Geographic location is an important factor in understanding disparities in access to health-care and social services. The objective of this cross-sectional study is to evaluate disparities in the geographic distribution of income-related... more
Geographic location is an important factor in understanding disparities in access to health-care and social services. The objective of this cross-sectional study is to evaluate disparities in the geographic distribution of income-related social service agencies relative to populations in need within Boston. Agency locations were obtained from a comprehensive database of social services in Boston. Geographic information systems mapped the spatial relationship of the agencies to the population using point density estimation and was compared to census population data. A multivariate logistic regression was conducted to evaluate factors associated with categories of income-related agency density. Median agency density within census block groups ranged from 0 to 8 agencies per square mile per 100 population below the federal poverty level (FPL). Thirty percent (n = 31,810) of persons living below the FPL have no access to income-related social services within 0.5 miles, and 77 % of perso...
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To evaluate whether glucocorticoid administration is associated with improved outcomes in children with anaphylaxis. We included children from the Pediatric Health Information System database who were diagnosed with anaphylaxis at 35 US... more
To evaluate whether glucocorticoid administration is associated with improved outcomes in children with anaphylaxis. We included children from the Pediatric Health Information System database who were diagnosed with anaphylaxis at 35 US children's hospitals between 2009 and 2013. Patients were stratified by disposition from the emergency department (ED), either hospitalized or discharged. We evaluated the association between glucocorticoid administration and prolonged length of stay (LOS), defined as hospital stay ≥2 days, and subsequent epinephrine administration among hospitalized children. Among discharged children, we assessed the association between glucocorticoid administration and ED revisits within 3 days. Analyses were adjusted for illness severity using ordering of laboratory tests, medications, oxygen, intravenous fluids, and admission to the intensive care unit. Among 5203 children hospitalized with anaphylaxis, 424 (8.2%) had prolonged LOS. Glucocorticoid administration was inversely associated with prolonged LOS (aOR, 0.61; 95% CI, 0.41-0.93) and with subsequent epinephrine use (aOR, 0.63; 95% CI, 0.43-0.84) among hospitalized children. Glucocorticoid administration was not associated with the odds of a 3-day revisit (aOR, 1.01; 95% CI, 0.50-2.05) among discharged patients. The use of glucocorticoids was inversely associated with prolonged LOS among children hospitalized with anaphylaxis, but was not associated with 3-day ED revisits among discharged children. These findings support the use of glucocorticoids in children hospitalized with anaphylaxis.
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Emergency department (ED) utilization by children is common and growing more expensive. Tracking trends and variability in ED charges is essential for policymakers who strive to improve the efficiency of the health care system and for... more
Emergency department (ED) utilization by children is common and growing more expensive. Tracking trends and variability in ED charges is essential for policymakers who strive to improve the efficiency of the health care system and for payers who prepare health care budget forecasts. Our objective was to examine trends and variability in ED charges for pediatric patients across Massachusetts. This was a comprehensive analysis of the statewide database containing all the visits of children aged 0 to 18 years evaluated in any of the state's EDs from 2000 to 2011, excluding patients with chronic medical conditions and those whose visits resulted in hospital admission. A validated system designed to specifically classify pediatric emergency patients into major diagnostic groups was used. Mean charges as well as interhospital variability of charges over time were examined for the most common diagnostic groups. Seventy-six hospitals provided emergency care in Massachusetts during the study period, with 6,249,923 pediatric patients treated and discharged. Statewide charges significantly increased from 2000 until 2007/2008, before plateauing or decreasing through 2011. There was no evidence that interhospital variability changed over time. With the exception of academic teaching status, no hospital-level factors emerged as consistent predictors of charges. Charges for common pediatric emergency conditions varied widely across Massachusetts EDs, and hospital-level factors by and large could not consistently explain the variability. Although a plateau (and in some cases decrease) of statewide pediatric emergency health care charges was observed after 2007, no evidence was found that interhospital variability decreased. These data may be useful in the ongoing effort to reform the economics of health care delivery systems.
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Using recordings of endotracheal intubation attempts obtained with a video-enabled laryngoscope with Miller and Macintosh blades, the authors sought to evaluate the association between laryngoscopic approach (right-sided vs. midline) and... more
Using recordings of endotracheal intubation attempts obtained with a video-enabled laryngoscope with Miller and Macintosh blades, the authors sought to evaluate the association between laryngoscopic approach (right-sided vs. midline) and intubation success, as well as adverse event rates in the pediatric emergency department (ED). This was a retrospective cohort study of children younger than 21 years who underwent endotracheal intubation with a C-MAC video laryngoscope in a tertiary care ED between August 2009 and May 2013. The primary outcome was successful endotracheal intubation on the first attempt. The secondary outcomes included time to intubation, video-recorded adverse events (oropharyngeal mucosal injury and aspiration), and physiologic adverse events. Multivariate regression models were used to determine the relationship between laryngoscope blade position and outcome measures adjusted for patient and provider factors. The cohort consisted of complete video recordings for 105 of 143 (73%) patient encounters with intubations. The first-pass success rate did not significantly differ based on laryngoscopic approach (adjusted odds ratio [aOR] = 0.76, 95% confidence interval [CI] = 0.29 to 2.0). Among patients successfully intubated on the first attempt, the median time to intubation was longer for the right-sided approach compared to the midline approach (42 seconds vs. 31.5 seconds; p < 0.05). The odds of mucosal injury and aspiration were higher among patients intubated using a right-sided approach compared to a midline approach (aOR = 4.1, 95% CI = 1.2 to 14.5; aOR = 7.7, 95% CI = 1.5 to 39.5, respectively). Rates of physiologic adverse events did not differ based on approach. First-pass success rate did not differ based upon laryngoscopic approach type; however, a right-sided approach was associated with a longer time to intubation, as well as higher rates of mucosal injury and aspiration among patients undergoing video-enabled intubation in a pediatric ED.
