Clinician observations of preschoolers' behavior help to predict ADHD at school age

Consider how preschool children behave across multiple contexts to identify those at risk for later ADHD, study emphasizes Don't rely on one source of information about your preschoolers' inattention or hyperactivity. Rather, consider how your child behaves at home as well as information from his or her teacher and a clinician. This advice comes from Sarah O'Neill, of The City College of New York, based on research she conducted at Queens College (CUNY), in an article published in Springer's Journal of Abnormal Child Psychology. The study examines how well parent, teacher, and clinician ratings of preschoolers' behavior are able to predict severity and diagnosis of attention deficit hyperactivity disorder (ADHD) at age six Professional Counselor Continuing Education Characterized by developmentally inappropriate levels of inattention, hyperactivity, and impulsivity, ADHD is one of the most frequently diagnosed childhood psychiatric disorders. Although many studies focusing on school-aged children have shown that parents and teachers -- rather than clinician observations alone -- are more likely to assess ADHD accurately, scant evidence exists to support similar conclusions with preschoolers. To fill this gap in the research, O'Neill and colleagues followed a group of 104 hyperactive and/or inattentive three- and four-year-olds for a period of two years. Both parents and teachers rated the preschoolers' behavior. In addition, clinicians, who were blind to parent and teacher reports, completed ratings of preschoolers' behavior during a psychological testing session. By the time the children reached age six, more than half (53.8 percent) had been diagnosed with ADHD. The likelihood of such a diagnosis increased when all three informants had rated the child as high on symptoms at age three or four. Furthermore, after analyzing the reports separately, the research team found that parents' reports were critical, particularly when combined with either teacher or clinician reports. Teacher reports alone were not as useful, and the research team ascribed the relative inability of educators' reports to predict a child's ADHD status over time to possible situational variables. Preschoolers may initially have difficulty adjusting to the structured classroom setting, but this disruptive behavior is time-limited to the transition to school. Teachers' perceptions of "difficult" behavior may also be affected by factors such as classroom setting and size as well as their expectations of children's behavior. As a result of the study findings, O'Neill and her team emphasize the importance of using information from multiple informants who have seen the child in different settings. Parent reports of preschoolers' behavior appear to be crucial, but these alone are not sufficient. Augmenting the parent report with that of the teacher and/or clinician is necessary. Also important are clinician observations of preschoolers during psychological testing, which are predictive of an ADHD diagnosis and its severity over time. Being able to identify children at risk for poorer outcomes may help educators and clinicians to plan appropriate interventions. "Consider a preschool child's behavior in different contexts," O'Neill emphasized. "Although parents' reports of preschoolers' inattention, hyperactivity, or impulsivity are very important, ideally we would not rely solely on them. At least for young children, the clinician's behavioral observations appear to hold prognostic utility." ### Reference: O'Neill, S. et al. (2013). Reliable Ratings or Reading Tea Leaves: Can Parent, Teacher, and Clinician Behavioral Ratings of Preschoolers Predict ADHD at Age Six? Journal of Abnormal Child Psychology. DOI 10.1007/s10802-013-9802-4

