Diagnostic accuracy of a brief screening tool for attention deficit hyperactivity disorder in UK prison inmates.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is overrepresented in prison, making it imperative to identify a screening tool that can be quickly applied to efficiently detect the disorder. We explored the discrimination ability of a widely used ADHD screen, the Barkley Adult ADHD Rating Scale (BAARS-IV), against a clinical diagnostic interview. A brief version of the screen was then developed in order to simplify its use in the prison context, and maximize its diagnostic properties. METHOD: A cross-sectional study of 390 male prison inmates was performed in the UK, all participants were screened and interviewed via the Diagnostic Interview for ADHD in Adults 2.0 (DIVA-2). RESULTS: A total of 47 (12.1%) inmates screened positive for ADHD using the full BAARS-IV, and 96 (24.6%) were clinically diagnosed, for a sensitivity of 37.9 and a specificity of 96.3. Our models identified the six items that most predicted ADHD diagnosis, with adjusted odds ratios ranging from 2.66 to 4.58. Sensitivity, specificity and accuracy were 0.82, 0.84 and 0.84, respectively, for the developed brief scale, and 0.71, 0.85 and 0.81 for its validation. Weighted probability scores produced an area under the curve of 0.89 for development, and 0.82 for validation of the brief scale. CONCLUSIONS: The original BAARS-IV performed poorly at identifying prison inmates with ADHD. Our developed brief scale substantially improved diagnostic accuracy. The brief screening instrument has great potential to be used as an accurate and resource-effective tool to screen young people and adults for likely ADHD in the criminal justice system.

Secular changes in rehospitalization of very low birth weight infants.

Neonatal survival among very low birth weight infants (less than 1,500 g) has improved dramatically during the last decade. Concern about the quality of life among these survivors has focused mainly on the prevalence of severe motor, sensorineural, and intellectual impairment. This study examined the possible effects of increasing survival on less serious morbidity as evidenced by hospital readmission patterns. The experience of VLBW survivors in a geographically defined population has been compared with that of a randomly selected group of heavier infants. As VLBW infant survival rates improved from 35% to 48% between 1968 to 1972 and 1974 to 1978, the rehospitalization rate before 2 years of age increased from 22% to 27%. In contrast, among heavier infants, rehospitalization rates decreased from 9.8% to 8.9%. The relative risk of readmission associated with VLBW thus increased from 2.2 to 3.0. Although this increase in the overall relative risk of rehospitalization in VLBW infants was not statistically significant, there was a dramatic and statistically significant increase in the relative risk of being readmitted because of structural defects (particularly hernias). Overall, there was a marked decline in the number of days spent in the hospital in both birth weight groups.

Health and school performance of teenagers born before 29 weeks gestation.

OBJECTIVE: To ascertain the health and school performance of teenagers born before 29 weeks gestation (extremely low gestational age (ELGA)) and to compare those in mainstream school with classroom controls. METHODS: Three geographically defined cohorts of babies born in 1983 and 1984 were traced at the age of 15-16 years. Their health, abilities, and educational performance were ascertained using postal questionnaires to the teenagers themselves, their parents, their general practitioners, and the teachers of those in mainstream school. Identical questionnaires were sent to classroom controls. RESULTS: Of the 218 teenagers surviving to the age of 16 years, information was obtained on 179. Of these, 29 were in special schools and 150 in mainstream school, 10 of whom had severe motor or sensory impairment. Using the Child Health Questionnaire, parents of teenagers in mainstream school reported a higher incidence of problems than controls in physical functioning (difference in mean scores 9.0 (95% confidence interval (CI) 4.9 to 13.1)) and family life (difference in mean scores for family cohesion 7.0 (95% CI 1.6 to 12.4)). In all areas of learning, teachers rated the ability of the ELGA teenagers in mainstream school lower than the control group. Parents of teenagers in special schools reported a higher rate of problems in most areas. CONCLUSIONS: One in six ELGA survivors at age 16 years have severe disabilities and are in special schools. Most ELGA survivors are in mainstream school and are coping well as they enter adult life, although some will continue to need additional health, educational, and social services.

