Novel Quality Control Metric for the Pharmacotherapy of Major Depressive Disorder: Measuring Guideline Concordance and Its Impact on Symptom Severity.

Objective: Studies suggest that people with major depressive disorder (MDD) often receive treatment that is not concordant with practice guidelines. To evaluate this, we (1) developed a guideline concordance algorithm for MDD pharmacotherapy (GCA-8), (2) scored it using clinical data, and (3) compared its explanation of patient-reported symptom severity to a traditional concordance measure.Methods: This study evaluated 1,403 adults (67% female, 85% non-Hispanic/Latino White, mean age 43 years) with non-psychotic MDD (per ICD-10 codes), from the Penn State Psychiatry Clinical Assessment and Rating Evaluation System (PCARES) registry (visits from February 1, 2015, to April 13, 2021). We (1) scored 1-year concordance using the Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines and deviation from 8 pharmacotherapy-related criteria and (2) examined associations between concordance and Patient Health Questionnaire depression module (PHQ-9) scores.Results: The mean GCA-8 score was 6.37 (standard deviation [SD] = 1.30; 8.00 = perfect concordance). Among those who switched drugs (n = 671), 81% (n = 542) did not have their dose increased to the recommended maximum before switching. In our adjusted analyses, we found that a 1 SD increase in the GCA-8 was associated with a 0.78 improvement in the mean PHQ-9 score (P < .001). The comparison concordance measure was not associated with the mean PHQ-9 score (ß = -0.20; P = .20; R2 = 0.53), and adding the GCA-8 score significantly improved the model (R2 = 0.54; Vuong test P = .008).Conclusions: By measuring naturalistic MDD pharmacotherapy guideline concordance with the GCA-8, we revealed potential treatment gaps and an inverse association between guideline concordance and MDD symptom severity.

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

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

Social and Monetary Reward Processing in Youth with Early Emerging Personality Pathology: An RDoC-Informed Study.

Very little is known about the mechanisms underlying the development of personality disorders, hindering efforts to address early risk for these costly and stigmatized disorders. In this study, we examined associations between social and monetary reward processing, measured at the neurophysiological level, and personality pathology, operationalized through the Level of Personality Functioning (LPF), in a sample of early adolescent females (Mage = 12.21 years old, SD = 1.21). Female youth with (n = 80) and without (n = 30) a mental health history completed laboratory tasks assessing social and monetary reward responsiveness using electroencephalogram (EEG) and completed ratings of personality pathology. Commonly co-occurring psychopathology, including depression, anxiety, attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) were also assessed. At the bivariate level, significant associations did not emerge between psychopathology and reward processing variables. When covarying symptoms of depression, anxiety, ADHD, ODD, and CD, an enhanced reward positivity (RewP) component to social reward feedback (accounting for response to social rejection) was associated with higher levels of personality impairment. Results were specific to social rather than monetary reward processing. Depression, anxiety, and ODD also explained unique variance in LPF. These findings suggest that alterations in social reward processing may be a key marker for early emerging personality pathology. Future work examining the role of social reward processing on the development of LPF across adolescence may guide efforts to prevent the profound social dysfunction associated with personality pathology.

Gender differences in transdiagnostic domains and function of adults measured by DSM-5 assessment scales at the first clinical visit: a cohort study.

BACKGROUND: Measurement-based care has been called for as best practice in psychiatric care and learning health systems and use of transdiagnostic measures was suggested as part of the DSM-5. Our objective is to examine gender differences in first visit socioeconomic, transdiagnostic, and functional characteristics of a dynamic, real-world measurement-based care cohort. METHODS: Transdiagnostic, functional, and clinical measures were collected from 3,556 patients at first visit in an ambulatory psychiatric clinic. All patients were evaluated at the first visit by board-certified psychiatrists or licensed clinical psychologists. Demographic variables and clinical diagnoses were collected from the Electronic Medical Record. Self-report measures were collected that assessed transdiagnostic symptoms (DSM-5 Level 1 Cross-cutting Measure and Level 2 symptom scales), disability, alcohol use, attention deficit hyperactivity disorder (ADHD) symptoms, depression, anxiety, mania, suicidal thoughts and behaviors, and trauma exposure. RESULTS: Men and women did not differ in age, BMI, household income, high school graduation rate, race, or ethnicity, but women were more likely to be formerly married and less likely to have commercial insurance. Compared to men, women reported significantly higher overall psychopathology on the transdiagnostic Level 1 Cross-cutting measure and had higher depression, anxiety, sleep, anger, ADHD combined presentation, and suicidality severity. Women also had higher disability scores than men. However, men reported higher alcohol, tobacco and substance use, and more risky behavior than women. Trauma exposure differed significantly by gender; men reported more exposure to accidents, war-related trauma, serious accidents, and major disasters and women reported more unwanted sexual contact. CONCLUSIONS: This cross-sectional study of a transdiagnostic, ecologically-valid real-word measurement-based care cohort demonstrates gender differences in socioeconomic factors, trauma exposure, transdiagnostic symptoms, and functioning.