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Advanced diagnostic imaging is commonly used in the evaluation of suspected appendicitis in children. Despite its inferior diagnostic performance, ultrasonography (US) is now preferred to computed tomography (CT) owing to concerns about... more
Advanced diagnostic imaging is commonly used in the evaluation of suspected appendicitis in children. Despite its inferior diagnostic performance, ultrasonography (US) is now preferred to computed tomography (CT) owing to concerns about ionizing radiation exposure. With changes in imaging modalities, the influence on outcomes should be assessed. To review trends in the use of US and CT for children with appendicitis and to investigate simultaneous changes in the proportions of negative appendectomy, appendiceal perforation, and emergency department (ED) revisits. We reviewed the Pediatric Health Information System administrative database for children who presented to the ED with the diagnosis of appendicitis or who underwent an appendectomy in 35 US pediatric institutions from January 1, 2010, through December 31, 2013. We studied the use of US and CT for trends and their association with negative appendectomy, appendiceal perforation, and 3-day ED revisits. Our investigation includ...
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To determine the predictive value of ultrasonography (US) for appendicitis in children when combined with clinical assessment based on the Pediatric Appendicitis Score (PAS). Observational study of children aged 3-18 years who had an US... more
To determine the predictive value of ultrasonography (US) for appendicitis in children when combined with clinical assessment based on the Pediatric Appendicitis Score (PAS). Observational study of children aged 3-18 years who had an US examination for possible appendicitis. A PAS was calculated on the basis of historical elements, examination, and laboratory studies and was used to classify patients into 3 risk groups (low, medium, high). The predictive value of the PAS for appendicitis was calculated and stratified by the result of the US (positive, negative, or equivocal). A total of 728 children with a median age 11.7 (IQR 7.8-14.9) years were studied; 29% had appendicitis. The negative predictive value of US decreased with increasing PAS-based risk assignment: low risk 1.00 (95% CI, 0.97-1.00), medium risk 0.94 (0.91-0.97), and high risk 0.81 (0.73-0.89). With increasing PAS, the positive predictive value increased: low risk 0.73 (0.47-0.99), medium risk 0.90 (0.82-0.98), and h...
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To measure the hospital-level variation in admission rates for children receiving treatment of common pediatric illnesses across emergency departments (EDs) in US children's hospitals. We performed a multi-center cross sectional study... more
To measure the hospital-level variation in admission rates for children receiving treatment of common pediatric illnesses across emergency departments (EDs) in US children's hospitals. We performed a multi-center cross sectional study of children presenting to the EDs of 35 pediatric tertiary-care hospitals participating in the Pediatric Health Information System (PHIS). Admission rates were calculated for visits occurring between January 1, 2009, and December 31, 2012, associated with 1 of 7 common conditions, and corrected to adjust for hospital-level severity of illness. Conditions were selected systematically based on frequency of visits and admission rates. A total of 1288706 ED encounters (13.8% of all encounters) were associated with 1 of the 7 conditions of interest. After adjusting for hospital-level severity, the greatest variation in admission rates was observed for concussion (range 5%-72%), followed by pneumonia (19%-69%), and bronchiolitis (19%-65%). The least vari...
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Thirty-five percent of children experience syncope at least once. Although the etiology of pediatric syncope is usually benign, many children undergo low-yield diagnostic testing. We conducted a quality improvement intervention to reduce... more
Thirty-five percent of children experience syncope at least once. Although the etiology of pediatric syncope is usually benign, many children undergo low-yield diagnostic testing. We conducted a quality improvement intervention to reduce the rates of low-yield diagnostic testing for children presenting to an emergency department (ED) with syncope or presyncope. Children 8 to 22 years old presenting to a tertiary care pediatric ED with syncope or presyncope were included. We excluded children who were ill-appearing, had previously diagnosed cardiac or neurologic disease, ingestion, or trauma. We measured diagnostic testing rates among children presenting from July 2010 through October 2012, during which time we implemented a quality improvement intervention. Patient follow-up was performed 2 months after the ED visit to ascertain subsequent diagnostic testing and medical care. A total of 349 patients were included. We observed a reduction in the rates of low-yield diagnostic testing ...
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To compare the accuracy of rapid cranial magnetic resonance imaging (MRI) with that of computed tomography (CT) for diagnosing ventricular shunt malfunction. We performed a single-center, retrospective cohort study of children ≤21 years... more
To compare the accuracy of rapid cranial magnetic resonance imaging (MRI) with that of computed tomography (CT) for diagnosing ventricular shunt malfunction. We performed a single-center, retrospective cohort study of children ≤21 years of age who underwent either rapid cranial MRI or cranial CT in the emergency department (ED) for evaluation of possible ventricular shunt malfunction. Each neuroimaging study was classified as "normal" (unchanged or decreased ventricle size) or "abnormal" (increased ventricle size). We classified a patient as having a ventricular shunt malfunction if operative revision for relief of mechanical causes of altered shunt flow was needed within 72 hours of initial ED evaluation. Our primary analysis tested noninferiority of the accuracy of rapid cranial MRI to CT for diagnosing shunt malfunction (noninferiority margin 10%). We included 698 ED visits for 286 unique patients, with a median age at visit of 10.0 years (interquartile range 5.9-15.5 years). Patients underwent CT in 336 (48%) or rapid cranial MRI in 362 (52%) of ED visits for evaluation of possible shunt malfunction. Patients had operative revision for ventricular shunt malfunction in 140 ED visits (20%). The accuracy of rapid cranial MRI was not inferior to that of CT scan for diagnosing ventricular shunt malfunction (81.8% MRI vs 82.4% CT; risk difference 2.0%; 95% confidence interval, -4.2% to 8.2%). Rapid cranial MRI was not inferior to CT for diagnosing ventricular shunt malfunction and offers the advantage of sparing a child ionizing radiation exposure.