New Data Reveal Extent of Genetic Overlap Between Major Mental Disorders

Schizophrenia, Bipolar Disorder Share the Most Common Genetic Variation Press Release • August 12, 2013 The largest genome-wide study of its kind has determined how much five major mental illnesses are traceable to the same common inherited genetic variations. Researchers funded in part by the National Institutes of Health found that the overlap was highest between schizophrenia and bipolar disorder; moderate for bipolar disorder and depression and for ADHD and depression; and low between schizophrenia and autism. Overall, common genetic variation accounted for 17-28 percent of risk for the illnesses. “Since our study only looked at common gene variants, the total genetic overlap between the disorders is likely higher,” explained Naomi Wray, Ph.D., University of Queensland, Brisbane, Australia, who co-led the multi-site study by the Cross Disorders Group of the Psychiatric Genomics Consortium (PGC), which is supported by the NIH’s National Institute of Mental Health (NIMH). “Shared variants with smaller effects, rare variants, mutations, duplications, deletions, and gene-environment interactions also contribute to these illnesses.” Dr. Wray, Kenneth Kendler, M.D., of Virginia Commonwealth University, Richmond, Jordan Smoller, M.D., of Massachusetts General Hospital, Boston, and other members of the PGC group report on their findings August 11, 2013, in the journal Nature Genetics. “Such evidence quantifying shared genetic risk factors among traditional psychiatric diagnoses will help us move toward classification that will be more faithful to nature,” said Bruce Cuthbert, Ph.D., director of the NIMH Division of Adult Translational Research and Treatment Development and coordinator of the Institute’s Research Domain Criteria (RDoC) project, which is developing a mental disorders classification system for research based more on underlying causes. Earlier this year, PGC researchers – more than 300 scientists at 80 research centers in 20 countries – reported the first evidence of overlap between all five disorders. People with the disorders were more likely to have suspect variation at the same four chromosomal sites. But the extent of the overlap remained unclear. In the new study, they used the same genome-wide information and the largest data sets currently available to estimate the risk for the illnesses attributable to any of hundreds of thousands of sites of common variability in the genetic code across chromosomes. They looked for similarities in such genetic variation among several thousand people with each illness and compared them to controls – calculating the extent to which pairs of disorders are linked to the same genetic variants. The overlap in heritability attributable to common genetic variation was about 15 percent between schizophrenia and bipolar disorder, about 10 percent between bipolar disorder and depression, about 9 percent between schizophrenia and depression, and about 3 percent between schizophrenia and autism. The newfound molecular genetic evidence linking schizophrenia and depression, if replicated, could have important implications for diagnostics and research, say the researchers. They expected to see more overlap between ADHD and autism, but the modest schizophrenia-autism connection is consistent with other emerging evidence. The study results also attach numbers to molecular evidence documenting the importance of heritability traceable to common genetic variation in causing these five major mental illnesses. Yet this still leaves much of the likely inherited genetic contribution to the disorders unexplained – not to mention non-inherited genetic factors. For example, common genetic variation accounted for 23 percent of schizophrenia, but evidence from twin and family studies estimate its total heritability at 81 percent. Similarly, the gaps are 25 percent vs. 75 percent for bipolar disorder, 28 percent vs. 75 percent for ADHD, 14 percent vs. 80 percent for autism, and 21 percent vs. 37 percent for depression. Among other types of genetic inheritance known to affect risk and not detected in this study are contributions from rare variants not associated with common sites of genetic variation. However, the researchers say that their results show clearly that more illness-linked common variants with small effects will be discovered with the greater statistical power that comes with larger sample sizes. “It is encouraging that the estimates of genetic contributions to mental disorders trace those from more traditional family and twin studies. The study points to a future of active gene discovery for mental disorders” said Thomas Lehner, Ph.D., chief of the NIMH Genomics Research Branch, which funds the project.

Common inherited genetic variation (single nucleotide polymorphisms, or SNPs) accounted for up to about 28 percent of the risk for some disorders, such as ADHD (dark green). Among pairs of disorders (light green), schizophrenia and bipolar disorder (SCZ-BPD) shared about 16 percent of the same common genetic variation (coheritabilities). Source: Cross-Disorder Group of the Psychiatric Genomics Consortium Professional Counselor Continuing Education Reference Cross-Disorder Group of the Psychiatric Genomics Consortium. Genetic relationship between five psychiatric disorders estimated from genome-wide SNPs. Nature Genetics, August 11, 2013 Grants R01MH065562, R01MH43518, R01MH065554, R01MH65707, R01MH065571, R01MH65588, R01MH65578, R01MH65558 ### The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the NIMH website. About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the NIH website. Press Contact(s) Jules Asher NIMH Press Office 301-443-4536 NIMHPress@nih.gov More Science News about: Attention Deficit Hyperactivity Disorder (ADHD) Autism Bipolar Disorder Depression Schizophrenia Contact the Press Office Phone: 301-443-4536 Email: NIMHpress@mail.nih.gov Press Resources Mental Health Information Statistics on Mental Disorders Summaries of Scientific Meetings Information about NIMH RePORTER: Research Portfolio Online Reporting Tool Expenditures and Results PubMed Central: An Archive of Life Sciences Journals Recommendations for Reporting on Suicide News from the Field News from the Field NIMH-Funded Science on EurekAlert Teen Eating Disorders Increase Suicide Risk The Love Hormone is 2-Faced Fear Factor: Missing Brain Enzyme Leads to Abnormal Levels of Fear in Mice, Reveals New Research More news from the field... Bookmark & Share Newsletters RSS Feeds Facebook

