CASE:DL is an 8-year-old Mexican boy with a posterior atrial septal defect and partial anomalous pulmonary venous return of the right lower pulmonary vein with resultant right heart dilation with normal right ventricular systolic and diastolic function and no arrhythmias. Surgical repair was deferred, and DL's condition was being medically managed with furosemide 0.5 mg/kg BID and spironolactone 0.5 mg/kg BID.DL presents for developmental assessment due to poor performance in school following a lifting of COVID-19 pandemic restrictions and return to in-person classes. He has been attending full-time classes for 3 months without improvements in math, reading, and writing skills. Current attentional concerns at school include an inability to complete tasks without getting distracted by minimal stimuli and highly impulsive behavior.At the first assessment, DL was performing below grade expectations (e.g., reading by syllable without text comprehension, demonstrating preoperational addition and subtraction skills, inability to take dictation)-all of which was viewed as negatively impacted by attentional deficits. DL met DSM-5 criteria for ADHD, predominantly inattentive type. He was started on 10-mg immediate-release methylphenidate PO at 8 am with breakfast and a second dose of 10-mg immediate-release methylphenidate PO 4 hours after the first dose.After a month, at the first follow-up consultation, improvement in attention span, impulsivity, and school performance were observed, including reading skills and math proficiency. However, DL's mother raised concerns about circumoral cyanosis and acrocyanosis in the fingers of both hands after playing outside. These signs were not previously observed. During physical examination at the same visit, heart rate, blood pressure, and oximetry were within baseline ranges and his cardiac examination was unchanged. DL's dosage of methylphenidate was lowered to 10-mg immediate-release methylphenidate PO QD in the mornings with breakfast (8 am).DL did not return to clinic for another 2 months, having discontinued the medication after 2 months of treatment given financial limitations. His mother reported that DL's exertional circumoral cyanosis and acrocyanosis resolved while he was off medication. However, she observed an increase in inattentive symptoms and impulsivity and decline in his academic skills. She asked if our team was able continue the treatment despite the drug side effects, since she believed the benefits outweighed the disadvantages.Given these concerns, the team requested an updated cardiology assessment. The Cardiologist recommended discontinuation of methylphenidate and recommended follow-up with cardiothoracic surgery for reassessment of the surgical timeline.Given the limited treatment options in Mexico, what would you do next as the treating developmental-behavioral clinician…?

Background: Attention deficit hyperactivity disorder is a common neurodevelopmental disorder. Accessing services for this disorder is a worldwide challenge and requires innovative interventions. Aims: We aimed to investigate the effectiveness of tele-collaborative care for attention deficit hyperactivity disorder in primary health care centres in Dubai. Methods: Six trained physicians started collaborative care clinics across Dubai. Eligible children aged 6-12 years attending primary health care centres with attention deficit hyperactivity disorder were randomly selected to receive tele-health collaborative care, or standard treatment. Baseline assessments were conducted using the Vanderbilt Behavioral Assessment Scale, the Columbia Impairment Scale, the Childhood Behavior Checklist, and the Strength and Difficulties Questionnaire. Waiting times and clinical and functional outcomes were measured in both groups and compared. Continuous variables were presented as means and standard deviations, categorical variables such as sex were presented as numbers and percentages, and continuous outcome variables were compared using the Student t-test. Results: Among the referred children (n = 112), 11 boys and 6 girls met the eligibility criteria (mean age 7.8 years). The dropout rate at 6 months in the control group was 80%, compared with 50% in the intervention group. The mean waiting time was significantly shorter in the intervention group (1.3 weeks) than the control group (7.1 weeks); P = 0.026. The mean difference in the Childhood Behavior Checklist total score over time was significantly higher in the intervention group (P = 0.042), but the mean difference in the Vanderbilt scale was not significant. Conclusion: Tele-collaborative care for children with attention deficit hyperactivity disorder within primary health care is feasible.