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To identify independent predictors of and use recursive partitioning to develop a multivariate regression tree predicting symptom duration greater than 28 days after a sport-related concussion. We conducted a prospective cohort study of... more
To identify independent predictors of and use recursive partitioning to develop a multivariate regression tree predicting symptom duration greater than 28 days after a sport-related concussion. We conducted a prospective cohort study of patients in a sports concussion clinic. Participants completed questionnaires that included the Post-Concussion Symptom Scale (PCSS). Participants were asked to record the date on which they last experienced symptoms. Potential predictor variables included age, sex, score on symptom inventories, history of prior concussions, performance on computerized neurocognitive assessments, loss of consciousness and amnesia at the time of injury, history of prior medical treatment for headaches, history of migraines, and family history of concussion. We used recursive partitioning analysis to develop a multivariate prediction model for identifying athletes at risk for a prolonged recovery from concussion. A total of 531 patients ranged in age from 7 to 26 years (mean 14.6 ± 2.9 years). The mean PCSS score at the initial visit was 26 ± 26; mean time to presentation was 12 ± 5 days. Only total score on symptom inventory was independently associated with symptoms lasting longer than 28 days (adjusted odds ratio 1.044; 95% confidence interval [CI] 1.034, 1.054 for PCSS). No other potential predictor variables were independently associated with symptom duration or useful in developing the optimal regression decision tree. Most participants (86%; 95% CI 80%, 90%) with an initial PCSS score of <13 had resolution of their symptoms within 28 days of injury. The only independent predictor of prolonged symptoms after sport-related concussion is overall symptom burden.
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Migraine headache is a common pediatric complaint among emergency department (ED) patients. There are limited trials on abortive therapies in the ED. The objective of this study was to apply a comparative effectiveness approach to... more
Migraine headache is a common pediatric complaint among emergency department (ED) patients. There are limited trials on abortive therapies in the ED. The objective of this study was to apply a comparative effectiveness approach to investigate acute medication regimens for the prevention of ED revisits. Retrospective study using administrative data (Pediatric Health Information System) from 35 pediatric EDs (2009-2012). Children aged 7 to 18 years with a principal diagnosis of migraine headache were studied. The primary outcome was a revisit to the ED within 3 days for discharged patients. The primary analysis compared the treatment regimens and individual medications on the risk for revisit. The study identified 32 124 children with migraine; 27 317 (85%) were discharged, and 5.5% had a return ED visit within 3 days. At the index visit, the most common medications included nonopioid analgesics (66%), dopamine antagonists (50%), diphenhydramine (33%), and ondansetron (21%). Triptans and opiate medications were administered infrequently (3% each). Children receiving metoclopramide had a 31% increased odds for an ED revisit within 3 days compared with prochlorperazine. Diphenhydramine with dopamine antagonists was associated with 27% increased odds of an ED revisit compared with dopamine antagonists alone. Children receiving ondansetron had similar revisit rates to those receiving dopamine antagonists. The majority of children with migraines are successfully discharged from the ED and only 1 in 18 required a revisit within 3 days. Prochlorperazine appears to be superior to metoclopramide in preventing a revisit, and diphenhydramine use is associated with increased rates of return.
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To estimate the prevalence of Lyme infection among children presenting with acute, nontraumatic hip pain in a Lyme endemic region and to investigate predictors of Lyme disease among children with suspected transient synovitis.... more
To estimate the prevalence of Lyme infection among children presenting with acute, nontraumatic hip pain in a Lyme endemic region and to investigate predictors of Lyme disease among children with suspected transient synovitis. Retrospective cross-sectional study of children with unilateral hip pain who were brought to an academic pediatric emergency department. Cases were identified by specific discharge diagnoses or radiologic imaging. Lyme infection was determined by serologic criteria, and a minimum prevalence was estimated for the entire study population; maximum estimate was determined for those who had Lyme testing. Multivariate regression was used to identify discriminating clinical findings for Lyme disease among those with nonseptic arthritis. Three hundred eighty-five children with a median age of 5.4 years were studied; 15% of children had fever ≥38.0°C and 40% had pain for less than 24 hours at evaluation. Lyme infection was identified in 5.2% (95% CI 3.2%-7.9%). A maximum estimate of Lyme disease was calculated to be 8.0% (95% CI 4.9%-12.0%). Regression analysis did not identify any practical clinical predictors of Lyme infection. Lyme infection occurred in approximately 5% of children with acute, nontraumatic hip pain who were evaluated in a pediatric emergency department in a Lyme endemic region. Based on this estimate, we do not recommend routine Lyme testing when transient synovitis is suspected; however, Lyme testing should be considered in children having laboratory studies obtained for alternative diagnoses such as septic/pyogenic arthritis and for those with an atypical clinical course for transient synovitis.
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Our objective was to estimate the lifetime prevalence of psychopathology in a sample of youth with and without attention deficit hyperactivity disorder (ADHD) through young adulthood using contemporaneous diagnostic and analytic... more
Our objective was to estimate the lifetime prevalence of psychopathology in a sample of youth with and without attention deficit hyperactivity disorder (ADHD) through young adulthood using contemporaneous diagnostic and analytic techniques. We conducted a case-control, 10-year prospective study of ADHD youth. At baseline, we assessed consecutively referred male, Caucasian children with (n=140) and without (n=120) DSM-III-R ADHD, aged 6-18 years, ascertained from psychiatric and pediatric sources to allow for generalizability of results. At the 10-year follow-up, 112 (80%) and 105 (88%) of the ADHD and control children, respectively, were reassessed (mean age 22 years). We created the following categories of psychiatric disorders: Major Psychopathology (mood disorders and psychosis), Anxiety Disorders, Antisocial Disorders (conduct, oppositional-defiant, and antisocial personality disorder), Developmental Disorders (elimination, language, and tics disorder), and Substance Dependence Disorders (alcohol, drug, and nicotine dependence), as measured by blinded structured diagnostic interview. The lifetime prevalence for all categories of psychopathology were significantly greater in ADHD young adults compared to controls, with hazard ratios and 95% confidence intervals of 6.1 (3.5-10.7), 2.2 (1.5-3.2), 5.9 (3.9-8.8), 2.5 (1.7-3.6), and 2.0 (1.3-3.0), respectively, for the categories described above. By their young adult years, ADHD youth were at high risk for a wide range of adverse psychiatric outcomes including markedly elevated rates of antisocial, addictive, mood and anxiety disorders. These prospective findings provide further evidence for the high morbidity associated with ADHD across the life-cycle and stress the importance of early recognition of this disorder for prevention and intervention strategies.