A Pilot Study on the Effectiveness of Prazosin as a Treatment of Post-Traumatic Stress Disorder-Related Nightmares in Women with Bulimia Nervosa.

Objectives Post-traumatic stress disorder (PTSD) symptoms are reported in over 36% of individuals with bulimia nervosa. To date, none of the clinical trials have examined nightmare reduction in this population. We evaluated the effectiveness of prazosin in bulimic females experiencing PTSD-related nightmares. We hypothesized that prazosin will decrease nightmares, normalize cortisol levels and secretory patterns, and improve sleep. Methods Our seven-week prospective, randomized, double-blind, placebo-controlled crossover pilot trial recruited eight adult women. Each participant received three weeks of prazosin and a placebo, separated by a one-week washout period. The order of treatment was counterbalanced across participants. Self-reports, clinician-administered scales, and salivary cortisol was collected to measure outcomes. Results A significant treatment effect was seen in nightmare intensity on the Clinician-Administered PTSD Scale (CAPS-I) (p=0.026) and a marginally significant effect on nightmare frequency (p=0.069). The only significant main effect of treatment on self-reported sleep parameters was on nightmares. Cortisol secretory patterns did not change, but on average, study participants had significantly higher cortisol levels compared to normative values. ANOVA showed a significant main effect of time for cortisol (F(4, 28) = 6.15, p=.001) but no within or between groups significant effects (ps>.179). Follow-up tests showed the effect of time was linear (F(1, 7) = 10.77, p=.013). Conclusion Prazosin significantly reduced intensity and marginally reduced the frequency of PTSD-related nightmares in bulimia nervosa but did not affect subjective sleep efficiency, quality, cortisol levels, or diurnal cortisol secretory pattern. Larger trials using objective sleep measures are warranted to replicate these findings.

Cognitive Disengagement Syndrome (CDS) (Formerly Sluggish Cognitive Tempo), Autism, and Insomnia Symptoms in Childhood Predict CDS in Adolescence: A Longitudinal Population-Based Study.

Our study is the first using multiple variables to compare concurrent with longitudinal predictors of cognitive disengagement syndrome (CDS). The population-based sample comprised 376 youth (mean baseline age 8.7 and follow-up 16.4 years) rated by parents on the Pediatric Behavior Scale. The baseline CDS score was the strongest predictor of follow-up CDS. Baseline autism and insomnia symptoms also predicted follow-up CDS above and beyond baseline CDS. Autism, insomnia, inattention, somatic complaints, and excessive sleep were concurrently related to CDS at baseline and follow-up. Additionally, follow-up depression was associated with follow-up CDS, and baseline hyperactivity/impulsivity was negatively associated with baseline CDS. Oppositional defiant/conduct problems and anxiety were nonsignificant. Age, sex, race, and parent occupation were unrelated to CDS, and correlations between baseline CDS and 15 IQ, achievement, and neuropsychological test scores were nonsignificant. Results indicate childhood CDS is the strongest risk factor for adolescent CDS, followed by autism and insomnia symptoms.

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

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

Do Language-Related Cognitive Capacities Help Predict Adjustment in Children with Attention-Deficit/Hyperactivity Disorder?

The goal of this paper was to examine the role that language-related cognitive capacities (LRCC) might play in explaining adjustment of 7 to 12 year-old children (Mage = 9.24; SDage = 0.91) with and without ADHD. The sample was comprised of 178 children with ADHD and 86 typically-developing children (77.3% male; 81.4% White; 9.5% Black; 1.9% Hispanic; 0.8% Asian; 5.7% multiracial; 0.8% did not report race/ethnicity). Using simultaneous regression, we examined whether LRCC accounted for unique variance in achievement, attention problems, oppositional problems, conduct problems, and internalizing, over and above what standard covariates and ADHD diagnostic status could explain. Finally, we examined LRCC as a mediator of the relation between ADHD diagnostic status and these adjustment measures. Results indicated that LRCC significantly predicted 6 of 7 and partially mediated 5 of 7 measures, suggesting that language-related constructs warrant greater attention in diagnosis and treatment of ADHD.

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

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

The Disruptive Behavior Disorders Rating Scale: Updated Factor Structure, Measurement Invariance, and National Caregiver Norms.

