Publications by authors named "Melissa Mulraney"

34 Publications

Neural correlates of irritability in a community sample of children.

J Affect Disord 2021 Sep 5;292:223-226. Epub 2021 Jun 5.

Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; School of Psychology, Deakin University, Geelong, Australia.

Irritability has been associated with aberrant patterns of neural activation, yet little is known about structural brain correlates of irritability. As such, we aimed to investigate associations between irritability and gray matter volume (GMV) in a community sample of children enriched for irritability. The sample comprised children (n=162) aged 9-11 years with and without Attention-Deficit/Hyperactivity Disorder (ADHD), participating in a cohort study with magnetic resonance imaging data available. Mixed effects linear regression analyses tested the associations between irritability symptoms and regional GMV (extracted using Freesurfer). Irritability was associated with smaller gray matter volume across multiple brain regions implicated in executive functioning, and emotion and reward processing including frontal regions and the cingulate.
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http://dx.doi.org/10.1016/j.jad.2021.05.093DOI Listing
September 2021

A brief clinician training program to manage sleep problems in ADHD: what works and what do clinicians and parents think?

Sleep Med 2021 Apr 20. Epub 2021 Apr 20.

Health Services, Centre for Community Child Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Health Services Research Unit, The Royal Children's Hospital, Parkville, Victoria, Australia.

Objective/background: Brief behavioural sleep interventions have been shown to be effective in treating sleep problems in children with ADHD. Little research, however, has focused on the translational aspects of these programs from the consumer perspective. This study aimed to explore clinician and parent views of a brief training program in managing sleep problems in children with ADHD.

Participants: Fifty-nine community-based clinicians (32 paediatricians, 27 psychologists) were trained to deliver a brief behavioural sleep intervention as part of the Sleeping Sound with ADHD translational trial; 183 families were allocated to receive the sleep intervention and 115 provided follow-up data.

Methods: Clinicians reported on competency, confidence and perceived barriers pre- and post-training. Parents reported on usefulness of the program and frequency of sleep strategy use at 3 months post-randomisation. Parent-report of severity of the child sleep problem was also measured at 3 and 6 months post-randomisation.

Results: Clinicians' feelings of competency and confidence in managing sleep difficulties increased from pre-to post-training, while perceptions of barriers decreased. Parent-reported usefulness of the program and frequency of sleep use varied by program domain and sleep strategy. Increased parent-reported use of sleep strategies was associated with improved sleep at 3 and 6 months post-randomisation.

Conclusions: A brief sleep training program leads to improvements in clinician confidence and competence in managing sleep problems in children with ADHD and positive parent perspectives. The findings highlight the potential for the Sleeping Sound with ADHD program to be optimized to better help parents in their implementation of sleep strategies.
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http://dx.doi.org/10.1016/j.sleep.2021.04.007DOI Listing
April 2021

A brief clinician training program to manage sleep problems in ADHD: what works and what do clinicians and parents think?

Sleep Med 2021 Apr 20. Epub 2021 Apr 20.

Health Services, Centre for Community Child Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Health Services Research Unit, The Royal Children's Hospital, Parkville, Victoria, Australia.

Objective/background: Brief behavioural sleep interventions have been shown to be effective in treating sleep problems in children with ADHD. Little research, however, has focused on the translational aspects of these programs from the consumer perspective. This study aimed to explore clinician and parent views of a brief training program in managing sleep problems in children with ADHD.

Participants: Fifty-nine community-based clinicians (32 paediatricians, 27 psychologists) were trained to deliver a brief behavioural sleep intervention as part of the Sleeping Sound with ADHD translational trial; 183 families were allocated to receive the sleep intervention and 115 provided follow-up data.

Methods: Clinicians reported on competency, confidence and perceived barriers pre- and post-training. Parents reported on usefulness of the program and frequency of sleep strategy use at 3 months post-randomisation. Parent-report of severity of the child sleep problem was also measured at 3 and 6 months post-randomisation.

Results: Clinicians' feelings of competency and confidence in managing sleep difficulties increased from pre-to post-training, while perceptions of barriers decreased. Parent-reported usefulness of the program and frequency of sleep use varied by program domain and sleep strategy. Increased parent-reported use of sleep strategies was associated with improved sleep at 3 and 6 months post-randomisation.

Conclusions: A brief sleep training program leads to improvements in clinician confidence and competence in managing sleep problems in children with ADHD and positive parent perspectives. The findings highlight the potential for the Sleeping Sound with ADHD program to be optimized to better help parents in their implementation of sleep strategies.
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http://dx.doi.org/10.1016/j.sleep.2021.04.007DOI Listing
April 2021

A novel school-based approach to screening for attention deficit hyperactivity disorder.

Eur Child Adolesc Psychiatry 2021 Jan 29. Epub 2021 Jan 29.

Mental Health Institute of The Second Xiangya Hospital, Key Laboratory of Psychiatry and Mental Health of Hunan Province, Central South University, Changsha, China.