Research Interests: Psychology, Anxiety Disorders, Attention-Deficit/Hyperactivity Disorder, Adolescent, Psychological Medicine, and 22 moreMovement disorders, Antisocial Personality Disorder, Developmental Coordination Disorder, Humans, Child, Psychological, Female, Male, Nicotine Dependence, Young Adult, Follow-up studies, Substance Dependence, Life Cycle, Mood Disorders, Public health systems and services research, Time Factors, Anxiety Disorder, Mood Disorder, Neurosciences, Prospective Study, Substance-Related Disorders, and Confidence Interval
The validity of parent reports of children's attention-deficit/hyperactivity disorder (ADHD) symptoms has been questioned, especially in clinical trials. Some... more
The validity of parent reports of children's attention-deficit/hyperactivity disorder (ADHD) symptoms has been questioned, especially in clinical trials. Some advocate the exclusive use of teacher reports, maintaining that parent reports are not sensitive to changes in ADHD symptoms. This study compares the ability of parent and teacher reports to document change during clinical trials of long-acting treatments. We conducted a literature search of Medline to identify any published clinical trials in pediatric ADHD that met the following criteria: 1) used a randomized design, 2) examined the efficacy of long-acting agents or standard formulations using 3-times-a-day dosing, and 3) used both parent and teacher reports of the same measure of ADHD symptoms as a study outcome. For each measurement of ADHD symptoms, we calculated effect sizes for parent and teacher reports. Three large, randomized, controlled clinical trials were identified (N = 1445 subjects). For every outcome for which teacher reports documented significant improvement, parent reports did also. Pooled analysis revealed a larger effect captured by the parent report relative to the teacher report. Results suggest that parent reports are at least as sensitive to detecting change in ADHD symptoms as teacher reports in clinical trials that assess the efficacy of long-acting agents. These results suggest that parent reports are informative for detecting change during treatment of children with ADHD.
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Few studies have demonstrated improvement in adherence to Pediatric Advanced Life Support guidelines for severe sepsis and septic shock. We sought to improve adherence to national guidelines for children with septic shock in a pediatric... more
Few studies have demonstrated improvement in adherence to Pediatric Advanced Life Support guidelines for severe sepsis and septic shock. We sought to improve adherence to national guidelines for children with septic shock in a pediatric emergency department with poor guideline adherence. Prospective cohort study of children presenting to a tertiary care pediatric emergency department with septic shock. Quality improvement (QI) interventions, including repeated plan-do-study-act cycles, were used to improve adherence to a 5-component sepsis bundle, including timely (1) recognition of septic shock, (2) vascular access, (3) administration of intravenous (IV) fluid, (4) antibiotics, and (5) vasoactive agents. The intervention focused on IV fluid delivery as a key driver impacting bundle adherence, and adherence was measured using statistical process control methodology. Two-hundred forty-two patients were included: 126 subjects before the intervention (November 2009 to March 2011), and 116 patients during the QI intervention (October 2011 to May 2013). We achieved 100% adherence for all metrics, including (1) administration of 60 mL/kg IV fluid within 60 minutes (increased from baseline adherence rate of 37%), (2) administration of vasoactive agents within 60 minutes (baseline rate of 35%), and (3) 5-component bundle adherence (baseline rate of 19%). Improvement was sustained over 9 months. The number of septic shock cases between each death from this condition increased after implementation of the QI intervention. Using QI methodology, we have demonstrated improved adherence to national guidelines for severe sepsis and septic shock.
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To define reference ranges for oxygen saturation (SpO(2) ) values in healthy full-term infants in the first days of life and in preterm infants off supplemental oxygen as they approach neonatal intensive care unit (NICU) discharge. From... more
To define reference ranges for oxygen saturation (SpO(2) ) values in healthy full-term infants in the first days of life and in preterm infants off supplemental oxygen as they approach neonatal intensive care unit (NICU) discharge. From April 2009 to March 2010, we enrolled convenience samples of full-term infants from the newborn nursery and former preterm infants who did not require supplemental oxygen at the time of discharge from the NICU. Overnight SpO(2) and signal quality recordings were obtained and analyzed for duration of artifact-free recording time (AFRT), time (s) with SpO(2) less than several different target saturations (90-95%), and number of falls in SpO(2) by ≥4% and ≥10%. We studied 102 full-term infants and 52 preterm infants. Preterm and full-term infants spent similar amounts of time less than 90%, 91%, 92%, 93%, 94%, and 95% although preterm infants had more falls in SpO(2) by ≥4% per hour of AFRT. Over 67% of term and preterm infants spent less than 6% of their time below 93%. These data represent reference SpO(2) ranges for both preterm infants not requiring supplemental oxygen at NICU discharge and full-term infants in the first days of life. As we currently lack guidelines dictating the optimal target oxygen saturations for infants and the acceptable maximal time that they can safely spend below set target saturations, our data may serve as a guide to interpreting SpO(2) recordings of premature outpatient infants who are weaning from supplemental oxygen.
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Attention-deficit/hyperactivity disorder (ADHD) is a strong risk factor for smoking. Since both ADHD and smoking are familial disorders, one way to further our understanding of this association is to examine the familial relationship... more
Attention-deficit/hyperactivity disorder (ADHD) is a strong risk factor for smoking. Since both ADHD and smoking are familial disorders, one way to further our understanding of this association is to examine the familial relationship between them. Our aim was to evaluate the familial association between ADHD and smoking in families ascertained from girls with and without ADHD. Subjects were derived from a longitudinal case-control family study of girls with (n = 140) and without (n = 122) ADHD ascertained from pediatric and psychiatric clinics, and their biological first-degree relatives. Diagnoses of ADHD and smoking (i.e., full or subthreshold nicotine dependence) were made with structured psychiatric interviews. We stratified the relatives into four groups based on probands' ADHD and smoking status: (1) relatives of controls without smoking (probands n = 100, relatives n = 317), (2) relatives of controls with smoking (probands n = 22, relatives n = 71), (3) relatives of ADHD girls without smoking (probands n = 100, relatives n = 320), and (4) relatives of ADHD girls with smoking (probands n = 39, relatives n = 133). We compared the rates of ADHD and smoking across the four relative groups using survival analysis. ADHD in the proband increased the risk for ADHD in the relatives irrespective of probands' smoking and smoking in the proband increased the risk for smoking in the relatives irrespective of probands' ADHD status. Furthermore, we found statistically significant evidence for cosegregation of smoking and ADHD, suggesting that the two disorders are transmitted together through families more often than expected by chance. These findings support the hypothesis that the combination of ADHD and smoking comprises an etiologically distinct familial subtype of ADHD in girls.