The cardiovascular (CV) impact of stimulants has been examined for decades, with investigations ranging from small sample targeted studies of heart rate (HR) and blood pressure (BP), to large scale epidemiologic investigations. The preponderance of evidence is reassuring, albeit generally based on healthy samples using variable methodology, excluding those at theoretic high risk (eg, comorbid cardiac illness). Screening for theoretically vulnerable patients are recommended, as well as monitoring for CV symptoms and BP/HR, with shared inquiry/further evaluation if concerned. Future investigations to support the identification of risk are needed, while attention to stimulant-associated CV risk is an opportunity for clinicians to engage in general CV risk identification and intervention.

CASE: Phillip is a young man born with hypoplastic left heart syndrome referred to your practice for a range of mental health concerns. He underwent palliation to an extracardiac Fontan in infancy and experienced multiple complications over the next decade including valvular regurgitation and arrhythmias necessitating a pacemaker. Phillip continued to have systolic heart failure with New York Heart Association class II symptoms, managed with 4 medications and anticoagulation. Despite this complex history, Phillip had intact cognitive abilities, achieved typical milestones, and performed well academically in secondary school. His first year of college proved to be more challenging, and Phillip presented to the outpatient psychiatry service with an acute depressive episode. His family history included depression, without known attention-deficit/hyperactivity disorder (ADHD). Treatment, including a selective serotonin reuptake inhibitor, cognitive behavioral therapy, and family support, led to near resolution of his symptoms of depression. In subsequent appointments, Phillip described a long history of inattention and disorganization with onset in childhood. This contributed to the decision to leave college, despite remission of symptoms of depression. Phillip was unable to study for any extended period without "perfect conditions," described as the absence of potential distractions except for background music. Despite attempts to maintain "perfect conditions," Phillip was often off task and "hyperfocusing" on irrelevant topics. Phillip struggled with planning and time management and would misplace items daily. Moreover, although the importance of self-care was well understood, Phillip often forgot to take his cardiac medication or to exercise, and he admitted to inconsistent sleep habits because of losing track of time. Based on a comprehensive psychiatric evaluation including retrospective report from a parent, Phillip was diagnosed with ADHD, coexisting with major depressive disorder, in remission. Significant ADHD symptoms were documented by interview, self-report, and administration of an abbreviated neuropsychological battery. Considering concerns regarding use of stimulants in a patient with congenital heart disease, including death, stroke, and myocardial infarction,(1,2) how would you assess the risks-benefits of use of stimulants with Phillip? REFERENCES 1. Wilens TE, Prince JB, Spencer TJ, et al. Stimulants and sudden death: what is a physician to do? Pediatrics. 2006;118:1215-1219. 2. Zito JM, Burcu M. Stimulants and pediatric cardiovascular risk. J Child Adolesc Psychopharmacol. 2017;27:538-545.

OBJECTIVE:The Before School Functioning Questionnaire and Parent Rating of Evening and Morning Behavior-Revised assess early morning (BSFQ, PREMB-R AM subscale) and late afternoon/evening (PREMB-R PM subscale) functional impairment in children with ADHD. Clinically meaningful improvements were identified and applied to a trial of delayed-release and extended-release methylphenidate (DR/ER-MPH) in children with ADHD (NCT02520388) to determine if the statistically-determined improvements in functional impairment were also clinically meaningful. METHOD:Clinically meaningful improvements in BSFQ/PREMB-R were established post hoc by receiver operating characteristics curves, using anchors of Clinical Global Impression-Improvement (CGI-I) = 1 and CGI-I ≤ 2. Percentages of participants achieving these thresholds were calculated. RESULTS:Thresholds for CGI-I = 1/CGI-I ≤ 2, respectively, were 27/20 (BSFQ), 5/3 (PREMB-R AM), and 9/5 (PREMB-R PM)-point decreases. More children achieved clinically meaningful improvements with DR/ER-MPH versus placebo (all p < .05). CONCLUSION:DR/ER-MPH increased proportions of children achieving clinically meaningful improvements in BSFQ and PREMB-R.

