 and p = 0.02) and externalizing (p = 0.02 and p = 0.004) behaviors in the 6-11 age group; (2) externalizing (p = 0.049 and p = 0.006) behaviors in the 12-16 age group. Multivariable regression showed parent-offspring conflict and increased sedentary time were the most common risk factors, while physical activity and number of close friends were protective factors for behavior problems in RS students (p < 0.01 or 0.05). The present study revealed that students' psychosocial and behavioral problems increased in the early stage of schools reopened unexpectedly. These findings suggest that close attention must be paid and holistic strategies employed in the school reopening process of post-COVID-19 period.

Association between perinatal depression and risk of attention deficit hyperactivity disorder among children: a retrospective cohort study.

PURPOSE: Perinatal depression has previously been identified as a risk factor for attention deficit hyperactivity disorder (ADHD) in the offspring. Population-based studies utilizing diagnosis data are needed to better understand the relationship between these two variables. The objective of this study was to examine the association between perinatal depression and the risk of ADHD among children born during a 5 or-more-year follow-up period. METHODS: The sample was drawn from a population-based cohort of privately insured mother-child pairs within the state of Iowa. Hazard ratios for risk of ADHD by exposure to perinatal depression were estimated using adjusted Cox proportional-hazard models. RESULTS: Among the 5,635 mother-child pairs, 484 mothers were diagnosed with depression during the perinatal period, and 269 children were diagnosed with ADHD. After adjustment for confounders, children born to mothers with perinatal depression were over three times more likely to be diagnosed with ADHD (HR 3.16 (95% CI 2.35, 4.23)). CONCLUSIONS: Children born to mothers with perinatal depression were found to be at increased risk of ADHD. This finding suggests that ADHD and its adverse sequelae could be mitigated by increasing maternal depression intervention efforts as well as ADHD screening and treatment efforts targeted to this vulnerable population.

Genetic Influence on Efficacy of Pharmacotherapy for Pediatric Attention-Deficit/Hyperactivity Disorder: Overview and Current Status of Research.

Multiple stimulant and non-stimulant medications are approved for the treatment of attention-deficit/hyperactivity disorder (ADHD), one of the most prevalent childhood neurodevelopmental disorders. Choosing among the available agents and determining the most effective ADHD medication for a given child can be a time-consuming process due to the high inter-individual variability in treatment efficacy. As a result, there is growing interest in identifying predictors of ADHD medication response in children through the burgeoning field of pharmacogenomics. This article reviews childhood ADHD pharmacogenomics efficacy studies published during the last decade (2009-2019), which have largely focused on pharmacodynamic candidate gene investigations of methylphenidate and atomoxetine response, with a smaller number investigating pharmacokinetic candidate genes and genome-wide approaches. Findings from studies which have advanced the field of ADHD pharmacogenomics through investigation of meta-analytic approaches and gene-gene interactions are also overviewed. Despite recent progress, no one genetic variant or currently available pharmacogenomics test has demonstrated clinical utility in pinpointing the optimal ADHD medication for a given individual patient, highlighting the need for further investigation.

Developing the Evidence-Grading Tools and Process for the Complex Attention-Deficit/Hyperactivity Disorder Guideline.

Clinical practice guidelines (CPGs) rely on a robust assessment of the quality of evidence supporting guideline recommendations. For the Society for Developmental and Behavioral Pediatrics (SDBP) CPG for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit Hyperactivity Disorder (ADHD), the nature of the evidence and resource constraints led the guideline panel to develop an innovative, yet rigorous, approach to evidence grading. This study will (1) describe the challenges of evidence grading for the SDBP Complex ADHD Guideline; (2) discuss the rationale, process, and tools developed to conduct evidence grading; and (3) report on the experiences and readiness of the volunteer reviewers with diverse background in research methodology to conduct evidence grading. This evidence review process may serve as an example of approaches that can be used by other groups tasked with evaluating the evidence in support of new CPGs.