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Research Interests: Psychology, Neuropsychology, Mathematics, Semantics, Attention-Deficit/Hyperactivity Disorder, and 16 moreAttention, Reading, Adolescent, Executive Function, Color Perception, Reading Disability, Humans, Child, Discrimination Learning, Male, Reaction Time, Socioeconomic Status, Learning Disorders, Learning Disabled, Psychomotor Disorders, and Neurosciences
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Recent studies have suggested an association between candidate genes (i.e., COMT, SLC6A4) and conduct disorder (CD). However, it is not clear if these relations extend to CD within the context of attention-deficit/hyperactivity disorder... more
Recent studies have suggested an association between candidate genes (i.e., COMT, SLC6A4) and conduct disorder (CD). However, it is not clear if these relations extend to CD within the context of attention-deficit/hyperactivity disorder (ADHD). Also, it is uncertain whether the risk is specific to aggressive symptoms or is a risk for CD generally. The aim of this study was to examine the role of the COMT and SLC6A4 genes in the risk for CD and its symptomatic subtypes in the context of ADHD. We examined subjects with ADHD (n = 444, age range 6-55 years) aggregated across four completed studies. Psychiatric diagnoses were determined by structured interviews. We tested the association between genotype and the diagnosis of CD and aggressive and covert symptom counts. There was no significant association between variations in functional polymorphisms of either the COMT gene or the SLC6A4 gene and the risk for CD. The COMT gene was associated with increased aggressive CD symptoms but not covert CD symptoms. The SLC6A4 gene was not associated with either symptom subtype. These findings contribute to our understanding of the genetic basis of antisocial behavior in the ADHD population and provide additional support for the notion that aggressive and covert CD symptom subtypes are etiologically distinct.
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The main aim of this study was to evaluate the association between attention-deficit/hyperactivity disorder (ADHD) and major depression (MD) in adolescent and young adult females. Subjects were females with (n = 140) and without (n = 122)... more
The main aim of this study was to evaluate the association between attention-deficit/hyperactivity disorder (ADHD) and major depression (MD) in adolescent and young adult females. Subjects were females with (n = 140) and without (n = 122) ADHD ascertained from pediatric and psychiatric settings. Subjects were followed prospectively for 5 years into adolescence and young adulthood and reassessed in multiple nonoverlapping domains including psychiatric, cognitive, interpersonal, family, and educational functioning. Females with ADHD had a 2.5 times higher risk for MD at adolescent follow-up compared with control females, adjusting for psychiatric comorbidity. MD in females with ADHD was associated with an earlier age at onset, greater than twice the duration, more severe depression-associated impairment, a higher rate of suicidality, and a greater likelihood of requiring psychiatric hospitalization than MD in control girls. Parental MD and proband mania were significant predictors of MD among females with ADHD, independently of other predictors. MD emerging in the context of ADHD in females is an impairing and severe comorbidity worthy of further clinical and scientific considerations.
Research Interests: Attention-Deficit/Hyperactivity Disorder, Bipolar Disorder, Adolescent, Comorbidity, Pregnancy, and 15 moreHumans, Major Depressive Disorder, Hospitalization, Female, Young Adult, Follow-up studies, Social Environment, Risk factors, Phenotype, Major Depression, Adult, Risk Factors, Age of Onset, Case Control Studies, and The American
Little is known about the risks and characteristics of attention-deficit/hyperactivity disorder (ADHD) patients who misuse or divert their stimulant medications. As part of a 10-year longitudinal study of youths with ADHD, the authors... more
Little is known about the risks and characteristics of attention-deficit/hyperactivity disorder (ADHD) patients who misuse or divert their stimulant medications. As part of a 10-year longitudinal study of youths with ADHD, the authors evaluated medication diversion or misuse at the last follow-up period. Structured psychiatric interviews for diagnosis and a self-report questionnaire regarding medication use in medicated subjects with ADHD compared with controls without ADHD receiving psychotropics for non-ADHD treatment were employed. Of 98 subjects receiving psychotropic medications (mean age of 20.8 +/- 5 years), 55 (56%) were ADHD subjects and 43 (44%) were controls receiving medications for other purposes. The authors found that 11% of the ADHD group reported selling their medications compared with no subjects in the control group (z = 0.00, p <.05). An additional 22% of the ADHD group reported misusing their medications compared with 5% of the control subjects (z = 1.7 p =.09) and that those with conduct or substance use disorders accounted for the misuse and diversion. A minority of subjects reported escalating their doses and concomitant use with alcohol and drugs. The data indicate that the majority of ADHD individuals, particularly those without conduct or substance use disorders, use their medications appropriately. The authors' findings also highlight the need to monitor medication use in ADHD individuals with conduct and/or substance use disorders and to carefully select agents with a low likelihood of diversion or misuse in this group.
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Research Interests: Anxiety Disorders, Attention-Deficit/Hyperactivity Disorder, Family, Risk assessment, Adolescent, and 18 moreLinear models, Comorbidity, Risk Analysis, Oppositional Defiant Disorder, Humans, Child, Female, Male, Young Adult, Conduct Disorder, Risk factors, Mood Disorders, Longitudinal Studies, Risk Factors, Psychiatric, Risk Assessment, Substance-Related Disorders, and Case Control Studies
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Concerns about gender bias in the diagnostic criteria for conduct disorder (CD) have prompted some researchers to recommend that the diagnostic threshold in girls be lowered. Since CD is a highly familial condition, the authors assessed... more
Concerns about gender bias in the diagnostic criteria for conduct disorder (CD) have prompted some researchers to recommend that the diagnostic threshold in girls be lowered. Since CD is a highly familial condition, the authors assessed the diagnostic validity of subthreshold CD in girls using family study methodology. They compared the rates of antisocial disorders (CD and antisocial personality disorder) in relatives of four groups of index children: children with attention deficit hyperactivity disorder (ADHD) and full, subthreshold, or no CD diagnoses and non-ADHD/non-CD control subjects. Results showed no interaction between gender and familiality across the four groups. Furthermore, there was no significant evidence of familiality of subthreshold CD. From a family genetic perspective, the diagnostic threshold for CD does not appear to differ by gender. The current results support the possibility that differential rates of CD reflect actual differences in rates of antisocial behavior across gender.