Outpatient child psychiatry in a children's hospital is charged with care of mental illness severity in the setting of medical illness. Numbers of complex patients are increasing, coincident with high utilization of resources, as well as involvement of subspecialists. A nursing-level clinician may improve safety and quality of care, enhance patient responsiveness, and increase access through optimizing physicians' direct care. This type of clinician is even more relevant in child psychiatry, given the workforce shortage and because only a small fraction is comfortable with a medically complex cohort. To our knowledge, there is no existing psychiatry literature on the role of nursing care coordination for children with complex special health care needs.

Purpose of review To provide an up-to-date clinical review of U.S. Food and Drug Administration (FDA)-approved stimulant medications for attention-deficit/hyperactivity disorder (ADHD), including a framework for individualized treatment by primary care pediatric providers. Recent findings Stimulant medications are first-line agents for pediatric ADHD. Since 2012, 11 novel stimulant medications have been approved by the FDA for the treatment of ADHD. Because of an expanded formulary of available methylphenidate-based and amphetamine-based stimulants, primary care providers may be unfamiliar with some novel medications outside a select formulary. Summary The current broad formulary of methylphenidate-based and amphetamine-based stimulants provides primary care clinicians with a greater opportunity for personalized medicine within the patient-centered medical home. Through a systematic review of prior relevant medication trials, a consideration of daily symptom burden and thoughtful pragmatics, primary care providers can offer a more precise, customized stimulant treatment.

Technological advances coupled with increased access to care through the Patient Protection and Affordable Care Act have led to increases in the use of mental health services via real-time, secure, interactive videoconferencing. Telepsychiatry services for adults are increasingly well-supported, and mounting early evidence supports feasibility and acceptability for child telepsychiatry services and highlights improvements in access to care. However, data are limited describing the use of synchronous virtual psychotherapy visits with children. We will present data on the implementation and acceptability of child teletherapy in an outpatient psychiatry service at an academic medical center.

Stimulant class medications are known to cause elevations in cardiovascular (CV) parameters, heart rate (HR), and blood pressure (BP) in children with ADHD. The predominant findings in the literature are small mean increases in HR and BP, without consideration of putative moderating and mediating variables impacting CV response. Clinicians and families would benefit from an individualized approach to CV risk analysis. This presentation is an up-to-date literature review on the topic, inclusive of a unique post hoc CV examination in a large, ethnically diverse sample group of children with ADHD.

Suicide is the second leading cause of death for individuals ages 10 to 24 years. More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease, combined. Each day in our nation, there is an average of more than 3470 suicide attempts by young adults attending high school. The main objectives of our literature review are to highlight the importance of recognizing postdischarge period in patients at risk of suicide, critically analyzing the risk and protective factors to formulate an individualized safety plan during transition, and creating a model of response to suicide in a child fellow clinic.

Hauptman, Aaron J. MD; Acar, Diler MD; Hammerness, Paul MD; Fogler, Jason M. PhD; Stafford, Diane MDEditor(s): Suzuki, Joji MD Author Information

Objective: Children with ADHD frequently manifest behavioral difficulties in the morning prior to school. We sought to assess the reliability and validity of the Before-School Functioning Questionnaire (BSFQ) as a measure of morning behaviors impaired by ADHD. Method: We used pre-treatment data from a randomized crossover study of 6- to 12-year-old participants comparing the methylphenidate transdermal delivery system (MTS) with a placebo transdermal system (PTS) for a total of 4 weeks. Results: The BSFQ investigator–rated scale shows very good internal homogeneity (Cronbach’s α = .91), good test–retest reliability ( r = .60), good concurrent validity ( r range = .42-.86), and a strong treatment effect (effect size = −.93). The self-rated BSFQ showed lower levels of reliability and validity. Conclusion: The investigator-rated BSFQ should be used in future trials of ADHD medications aimed at assessing efficacy in the morning before school.