Epidemiology of cerebral palsy in England and Scotland, 1984-9.

AIMS: To report on the epidemiology of cerebral palsy in England and Scotland, to provide information on the prevalence of cerebral palsy and the severity of the disability or any co-morbidity. METHODS: Cerebral palsy registers were compiled from multiple sources of ascertainment covering all of Scotland and the counties of Merseyside, Cheshire, Berkshire, Buckinghamshire, Northamptonshire and Oxfordshire in England. All cases of cerebral palsy born in 1984 to 1989, to mothers resident in the area, were included. Denominator number of live births and neonatal deaths for determining birthweight specific prevalence were obtained from birth and death registrations. Learning, manual, and ambulatory disabilities were graded for severity. Any co-existing sensory (hearing or visual) morbidity was also graded for severity. RESULTS: There were 789,411 live births in 1984-9, with 3651 neonatal deaths (neonatal mortality 4.6 per 1000 live births) and 1649 cases of cerebral palsy--a cerebral palsy prevalence of 2.1 per 1000 neonatal survivors. The birthweight specific cerebral palsy prevalence ranged from 1.1 per 1000 neonatal survivors in infants weighting > or = 2500 g to 78.1 in infants weighing < 1000 g. There was no significant time trend in prevalence of cerebral palsy in any of the birthweight groups, in contrast to the fall in neonatal mortality observed in all birthweight groups. Of the 1649 cases of cerebral palsy, 550 (33.4%) had severe ambulatory disability (no independent walking), 390 (23.7%) had severe manual disability (incapable of feeding or dressing unaided), 381 (23.1%) had severe learning disability (IQ < 50), 146 (8.9%) had severe visual disability (vision < 6/60 in the better eye) and 12 had severe hearing disability (> 70 dB loss). CONCLUSIONS: Registers fill an important gap left by the lack of routine data on the prevalence of disability in children. The ability to record trends in the prevalence and the severity of the disability should inform those who have responsibility for providing services for children with disabilities.

Hypertension during pregnancy, with and without specific hypotensive treatment. I. Perinatal factors and neonatal morbidity.

In a prospective study, women who were hypertensive before the 28th wk of gestation were randomly allocated into two groups: those who received specific hypotensive therapy (Ht) and those who did not (Hu). The outcome was compared with a random sample of the hospital population (S) ascertained after delivery. In both hypertensive groups there was a higher incidence of clinical signs of possible fetal distress and instrumental delivery. Although there was no difference between the groups in the distribution of birthweight above and below the mean for gestational age, the treated hypertensive group had an excess of infants with relatively smaller head circumferences for their gestational age compared with both the untreated hypertensive group and the hospital sample. Tube-feeding was also more frequent in the treated hypertensive group. In the untreated hypertensive group there were more infants whose neurological status was categorized as questionable or abnormal in the neonatal period, compared with the sample. The different problems encountered by infants in the two hypertensive groups emphasized the need for further study of these babies. Their development during the first year of life will be examined in a subsequent paper.

Hypertension during pregnancy, with and without specific hypotensive treatment. II. The growth and development of the infant in the first year of life.

The growth and development of three groups of infants were prospectively assessed from birth to 12 mth. In two groups the mothers had been hypertensive before the 28th wk of gestation; one group was randomly allocated to specific hypotensive therapy, the other group was allocated to no specific treatment. The third group was a sample of the hospital population. General health, and the incidence of sight and hearing problems did not differ. Infants in the treated hypertensive group had had more perinatal problems, and there was an excess of infants with relatively small heads for their gestational age at birth. At 6 mth their heads were still smaller than the hospital sample, but by the age of 1 yr the difference was no longer present. The neurological status of infants in the untreated hypertensive group was less favourable in the neonatal period, and there was still an excess of infants in this group rated questionable on neurological assessment at the age of 12 mth. In both hypertensive groups there was an excess of infants with delayed fine-motor function at 6 mth, and in the untreated group there was an excess with delayed gross-motor function at 12 mth compared with the hospital sample. Our varied findings draw attention to the dangers of assessing the effects of different pregnancy conditions in terms of neonatal mortality and morbidity alone. Our date indicate that follow-up should extend for longer than 12 mth when the effects of adverse pregnancy factors and their management are under consideration. Further evaluation will be made when these children are 4 yr old.