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Research Interests: Attention-Deficit/Hyperactivity Disorder, Bipolar Disorder, Adolescent, Linear models, Comorbidity, and 13 moreOppositional Defiant Disorder, Prospective studies, Humans, Child, Major Depressive Disorder, Female, Follow-up studies, Conduct Disorder, Risk factors, Developmental, Behavioral and Developmental Pediatrics, Risk Factors, and Logistic Models
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Research Interests: Psychology, Consulting, Collaborative Problem Solving, Problem Solving, Oppositional Defiant Disorder, and 12 moreHumans, Child, Female, Male, Behavior Modeling, Conduct Disorder, Parent Training Programs, Mood Disorders, Questionnaires, Parent‐child Relations, Cooperative Behavior, and Mood Disorder
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Clinical trials have demonstrated that pharmacotherapies can safely treat attention-deficit/hyperactivity disorder (ADHD) in adulthood. Eligibility criteria in these trials may significantly limit their external validity by excluding a... more
Clinical trials have demonstrated that pharmacotherapies can safely treat attention-deficit/hyperactivity disorder (ADHD) in adulthood. Eligibility criteria in these trials may significantly limit their external validity by excluding a significant portion of adults with ADHD in the general population. In particular, exclusion criteria may frequently exclude individuals with comorbid mental health conditions, which are common in the adult ADHD population. We addressed the representativeness of clinical trials by comparing 146 adult clinical trial participants with DSM-IV ADHD and a community sample composed of 124 adults with DSM-IV ADHD and 123 non-ADHD controls. Subjects were compared on socioeconomic status, Hollingshead occupational code, cognitive measures, lifetime psychopathology, and Global Assessment of Functioning (GAF) scale ratings. Adults with ADHD in the community sample had higher rates of lifetime psychiatric comorbidity, lower GAF scores, and lower occupational codes than those in the clinical trial. The clinical trial eligibility criteria would have excluded 61% of community sample adults with ADHD. This excluded portion of the community sample had higher rates of lifetime psychiatric comorbidity and lower GAF scores than clinical trial participants. Adults with ADHD participating in the clinical trial had less evidence of functional impairment and endorsed less psychiatric comorbidity than the majority of community sample subjects with ADHD. This suggests that findings from clinical trials may have limited external validity for adults with ADHD in the general population, particularly for those adults with ADHD with the greatest burden of comorbid psychopathology.
Research Interests:
To examine the predictive utility of the Child Behavior Checklist-Pediatric Bipolar Disorder (CBCL-PBD) profile to help identify children at risk for bipolar disorder. Subjects were ascertained from 2 identically designed longitudinal... more
To examine the predictive utility of the Child Behavior Checklist-Pediatric Bipolar Disorder (CBCL-PBD) profile to help identify children at risk for bipolar disorder. Subjects were ascertained from 2 identically designed longitudinal case-control family studies of subjects (males and females aged 6-18 years) with DSM-III-R attention-deficit/hyperactivity disorder (ADHD). Based on data from the baseline assessment, ADHD subjects without a lifetime diagnosis of bipolar disorder were stratified by the presence (CBCL-PBD positive, N=28) or absence (CBCL-PBD negative, N=176) of a CBCL-PBD score > or = 210 (total of attention, aggression, and anxious/depressed subscales). Subjects were comprehensively assessed at follow-up with structured psychiatric interviews. Data were collected from April 1988 to February 2003. Over a mean follow-up period of 7.4 years, a positive CBCL-PBD score predicted subsequent diagnoses of bipolar disorder, major depressive disorder, and conduct disorder, as well as impaired psychosocial functioning and higher risk for psychiatric hospitalization. This work suggests that a positive CBCL-PBD score based on elevations on the attention problems, aggressive behavior, and anxious/depressed subscales predicts subsequent pediatric bipolar disorder and associated syndrome-congruent impairments. If confirmed in other studies, the CBCL-PBD score has the potential to help identify children at high risk to develop bipolar disorder.
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The objective of this study was to evaluate functional impairments in a nonreferred sample of adults identifying themselves as having been diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a clinician in their community.... more
The objective of this study was to evaluate functional impairments in a nonreferred sample of adults identifying themselves as having been diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a clinician in their community. We completed a survey in April and May 2003 of a community sample of 500 adults who reported having received a diagnosis of ADHD in the community and 501 gender- and age-matched comparisons from a national sample representative of the U.S. population. Adults with self-reports of diagnosed ADHD in the community were significantly less likely to have graduated high school (83% vs. 93% of controls; p < or = .001) or obtain a college degree (19% vs. 26%; p < .01), were less likely to be currently employed (52% vs. 72%; p < or = .001), and had significantly more mean job changes over 10 years (5.4 vs. 3.4 jobs; p < or = .001). They also were significantly more likely to have been arrested (37% vs. 18% of controls; p < or = .001) or divorced (28% vs. 15%; p < or = .001) and were significantly less satisfied (p < or = .001) with their family, social, and professional lives. Adults who reported having received a diagnosis of ADHD in the community had significant impairment in multiple domains of functioning compared with age- and gender-matched controls without this diagnosis, highly consistent with findings derived from carefully diagnosed referred samples.
Research Interests: Child Development, Socialization, Adolescent, Employment, Humans, and 16 moreChild, Personality Assessment Inventory, United States, Female, Clinical, Divorce, Male, Functional impairment, Data Collection, Social Adjustment, Questionnaires, Adult, Sex Factors, Clinical Psychiatry, Age Factors, and Educational Status
Evaluated the long-term stability of the Child Behavior Checklist (CBCL) in a longitudinal clinical sample of youth with attention deficit hyperactivity disorder (ADHD), testing the hypothesis that the CBCL scales will show stability over... more
Evaluated the long-term stability of the Child Behavior Checklist (CBCL) in a longitudinal clinical sample of youth with attention deficit hyperactivity disorder (ADHD), testing the hypothesis that the CBCL scales will show stability over time. Participants were 105 Caucasian, non-Hispanic boys with ADHD between the ages of 6 and 17 assessed at baseline and at a 4-year follow-up. Stability of CBCL scales were computed for dimensional (intraclass correlation coefficients [ICCs], Pearson correlations) and dichotomized scale scores (kappa coefficients and odds ratios [ORs]). Evidence was found for stability of the categorical and dimensional types of scores, as demonstrated by statistically significant stability of the Pearson correlation coefficients, kappas, and ORs. The robust findings obtained from ICCs and kappa coefficients document substantial stability for CBCL scales over time within individuals with ADHD. These results support the informativeness of the CBCL as a useful measure of longitudinal course in clinical samples of youth with ADHD.