Girls with ADHD more prone to self-injury, suicide as they enter adulthood

Visible symptoms can go undercover, UC Berkeley psychologists find Girls with Attention Deficit Hyperactivity Disorder (ADHD) – and their families – often look forward to the likely decline in visible symptoms such as fidgety or disruptive behavior as they mature into young women. However, new findings from UC Berkeley caution that, as they enter adulthood, girls with histories of ADHD are more prone to internalize their struggles and feelings of failure – a development that can manifest itself in self-injury and even attempted suicide LPC continuing education "Like boys with ADHD, girls continue to have problems with academic achievement and relationships, and need special services as they enter early adulthood," said Stephen Hinshaw, UC Berkeley professor of psychology and lead author of a study that reports after 10 years on the largest-ever sample of girls whose ADHD was first diagnosed in childhood. "Our findings of extremely high rates of cutting and other forms of self-injury, along with suicide attempts, show us that the long-term consequences of ADHD females are profound," he added. The study is published today (Tuesday, August 14) in the Journal of Consulting and Clinical Psychology. Its results are consistent with earlier findings by the UC Berkeley team that, as girls with ADHD grow older, they show fewer visible symptoms of the disorder, but continue to suffer in hidden ways. The findings challenge assumptions that girls can "outgrow" ADHD, and underscore the need for long-term monitoring and treatment of the disorder, Hinshaw said. The longitudinal study, which began when the girls were ages 6 to 12, is funded by grants from the National Institute of Mental Health. Since 1997, Hinshaw and his team have tracked a racially and socio-economically diverse group of girls with ADHD in the San Francisco Bay Area through early childhood summer camps, adolescence and now early adulthood. In addition to this new study, many others have been published by the team about the girls every five years. In the United States, more than 5 million children ages 3-17 – approximately one in 11 – have been diagnosed with ADHD, according to the Centers for Disease Control and Prevention. ADHD is characterized by poor concentration, distractibility, hyperactivity, impulsiveness and other symptoms that are inappropriate for the child's age. Evidence-based treatment includes stimulant medications and various forms of behavior therapy. The new UC Berkeley study, assessing the girls 10 years after it began, examined 140 of them, ages 17-24, comparing their behavioral, emotional and academic development to that of a demographically similar group of 88 girls without ADHD. It also gauged the symptoms of two major ADHD subtypes: Those who entered the study with poor attention alone versus those who had a combination of inattention plus high rates of hyperactivity and impulsivity. The study's major finding was that the group with combined inattention and hyperactivity-impulsivity during childhood was by far the most likely to manifest self-injury and suicide attempts in early adulthood. In fact, the study pointed out, more than half of the members of this subgroup were reported to have engaged in self-injurious behavior, and more than one-fifth had attempted suicide, Hinshaw said. "A key question is why, by young adulthood, young women with ADHD would show a markedly high risk for self-harm … Impulse control problems appear to be a central factor," the study said. In the first study on this group, published in 2002, the 6- to- 12-year old girls attended five-week camps where they were closely monitored as they partook in art and drama classes and outdoor activities. Those taking ADHD medication volunteered to go off the drug treatment for much of the summer camp study. The counselors and staff observing all the participants did not know which of them had been diagnosed with ADHD. That study found that girls with ADHD were more likely to struggle academically and to be rejected by their peers, compared to the comparison peer group. The five-year follow-up study, when the girls were 12 to 17 and experiencing early to mid-adolescence, found that the fidgety and impulsive symptoms tended to subside in the early teen years, but that the learning gap between girls with ADHD and their non-ADHD peers had widened, and eating disorders and substance abuse had surfaced. For the latest study, in which 95 percent of the original sample of girls participated, the researchers conducted intensive interviews with the subjects and their families. Those interviews include personal reports on behaviors such as self-harm and suicide attempts, drug use, eating habits and driving behavior. Researchers also measured key cognitive functions such as executive planning skills, which include goal-setting and monitoring, planning and keeping on task despite distractions. While many girls in the study showed improvement in ADHD symptoms during the 10-year period, certain problems persisted and new ones emerged, suggesting that careful monitoring and treatment are essential, Hinshaw said. "The overarching conclusion is that ADHD in girls portends continuing problems, through early adulthood," the study concluded. "Our findings argue for the clinical impact of ADHD in female samples, the public health importance of this condition on girls and women, and the need for ongoing examination of underlying mechanisms, especially regarding the high risk of self-harm in young adulthood." That said, Hinshaw added, "ADHD is a treatable condition, as long as interventions are monitored carefully and pursued over a number of years." ### In addition to Hinshaw, authors and researchers of the study are Elizabeth Owens, Christine Zalecki, Emily Schrodek and Erika Swanson at UC Berkeley; Suzanne Perrigue Huggins at the University of Maryland and Adriana Montenegro-Nevado at Palo Alto University