Induction of labour by different methods in primiparous women. I Some perinatal and postnatal problems.

A personal prospective study was made of some perinatal and postnatal problems associated with induction of labour by three different methods in primiparous women with unripe cervices. The methods of induction were: (A) amniotomy followed by intravenous oxytocin [49], (B) amniotomy followed by intravenous prostaglandin E2 [39], (C) prostaglandin E2 by the extra-amniotic route [42]. A spontaneous group (D) comprising 54 mother--infant pairs was also studied. Length of gestation was between 37 and 42 wk in all but 2 cases. There was no perinatal mortality, and no infant had hyaline membrane disease. A close association was found between method of delivery and method (or absence) or induction. The caesarean section rate was highest in group C and lowest in group D. The spontaneous vaginal delivery rate was lowest in group C and highest in group D. More infants in the three induction groups were admitted to the Special Care Baby Unit (SCBU) than in the spontaneous group. No significant associations were found between the severity of the conditions leading to induction and caesarean section rates, low Apgar scores, admissions to SCBU, or the favourability of the cervix before induction. Among those who intended to breast feed fewer infants in the spontaneous group changed from breast to bottle while in hospital and after discharge from hospital than in the combined induction groups. Success in breast-feeding was not significantly associated with method of delivery or whether the infant was admitted to SCBU or not.

Induction of labour by different methods in primiparous women. II. Neuro-behavioural status of the infants.

The infants of primiparous women in whom labour had been induced by three different methods were studied, together with a fourth group (D) who had laboured spontaneously. The methods of induction were: amniotomy followed by intravenous oxytocin (A), amniotomy followed by intravenous prostaglandin E2 (B), and prostaglandin E2 by the extra-amniotic route (C). Neurological assessments were made on the first day after birth, 4 days later, and at the age of 2 mth. No significant associations were found between method of delivery and neurological scores at any age. On day 1 infants with a lower Apgar score at 1 min had a lower neurological score than those with a high Apgar score (P < 0.05). On day 5 infants with a high serum bilirubin level (> 207 mumol/l) had a lower mean neurological score than those with a lower recorded serum bilirubin level (P < 0.05). By the age of 2 mth this difference had increased still further (P > 0.001). No differences were found in the mean neurological scores of infants in the four groups during the neonatal period, but at the age of 2 mth the mean score for infants in group A was significantly lower than that for infants in group C (P > 0.05) and D (P > 0.01). Among those children seen again at the age of 18 mth fine-motor adaptive performance was poorer for infants in group A than in groups B (P > 0.05), C (P > 0.005) and D (P > 0.01).

Obtaining parental consent--opting in or opting out?

In a population based project aimed at identifying children with specified disabilities within a health region, there was, rightly, concern about the transfer of data on named children across health district boundaries. Two methods of obtaining parental consent for this process were tested. High recruitment rates were achieved using an 'opting out' approach.

Patterns of neuropsychological function in a low-birthweight population.

An investigative analysis was carried out of the neuromotor and cognitive findings in a population-based study of low-birthweight infants (< 1750g) at 4 1/2 years of age to try to improve the understanding of the neuropathological basis of their deficits. Cluster analysis identified groups of children whose performance in the cognitive subscales of the British Ability Scales followed similar patterns, and also differentiated between children in neuromotor competence. Cluster membership correlated highly with language attainment, ability to copy shapes, behaviour as reported by parents and parents' and examiners' perception of attention span. Children in poorer-performing clusters were more likely to be born to mothers who had had a previous perinatal death, and were also more likely to have experienced septicaemia during the neonatal period. These findings are discussed in the light of evidence from the neuropathological and physiological literature.

Birth weight and hospital admission before the age of 2 years.