Research Interests:
Research Interests:
Despite the increased recognition of attention deficit hyperactivity disorder (ADHD) in adolescents, few controlled studies have assessed treatments for this age group. Adolescent issues, such as embarrassment at receiving medication at... more
Despite the increased recognition of attention deficit hyperactivity disorder (ADHD) in adolescents, few controlled studies have assessed treatments for this age group. Adolescent issues, such as embarrassment at receiving medication at school and experimentation with abusable substances, have accelerated efforts to find effective, well-tolerated treatments beyond traditional stimulants. Pemoline has been found effective for treating both children and adults with ADHD but has not been evaluated in adolescents with ADHD. Twenty-one adolescents (mean age 14 years old) diagnosed with ADHD by structured and clinical interviews participated in a 10-week, double-blind crossover design study of pemoline. Dosing was optimized with robust doses up to 3 mg/kg/day in one to two doses. Clinical evaluations of ADHD, depression, anxiety, and oppositional defiant disorder (ODD) symptoms were assessed weekly. Adolescents with ADHD exhibited a marked response to pemoline treatment relative to placebo on the ADHD rating scale (p = 0.001), with an average reduction of 3.02 points per week of treatment. Sixty percent of adolescents responded to pemoline, compared to 11% treated with placebo. This response was independent of gender or lifetime psychiatric comorbidity. Pemoline was well tolerated, with patients averaging 2.88 mg/kg/day in two doses per day, with a mean dose at end of follow-up of 181.1 mg (SD 45.6, range 112.5-262.5 mg). Side effects were mild, and no adverse hepatic events occurred. These findings resemble those reported in children and adults with ADHD. This trial suggests pemoline is well tolerated and effective in adolescents and may be a particularly useful ADHD treatment for adolescents.
Research Interests:
A growing literature suggests that anxiety disorders (ANX) co-occur with bipolar disorder (BPD), but the nature of this overlap is unknown. Thus, we investigated the familial association between BPD and ANX among the first-degree... more
A growing literature suggests that anxiety disorders (ANX) co-occur with bipolar disorder (BPD), but the nature of this overlap is unknown. Thus, we investigated the familial association between BPD and ANX among the first-degree relatives of children with BPD with and without comorbid ANX. We compared relatives of four proband groups defined by the presence or absence of BPD and ANX in the proband: (1) BPD + ANX (n = 23 probands, 74 relatives), (2) BPD without ANX (n = 11 probands, 38 relatives), (3) ANX without BPD (n = 48 probands, 167 relatives), and (4) controls without BPD or ANX (n = 118 probands, 385 relatives). All subjects were evaluated with structured diagnostic interviews. Diagnoses of relatives were made blind to the diagnoses of probands. The results show high rates of both BPD and ANX in relatives of children with BPD + ANX. Moreover, BPD and ANX cosegregated among the relatives of children with BPD + ANX. Although relatives of both ANX proband groups (with and without BPD) had high rates of ANX, and relatives of both BPD proband groups (with and without ANX) had high rates of BPD, the combined condition BPD + ANX was the predominant form of BPD among relatives of probands with BPD + ANX. These family-genetic findings suggest that the comorbid condition BPD+ANX may be a distinct clinical entity. More work is needed to evaluate whether the presence of comorbid ANX may be a marker of very early onset BPD.
Research Interests:
Adolescents and adults with attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUD) are increasingly recognized in clinical practice. The role of pharmacological treatment for ADHD in these comorbid individuals... more
Adolescents and adults with attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUD) are increasingly recognized in clinical practice. The role of pharmacological treatment for ADHD in these comorbid individuals remains unclear. A systematic review of the medical literature was conducted through PubMed, supplemented with data from scientific presentations, to evaluate the role of medication treatment of ADHD in substance abusing individuals with ADHD. Meta-analysis was used to evaluate the effects of medication therapy on ADHD and SUD outcomes in general, while specifically addressing trial design, trial duration, retention, class of medication, age group, concurrent psychotherapy, and outcome in both SUD and ADHD domains. Four studies in adolescents and five studies in adults with ADHD plus SUD were identified (two controlled and seven open studies; n = 222 subjects). The standard mean difference (SMD) indicated statistically significant improvements in ADHD and SUD that were not maintained when evaluating controlled studies only. Albeit limited by power, trial duration, retention rate, and age group did not influence outcome. No worsening of SUD or drug-drug interactions were observed in any of the studies. The results could not be accounted for by any single study or by publication bias. Treating ADHD pharmacologically in individuals with ADHD plus SUD has a moderate impact on ADHD and SUD that is not observed in controlled trials and does not result in worsening of SUD or adverse interactions specific to SUD. Further controlled trials evaluating the effect of novel combinations of psychotherapy and ADHD pharmacotherapy on SUD relapse in these groups are warranted.
Research Interests:
We evaluated correlates of the diagnosis of ADHD in youth by informant source. Ninety-four pairs of mother reports and youth self-reports on ADHD were independently assessed, using diagnostic interviews from a large study of youth of both... more
We evaluated correlates of the diagnosis of ADHD in youth by informant source. Ninety-four pairs of mother reports and youth self-reports on ADHD were independently assessed, using diagnostic interviews from a large study of youth of both genders with and without ADHD. Comparisons were made on measures of interpersonal, school, and family functioning; treatment history; and parental psychopathology by informant source. With the exception of higher rates of ADHD-associated impairment and higher frequency of treatment for ADHD in the combined youth-mother group. There were no other differences in any other clinical or familial correlates by informant source; both informant groups had higher levels of impairment in multiple nonoverlapping measures of dysfunction than controls. Males were overrepresented among the mother-only group. Maternal reports of ADHD result in a meaningful diagnosis of ADHD with high levels of impairment, regardless of endorsement by the affected youth.