The efficacy and safety of DR/ER-MPH, a delayed-release and extended-release methylphenidate, were evaluated in a phase 3 trial of children with ADHD. In addition to improving ADHD symptoms, DR/ER-MPH demonstrated statistically significant reductions in at-home functional impairment versus placebo (PBO); however, it is unknown if these improvements are clinically relevant. This post hoc analysis evaluated the clinical meaningfulness of DR/ER-MPH versus PBO in improving at-home functional impairment.

BACKGROUND:A previous small study suggested that Brain Network Activation (BNA), a novel ERP-based brain network analysis, may have diagnostic utility in attention deficit hyperactivity disorder (ADHD). In this study we examined the diagnostic capability of a new advanced version of the BNA methodology on a larger population of adults with and without ADHD.METHOD:Subjects were unmedicated right-handed 18- to 55-year-old adults of both sexes with and without a DSM-IV diagnosis of ADHD. We collected EEG while the subjects were performing a response inhibition task (Go/NoGo) and then applied a spatio-temporal Brain Network Activation (BNA) analysis of the EEG data. This analysis produced a display of qualitative measures of brain states (BNA scores) providing information on cortical connectivity. This complex set of scores was then fed into a machine learning algorithm.RESULTS:The BNA analysis of the EEG data recorded during the Go/NoGo task demonstrated a high discriminative capacity between ADHD patients and controls (AUC = 0.92, specificity = 0.95, sensitivity = 0.86 for the Go condition; AUC = 0.84, specificity = 0.91, sensitivity = 0.76 for the NoGo condition).CONCLUSIONS:BNA methodology can help differentiate between ADHD and healthy controls based on functional brain connectivity. The data support the utility of the tool to augment clinical examinations by objective evaluation of electrophysiological changes associated with ADHD. Results also support a network-based approach to the study of ADHD.

The goal of this presentation is to design and implement an electronic medical record (EMR) based on the means of identifying at-risk patients in a child psychiatry fellow outpatient clinic at an academic teaching hospital, using systematic data extraction over two years.

To test cognitive behavioral therapy (CBT) for persistent attention-deficit hyperactivity disorder (ADHD) symptoms in a sample of medication-treated adolescents. Forty-six adolescents (ages 14–18), with clinically significant ADHD symptoms despite stable medication treatment were randomly assigned to receive CBT for ADHD or wait list control in a cross-over design. Twenty-four were randomized to CBT, 22 to wait list, and 15 crossed-over from wait list to CBT. A blind independent evaluator (IE) rated symptom severity on the ADHD Current Symptom Scale, by adolescent and parent report, and rated each subject using the Clinical Global Impression Severity Scale (CGI), a global measure of distress and impairment. These assessments were performed at baseline, 4-months (post-CBT or post wait list), and 8-months (post-treatment for those originally assigned to the wait list condition and 4-month follow-up for those originally assigned to CBT). Trial Registration: http://clinicaltrials.gov/show/NCT01019252 . Using all available data, mixed effects modeling, and pooling for the wait list cross-over, participants who received CBT received a mean score 10.93 lower on the IE-rated parent assessment of symptom severity (95% CI: −12.93, −8.93; p  < .0001), 5.24 lower on the IE-rated adolescent assessment of symptom severity (95% CI: −7.21, −3.28; p  < .0001), and 1.17 lower IE-rated CGI (95% CI: −1.39, −.94; p  < .0001). Results were consistent across 100 multiple imputations (all p  < .0001). There was a greater proportion of responders after CBT by parent (50% vs. 18%, p  = .00) and adolescent (58% vs. 18% p  = .02) report. This study demonstrates initial efficacy of CBT for adolescents with ADHD who continued to exhibit persistent symptoms despite medications.