Admission rates to hospital of children born weighing 1500 g or less were compared with those born with birth weights over 1500 g in a retrospective analysis of routinely collected data from the Oxford Record Linkage Study. The children were born in the three five year periods 1968-72, 1974-8, and 1979-83 to women resident in Oxfordshire and West Berkshire. The main measures of the study were survival rates to 28 days after birth and hospital admissions of survivors up to the age of two years. Among babies weighing 1500 g or less, neonatal survival rates rose from 350.2 per 1000 total births in 1968-72 to 577.4 per 1000 among births in 1979-83. Over the same period, the proportion of children admitted to hospital at least once before the age of 2 years rose from 218.6 per 1000 survivors to 444.4 per 1000. In the children with birth weights over 1500 g, survival rates rose from 985.5 to 995.9 per 1000 births and hospital admission rates rose from 98.2 to 144.4 per 1000 survivors over the same time period. Although very low birthweight children did not contribute significantly to total hospital bed occupancy, because their numbers were small in relation to the total number of children in the population, their contribution increased between the five year periods 1968-72 and 1979-83. It should therefore be continuously monitored using routine systems.

Direct amplification of nodD from community DNA reveals the genetic diversity of Rhizobium leguminosarum in soil.

Sequences of nodD, a gene found only in rhizobia, were amplified from total community DNA isolated from a pasture soil. The polymerase chain reaction (PCR) primers used, Y5 and Y6, match nodD from Rhizobium leguminosarum biovar trifolii, R. leguminosarum biovar viciae and Sinorhizobium meliloti. The PCR product was cloned and yielded 68 clones that were identified by restriction pattern as derived from biovar trifolii [11 restriction fragment length polymorphism (RFLP) types] and 15 clones identified as viciae (seven RFLP types). These identifications were confirmed by sequencing. There were no clones related to S. meliloti nodD. For comparison, 122 strains were isolated from nodules of white clover (Trifolium repens) growing at the field site, and 134 from nodules on trap plants of T. repens inoculated with the soil. The nodule isolates were of four nodD RFLP types, with 77% being of a single type. All four of these patterns were also found among the clones from soil DNA, and the same type was the most abundant, although it made up only 34% of the trifolii-like clones. We conclude that clover selects specific genotypes from the available soil population, and that R. leguminosarum biovar trifolii was approximately five times more abundant than biovar viciae in this pasture soil, whereas S. meliloti was rare.

Debendox revisited.

Two further studies re-examine the findings by Golding et al. (1983) in Oxford that mothers of children born with oral clefts had been more frequently prescribed Debendox (Bendectin) than had the mothers of matched controls. In Cardiff, 86 283 total births between 1965 and 1979 included 139 infants with oral clefts. Detailed information was obtained about 93 of these infants and matched controls. The relative risk of the birth of an infant with an oral cleft to women prescribed Debendox within 69 days of the first day of their last menstrual period was 0.64 (95% confidence limits 0.12-3.34). No increased effect was found amongst women who smoked. In Aberdeen, 17 640 livebirths between 1976 and 1979 included 31 children with oral clefts. Compared with the non-exposed group the risk of a birth of an infant with an oral cleft to a woman prescribed Debendox in early pregnancy was 0.37 (95% confidence limits 0.09-1.47). These results do not confirm the previous findings in Oxford of a possible association between exposure to Debendox in early pregnancy and the occurrence of oral clefts in the child.

Perusing the literature: comparison of MEDLINE searching with a perinatal trials database.

The existence of a Register of Controlled Trials in Perinatal Medicine (National Perinatal Epidemiology Unit, Oxford, England) has offered an opportunity to assess the efficacy of online searching of MEDLINE, an example of a broad bibliographic database. Retrieval of all relevant randomized control trials (RCTs) in a given field is important in analyses in which results are pooled (meta-analyses). Reports of RCTs of prevention and treatment of neonatal hyperbilirubinemia and prevention of intraventricular hemorrhage (IVH) for the years 1966-1983 were sought in both the Register and MEDLINE files. Comparison of subject searches revealed a number of unlisted papers in each file that were then found to be present by an author search. In the MEDLINE searching an amateur was clearly less efficient than an expert, but the expert recovered only 29% of the relevant hyperbilirubinemia papers available in MEDLINE, and only 56% of the identified IVH RCTs. Some of the deficiencies in recovery have been corrected by indexing improvements, such as the capability of identifying text words in abstracts, and the addition of new medical subject heading terms (MeSH) such as RANDOM ALLOCATION. Efficiency will be best facilitated by authors and editors keeping the MeSH terms used by MEDLINE indexers in mind when they compose titles and abstracts.