Research Interests:
To evaluate the association between the clinical scales of the child behavior checklist (CBCL) and the comorbid diagnosis of oppositional defiant disorder (ODD) in a large sample of youth with attention deficit hyperactivity disorder... more
To evaluate the association between the clinical scales of the child behavior checklist (CBCL) and the comorbid diagnosis of oppositional defiant disorder (ODD) in a large sample of youth with attention deficit hyperactivity disorder (ADHD). The sample consisted of 101 girls and 106 boys ages 6 to17 with ADHD. Conditional probability analysis was used to examine the correspondence between CBCL Clinical Scales with the structured-interview derived diagnosis of ODD. Conditional probability analysis showed that the CBCL Aggression Scale best predicted a structured-interview derived diagnosis of ODD in boys and girls with ADHD. These findings suggest that the CBCL Aggression Scale could serve as a rapid and cost-effective screening instrument to help identify cases likely to meet clinical criteria for ODD in the context of ADHD
Research Interests:
The objective of this study is to further evaluate the association between asthma and ADHD, addressing issues of familiality in female probands. A case control study of referred ADHD proband girls, controls, and relatives are used.... more
The objective of this study is to further evaluate the association between asthma and ADHD, addressing issues of familiality in female probands. A case control study of referred ADHD proband girls, controls, and relatives are used. Participants include 140 ADHD proband girls and 122 non-ADHD comparisons, with 417 and 369 first-degree biological relatives, respectively. Relatives are stratified into four groups according to proband ADHD and asthma status. The authors compare rates of asthma and ADHD in relatives. ADHD does not increase the risk for asthma in probands. Patterns of familial aggregation are mostly consistent with independent transmission of ADHD and asthma in families of girl probands. The results extend to female probands' previously reported findings that asthma and ADHD are independently transmitted in families. These findings further support the conclusion that ADHD symptoms should not be dismissed as part of asthma symptomatology or a consequence of its treatment.
Research Interests: Psychology, Demography, Attention, Asthma, Humans, and 6 moreChild, Female, Male, Adult, Attention Disorders, and Case Control Study
Research Interests: Psychology, Cognitive Control, Anterior Cingulate, Magnetic Resonance Imaging, Attention, and 15 moreAdolescent, Brain Mapping, Humans, Female, Male, Three Dimensional Imaging, Middle Aged, Pilot study, Adult, Analysis of Variance, Attention Disorders, Pilot Projects, Control Group, Anterior cingulate cortex, and Medical Treatment
Children with velocardiofacial syndrome (VCFS), a contiguous deletion syndrome, have an increased prevalence of attention deficit/hyperactivity disorder (ADHD). The authors compared youth with VCFS+ADHD (from the SUNY Upstate VCFS... more
Children with velocardiofacial syndrome (VCFS), a contiguous deletion syndrome, have an increased prevalence of attention deficit/hyperactivity disorder (ADHD). The authors compared youth with VCFS+ADHD (from the SUNY Upstate VCFS Research Program) to those with ADHD but not VCFS (from the Massachusetts General Hospital Longitudinal Family Studies of ADHD). Children with VCFS+ADHD were more likely to be diagnosed with the inattentive subtype and differed from idiopathic ADHD in the frequency of several inattentive symptoms that appear linked to general cognitive functioning. After controlling for IQ differences, parents of children with VCFS+ADHD endorsed more thought and social problems on a rating checklist. Patterns of comorbidity also differed between the two groups of children with ADHD: Children with idiopathic ADHD had higher rates of comorbid major depression and disruptive behavior disorders. Children with VCFS+ADHD may have a different profile of ADHD symptoms and comorbidity when compared to children with idiopathic ADHD.
Research Interests: Psychology, Attention-Deficit/Hyperactivity Disorder, Intelligence, Social Problems, Personality Assessment, and 21 moreAttention, Adolescent, Comorbidity, Mental Retardation, Social behavior, Thinking, Humans, Child, Major Depressive Disorder, Female, Male, Major Depression, Cognitive Function, Learning Disorders, Social Behavior, Attention Disorders, Velocardiofacial Syndrome, Massachusetts General Hospital, Family Study, Cross Sectional Studies, and DiGeorge Syndrome
Although a small literature suggests that conduct disorder (CD) co-occurs with bipolar disorder (BPD), little is known about this overlap. Thus, we investigated the familial association of antisocial disorders (CD and/or antisocial... more
Although a small literature suggests that conduct disorder (CD) co-occurs with bipolar disorder (BPD), little is known about this overlap. Thus, we investigated the familial association of antisocial disorders (CD and/or antisocial personality disorder (ASPD)) and BPD among the first degree relatives of children with CD with and without comorbid BPD. We compared relatives of four proband groups defined by the presence or absence of CD and BPD in the proband: (1) CD+BPD (N=26 probands, 92 relatives; (2) BPD without CD (BPD) (N=19 probands, 53 relatives); (3) CD without BPD (CD) (N=16 probands, 58 relatives); and (4) controls without BPD or CD (N=102 probands, 338 relatives). All subjects were evaluated with structured diagnostic interviews. Diagnoses of relatives were made blind to the diagnoses of probands. The results show high rates of antisocial disorders and BPD in relatives of children with CD+BPD. Moreover, antisocial disorders and BPD cosegregated among the relatives of children with CD+BPD. While relatives of both CD proband groups with and without BPD had high rates of CD/ASPD, the combined condition CD/ASPD+BPD was found exclusively among relatives of probands with CD+BPD. Since we pooled two datasets, subjects were not all evaluated at the same time. Also, the lack of direct psychiatric interviews with children younger than 12 may have decreased the sensitivity of some diagnoses. These family-genetic findings suggest that CD and BPD represent separate disorders. Furthermore, they suggest that the comorbid condition of CD+BPD may be a distinct nosological entity. This suggests that clinicians treating CD or BPD children should consider the treatment implications of this comorbid condition.