OBJECTIVE:To test cognitive behavioral therapy (CBT) for persistent attention-deficit hyperactivity disorder (ADHD) symptoms in a sample of medication-treated adolescents. METHODS:Forty-six adolescents (ages 14-18), with clinically significant ADHD symptoms despite stable medication treatment were randomly assigned to receive CBT for ADHD or wait list control in a cross-over design. Twenty-four were randomized to CBT, 22 to wait list, and 15 crossed-over from wait list to CBT. A blind independent evaluator (IE) rated symptom severity on the ADHD Current Symptom Scale, by adolescent and parent report, and rated each subject using the Clinical Global Impression Severity Scale (CGI), a global measure of distress and impairment. These assessments were performed at baseline, 4-months (post-CBT or post wait list), and 8-months (post-treatment for those originally assigned to the wait list condition and 4-month follow-up for those originally assigned to CBT). TRIAL REGISTRATION:http://clinicaltrials.gov/show/NCT01019252. RESULTS:Using all available data, mixed effects modeling, and pooling for the wait list cross-over, participants who received CBT received a mean score 10.93 lower on the IE-rated parent assessment of symptom severity (95% CI: -12.93, -8.93; p < .0001), 5.24 lower on the IE-rated adolescent assessment of symptom severity (95% CI: -7.21, -3.28; p < .0001), and 1.17 lower IE-rated CGI (95% CI: -1.39, -.94; p < .0001). Results were consistent across 100 multiple imputations (all p < .0001). There was a greater proportion of responders after CBT by parent (50% vs. 18%, p = .00) and adolescent (58% vs. 18% p = .02) report. CONCLUSIONS:This study demonstrates initial efficacy of CBT for adolescents with ADHD who continued to exhibit persistent symptoms despite medications.

IMPORTANCEAlthough attention-deficit/hyperactivity disorder (ADHD) is highly prevalent in adolescents and often persists into adulthood, most studies about treatment were performed in children. Less is known about ADHD treatment in adolescents.OBJECTIVETo review the evidence for pharmacological and psychosocial treatment of ADHD in adolescents.EVIDENCE REVIEWThe databases of CINAHL Plus, MEDLINE, PsycINFO, ERIC, and the Cochrane Database of Systematic Reviews were searched for articles published between January 1, 1999, and January 31, 2016, on ADHD treatment in adolescents. Additional studies were identified by hand-searching reference lists of retrieved articles. Study quality was rated using McMaster University Effective Public Health Practice Project criteria. The evidence level for treatment recommendations was based on Oxford Centre for Evidence-Based Medicine criteria.FINDINGSSixteen randomized clinical trials and 1 meta-analysis, involving 2668 participants, of pharmacological and psychosocial treatments for ADHD in adolescents aged 12 years to 18 years were included. Evidence of efficacy was stronger for the extended-release methylphenidate and amphetamine class stimulant medications (level 1B based on Oxford Centre for Evidence-Based Medicine criteria) and atomoxetine than for the extended-release α2-adrenergic agonists guanfacine or clonidine (no studies). For the primary efficacy measure of total symptom score on the ADHD Rating Scale (score range, 0 [least symptomatic] to 54 [most symptomatic]), both stimulant and nonstimulant medications led to clinically significant reductions of 14.93 to 24.60 absolute points. The psychosocial treatments combining behavioral, cognitive behavioral, and skills training techniques demonstrated small- to medium-sized improvements (range for mean SD difference in Cohen d, 0.30-0.69) for parent-rated ADHD symptoms, co-occurring emotional or behavioral symptoms, and interpersonal functioning. Psychosocial treatments were associated with more robust (Cohen d range, 0.51-5.15) improvements in academic and organizational skills, such as homework completion and planner use.CONCLUSIONS AND RELEVANCEEvidence supports the use of extended-release methylphenidate and amphetamine formulations, atomoxetine, and extended-release guanfacine to improve symptoms of ADHD in adolescents. Psychosocial treatments incorporating behavior contingency management, motivational enhancement, and academic, organizational, and social skills training techniques were associated with inconsistent effects on ADHD symptoms and greater benefit for academic and organizational skills. Additional treatment studies in adolescents, including combined pharmacological and psychosocial treatments, are needed.