OBJECTIVE: To provide the first caregiver-report national norms for the Disruptive Behavior Disorders Rating Scale (DBDRS) and an updated evaluation of its factor structure and measurement invariance across child sex, informant sex, and child age. METHODS: Caregivers of children aged 5-12 years (N = 962) based in the United States completed the four DBDRS subscales. Using both severity scoring and dichotomous scoring procedures, confirmatory factor analyses supported a four-factor model of inattentive and hyperactive/impulsive symptoms, oppositional defiant symptoms, and conduct disorder symptoms. RESULTS: Measurement invariance was supported, indicating that the DBDRS functions similarly across demographic characteristics. Boys were reported to have more severe symptoms than girls (Cohen's d = 0.33 [inattention], 0.30 [hyperactivity/impulsivity], 0.18 [oppositional defiant disorder], 0.14 [conduct disorder]), female caregivers rated ADHD symptoms as more severe than male caregivers (ds = 0.15 and 0.19 for inattention and hyperactivity/impulsivity, respectively), and older children were reported to experience more inattention than younger children (d = 0.18). Overall, group differences were modest in magnitude. CONCLUSION: This psychometric study supports the continued use of the DBDRS in school-aged youth and will enhance the measure's clinical and research utility by providing the first caregiver-report norms.

Agreement between mother, father, and teacher ratings of cognitive disengagement syndrome (sluggish cognitive tempo) in children with autism and children with ADHD.

No studies have analyzed differences between mother, father, and teacher ratings of cognitive disengagement syndrome (CDS; formerly sluggish cognitive tempo). The sample included 1,115 children with autism and/or attention-deficit/hyperactivity disorder (ADHD) 4-16 years of age who were rated by mothers on the Pediatric Behavior Scale. Subsets of these children were also rated by fathers and/or teachers, resulting in 896 mother/father, 964 mother/teacher, and 745 father/teacher dyads. The CDS factor comprised four items assessing the core features of CDS: cognitive disengagement (in a fog/confused and stares/preoccupied/in own world) and hypoactivity (sluggish/slow moving/low energy and drowsy/sleepy/not alert). Overall, 37% of teachers, 22% of mothers, and 16% of fathers rated the children as significantly elevated on CDS symptoms. Teacher scores were significantly higher than mother scores, whose scores exceeded those of fathers. Agreement on whether a child had CDS was fair-moderate for mothers and fathers but poor for parents and teachers. Findings of more severe CDS teacher than parent ratings are in marked contrast to the opposite pattern found in studies of anxiety, depression, ADHD, oppositional behavior, conduct problems, autism, bullying, and victimization. Children may display fewer behavior problems at school than at home, and parents may be more aware of their child's internal state than teachers. However, teachers may be more aware of the cognitive component of CDS that might interfere with functioning in the classroom more so than at home. Cognitive demands in school may reveal and intensify CDS symptoms. Findings highlight the importance of multi-informant ratings in research and clinical practice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sluggish cognitive tempo: Association with neuropsychological test scores, motor incoordination, and dysgraphia in elementary school children.

Research on the relationship between sluggish cognitive tempo (SCT) and scores on neuropsychological tests (such as those measuring processing speed and reaction time) is inconclusive, and the association between SCT and motor incoordination and dysgraphia has not been objectively investigated. Mothers of 413 elementary school children (6-12 years of age) rated their children on the Pediatric Behavior Scale (PBS), which yields psychological problem scores, including SCT. Children were administered an extensive battery of neuropsychological tests assessing processing and performance speed, working memory, immediate and delayed recall, sustained attention, response inhibition, cognitive flexibility, fine motor manipulative skill, verbal fluency and retrieval, set shifting, and interference control, as well as intelligence and reading and math achievement. Only three of the 19 correlations between SCT and neuropsychological scores were significant, and all involved graphomotor tests (two timed and one untimed). In regression analysis, the strongest independent predictor of SCT was the maternal PBS incoordination factor score, followed by ratings of autism, inattention, and depression. Neuropsychological test scores did not contribute significantly more to predicting SCT. Among the incoordination PBS factor items, clumsy and draws or writes poorly were significant SCT predictors. Our novel and unexpected findings showed that motor incoordination was a stronger correlate of SCT than other variables assessed in our study, including those previously linked with SCT. Future SCT research needs to include measures of incoordination and dysgraphia in order to replicate and expand upon the current findings. Our results suggest that SCT traits are not reliably measured by currently available neuropsychological tests.

Multi-Informant Ratings of Childhood Limited Prosocial Emotions: Mother, Father, and Teacher Perspectives.