Follow up of babies delivered in a randomized controlled comparison of vacuum extraction and forceps delivery.

Babies delivered in a randomized controlled comparison of vacuum extraction vs. forceps delivery were reassessed at 9 months of age. There were no statistically significant differences between the two groups as regards head circumference, weight, or head circumference to weight ratio, nor in the results of hearing and vision tests. The reasons for hospital readmission, pediatric follow-up and parents' and health visitors' worries appeared to be unrelated to the mode of delivery in nearly all cases. The finding in the original trial that neonatal jaundice was more common following vacuum extraction was reinforced by an additional case of jaundice in the vacuum extractor group which had necessitated readmission to hospital.

Acid-base status at birth and neurodevelopmental outcome at four and one-half years.

Two hundred thirty term infants with measured acid-base status in umbilical arterial blood at birth were selected from 1210 consecutive deliveries for detailed neurodevelopmental follow-up at age 4 1/2 years; 203 were examined. Cutoff points approximately 1 SD from the mean (pH less than or equal to 7.10; base deficit greater than 12 mmol/L) were used to define acidosis. No statistically significant associations between acidosis and developmental outcome were found. The highest proportion of unimpaired children was found among those who were most severely acidotic at birth (pH less than or equal to 7.04; 2 SD below mean), but this finding was not statistically significant. These findings suggest that the ability of the fetus to produce an acidosis in response to the stress of labor may be beneficial to long-term outcome. The 10 nonacidotic babies with 1-minute Apgar scores of less than or equal to 3 showed statistically significant deficits in some areas. Coincident acidosis was not associated with a worse outcome for infants with low Apgar scores.

Comparing two methods of follow up in a multicentre randomised trial.

AIMS: To evaluate a parental questionnaire as a means of providing outcome measures for a multicentre randomised controlled trial of treatment for post-haemorrhagic ventricular dilatation. METHODS: The parents of 88 survivors were sent a questionnaire before a paediatric assessment at the age of 30 months. The parents' responses to individual questions taken mainly from the Griffiths' mental development scales and their perception of the child's ability to see and hear were compared with the paediatric findings. A model, based on the parents' responses to particular questions, allowed the categorisation of the children as normal, impaired, moderately or severely disabled; this was compared with similar categorisation based on the full paediatric assessment. RESULTS: Agreement on items concerning gross motor function ranged between 81 and 99%, concerning dressing between 77 and 80%, concerning feeding between 91 and 99%, and concerning language between 85 and 93%. Similar proportions of children were identified as disabled by the parents (60%) and by the paediatrician (66%). Of 29 children who had developmental quotients less than 70, parents identified 28 as disabled, 18 of them as severely disabled. They were not so good at identifying children with impairments without functional loss. CONCLUSIONS: Further work is required but there is sufficient encouragement from the results to pursue this methodology further for use in comparing groups in randomised trials.

School attainment, cognitive ability and motor function in a total Scottish very-low-birthweight population at eight years: a controlled study.

The prevalence of learning problems and of cognitive and motor impairment in a total geographically based very-low-birthweight population (N = 324) was compared at eight years of age with that in a population comprising two classroom peers, matched for gender and age (N = 590). 15 per cent of those with birthweights less than 1000g and 6 per cent of those weighing 1000 to 1499 g attended special schools. Index children in main-stream schools performed significantly less well in tests of neuromotor function than their comparison groups. Their mean IQs were 90.4 and 93.7 for those below and above 1000 g, respectively, while their comparison groups' IQs were 102.5 and 101.2. In all cognitive subscales apart from that testing short-term auditory sequential memory, both index groups were less competent. They were also less able in Word Reading and Basic Number Skills. These children placed heavy demands on mainstream schools, with 52 per cent and 37 per cent of the index groups, respectively, requiring learning support compared with 16 per cent in both comparison groups.