OBJECTIVE: Modest agreement between mothers', fathers', and teachers' reports of child psychopathology can cause diagnostic ambiguity. Despite this, there is little research on informant perspectives of youth's limited prosocial emotions (LPEs). We examined the relationship between mother-, father-, and teacher-reported LPE in a clinical sample of elementary school-aged children. METHOD: The sample included 207 primarily Caucasian (n = 175, 84.5%) children (136 boys; 65.7%) aged 6-13 years (M = 8.35, SD = 2.04) referred to an outpatient child diagnostic clinic focused on externalizing problems. We report the percentage of youth meeting LPE criteria as a function of informant perspective(s). Utilizing standard scores, we report distributions of informant dyads in agreement/disagreement regarding child LPE, followed up by polynomial regressions to further interrogate the relationship between mother-, father-, and teacher-reported LPE as it relates to conduct problems (CPs). RESULTS: The prevalence of child LPE was approximately twice as large when compared to those reported in community samples; mothers and fathers generally agreed on their child's LPE symptoms (55% agreement). Higher-order nonlinear interactions between mothers and fathers, as well as parents and teachers, emerged; discrepancies between informants, characterized by low levels of LPE reported by the child's mother, were predictive of youth at the highest risk for CPs. CONCLUSIONS: Our findings emphasize the clinical utility of gathering multiple reports of LPE when serious CPs are suspected. It may be beneficial for clinicians to give significant consideration to teacher reported LPE when interpreting multiple-informant reports of LPE.

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.

Comparison of the Cognitive Disengagement and Hypoactivity Components of Sluggish Cognitive Tempo in Autism, ADHD, and Population-Based Samples of Children.

An international Sluggish Cognitive Tempo (SCT) Work Group proposed a new term for SCT, "cognitive disengagement syndrome," that more accurately describes the syndrome than does SCT. According to the Work Group, symptoms of SCT represent a cognitive dimension (cognitive disengagement) and a motor dimension (hypoactivity). Our study determined (1) if distinct factors representing cognitive disengagement and hypoactivity emerged when SCT items were factor analyzed and (2) the degree of differences in cognitive disengagement and hypoactivity within diagnostic groups. Mothers rated 1,177 children with autism, 725 with ADHD-Combined, and 307 with ADHD-Inattentive (4-17 years) and 665 elementary school children (6-12 years) on the Pediatric Behavior Scale (PBS). SCT prevalence rates were autism 32%, ADHD-Inattentive 27%, ADHD-Combined 18%, and elementary school students 7%. Factor analysis of the SCT items yielded two factors reflecting cognitive disengagement (in a fog/confused and stares/preoccupied/in own world) and hypoactivity (sluggish/slow moving/low energy, drowsy/sleepy/not alert, and tires easily) in all diagnostic groups. Cognitive disengagement prevalence rates and scores were significantly higher than hypoactivity in the autism and ADHD-C groups and in the autism and ADHD-C subgroups of children with SCT (but not in the ADHD-I and elementary school total groups and SCT subgroups). Our findings factor analyzing five SCT items support two SCT subfactors: cognitive disengagement and hypoactivity.

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

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

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

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

Screening for ADHD in a general outpatient psychiatric sample of adults.

Adults (n = 805) seeking outpatient psychiatric care completed the Adult ADHD Self-Report Scale (ASRS) and measures of impairment and co-occurring psychopathology as part of a measurement-based care initiative. Diagnostic indicators of ADHD (i.e., formal diagnosis and/or medication treatment) were recorded from the electronic medical record (EMR). Agreement between screening positive for ADHD and EMR indicators for the diagnosis was explored, and clinical characteristics of adults identified with ADHD using these indicators were examined. Lastly, the contribution of ADHD to functional impairment was examined, controlling for the contribution of other demographic and psychiatric comorbidities. In the full sample, 54.78% of adults screened positive for ADHD based on the ASRS, and using EMR indicators, only 11.93% of adults were identified with ADHD. Agreement emerged between self-reported ADHD and ADHD EMR indicators, although adults screening positive for ADHD generally reported greater psychiatric complexity relative to adults identified with ADHD in the EMR. ADHD was associated with clinical impairment even when controlling for other psychiatric comorbidities. The considerable difference in prevalence of ADHD based on self-report screening versus EMR indicators suggests that ADHD may be overlooked in adult psychiatric care. Findings point to the importance of assessing adult ADHD in routine psychiatric care.

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

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

Inhibitory Control, Conduct Problems, and Callous Unemotional Traits in Children with ADHD and Typically Developing Children.

Compared children with CP/ADHD, CPCU/ADHD, ADHD-only, and controls on two measures of inhibitory control: a Simon/flanker task that measured response selection and a stop signal task that measured response inhibition. Results showed: (a) ADHD was associated with both measures of inhibitory control; (b) control children had better overall performance and ADHD-only had worse response selection than the CP groups; and (c) children with CPCU/ADHD had better response inhibition than children with ADHD-only or CP/ADHD. Results suggest inhibitory control dysfunction is associated with ADHD rather than CP and that response inhibition dysfunction distinguishes children with CP/ADHD from children with CPCU/ADHD.