Current approaches to screening for ADHD result in high rates of false positives. A proof of concept study to investigate the added benefits in the school-based detection of ADHD of adding a standardised teacher to teacher interview to traditional parent and teacher report questionnaires. A school-based study of diagnostic accuracy of ADHD using a novel 2-stage screening process. Participants were all 1026 pupils enrolled in grades 1 to 6 (ages 6-12 years) of a school in Hunan Province, China. The primary outcome was a diagnosis of ADHD on the Kiddie Schedule for Affective Disorders and Schizophrenia Present Lifetime version. 230 (22.4%) of the 1026 students screened positive at Stage 1 (parent and teacher questionnaires) (Sensitivity 0.86 [95% CI, 0.75 to 0.96], specificity 0.80 [95% CI, 0.78-0.83], false positive rate 0.20 (95% CI, 0.18 to 0.23), false negative rate was 0.14 (95% CI, 0.12 to 0.16). 65 remained screen-positive at the Stage 2 screen (teacher to teacher SNAP-IV interview). 36/65 (55.4%) of these Stage 2 screen positive participants and 1/144 (0.7%) of the screen negative subjects met DSM-IV criteria for ADHD (sensitivity 0.83 [95% CI, 0.71-0.95]; specificity of 0.97 [95% CI, 0.96-0.98]; false positive rate 0.03 [95% CI, 0.01 to 0.04], false negative rate 0.16 [95% CI, 0.15 to 0.19]. Adding teacher to teacher interviews to traditional questionnaire-based screening has the potential to improve the clinical utility of school-based screening for ADHD reducing the proportion of false positives, without a negative impact on sensitivity.
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http://dx.doi.org/10.1007/s00787-021-01721-wDOI Listing
January 2021

Clinicians' perceptions of the Australian Paediatric Mental Health Service System: Problems and solutions.

Aust N Z J Psychiatry 2021 05 18;55(5):494-505. Epub 2021 Jan 18.

Centre for Community Child Health, Murdoch Children's Research Institute and The Royal Children's Hospital Melbourne, Melbourne, VIC, Australia.

Objectives: Despite substantial investment by governments, the prevalence of mental health disorders in developed countries remains unchanged over the past 20 years. As 50% of mental health conditions present before 14 years of age, access to high-quality mental health care for children is crucial. Barriers to access identified by parents include high costs and long wait times, difficulty navigating the health system, and a lack of recognition of the existence and/or severity of the child's mental health disorder. Often neglected, but equally important, are clinician views about the barriers to and enablers of access to high-quality mental health care. We aimed to determine perspectives of Australian clinicians including child and adolescent psychiatrists, paediatricians, psychologists and general practitioners, on barriers and enablers within the current system and components of an optimal system.

Methods: A total of 143 clinicians (approximately 35 each of child and adolescent psychiatrists, paediatricians, child psychologists and general practitioners) from Victoria and South Australia participated in semi-structured phone interviews between March 2018 and February 2019. Inductive content analysis was applied to address the broad study aims.

Findings: Clinician-identified barriers included multi-dimensional family factors, service fragmentation, long wait times and inadequate training for paediatricians and general practitioners. Rural and regional locations provided additional challenges but a greater sense of collaboration resulting from the proximity of clinicians in rural areas, creating an opportunity to develop support networks. Suggestions for an optimal system included novel ways to improve access to child psychiatry expertise, training for paediatricians and general practitioners, and co-located multidisciplinary services.

Conclusion: Within the current mental health system for children, structural, training and workforce barriers prevent optimal access to care. Clinicians identified many practical and systemic ideas to improve the system. Implementation and evaluation of effectiveness and cost effectiveness of these ideas is the next challenge for Australia's children's mental health.
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http://dx.doi.org/10.1177/0004867420984242DOI Listing
May 2021

How long and how much? Wait times and costs for initial private child mental health appointments.

J Paediatr Child Health 2021 04 10;57(4):526-532. Epub 2020 Nov 10.

Health Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.

Aim: To determine: (i) wait times and out-of-pocket costs for children attending private specialists for initial mental health appointments; and (ii) whether these differed between specialists working in metropolitan versus rural areas and in low, medium and high socio-economic areas.

Methods: Prospective secret shopper study whereby a researcher posed as a parent seeking an appointment for her child with anxiety or attention-deficit/hyperactivity disorder. We contacted 317 private paediatrician, psychiatrist and psychologist practices in Victoria and South Australia between 12 March and 5 May 2019.

Results: One third (29.8%) of private practices were closed to new referrals. The average wait times for paediatricians, psychiatrists, and psychologists were 44, 41 and 34 days, respectively. Average out-of-pocket costs quoted were AU$120 for paediatricians, AU$176 for psychiatrists and AU$85 for psychologists.

Conclusion: Parents face extensive wait times and substantial out-of-pocket costs when seeking private mental health services for their child.
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http://dx.doi.org/10.1111/jpc.15253DOI Listing
April 2021

Persistence of disruptive mood dysregulation disorder in children with attention-deficit/hyperactivity disorder.

J Affect Disord 2021 01 28;278:502-505. Epub 2020 Sep 28.

Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; School of Psychology, Deakin University, Geelong, Australia.

Disruptive mood dysregulation disorder (DMDD) is common in children with ADHD yet it is not known how persistent DMDD is in this population. As such we aimed to investigate the persistence of disruptive mood dysregulation disorder (DMDD) in a community sample of children with ADHD. The sample comprised children (n = 136) participating in a cohort study with data available at age 7 and age 10. DMDD status was ascertained using proxy items from the Diagnostic Interview Schedule for Children, Version IV. Of those with DMDD at age 7 (n = 30), eight (21.1%) had DMDD that persisted at age 10. In the first study investigating the longitudinal course of DMDD in ADHD one in five children with ADHD+DMDD at age 7 continued to meet diagnostic criteria for DMDD three years later.
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http://dx.doi.org/10.1016/j.jad.2020.09.109DOI Listing
January 2021

Mindful Parenting Behaviors and Emotional Self-Regulation in Children With ADHD and Controls.

J Pediatr Psychol 2020 10;45(9):1074-1083

School of Psychology, Deakin University.

Objective: Mindfulness is defined as paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally and these behaviors can be applied to parenting. Thus far, it is not understood whether mindful parenting (MP) differs in parents of children with and without attention-deficit/hyperactivity disorder (ADHD), and how MP relates to other parenting practices and children's self-regulation.

Methods: This study examined the relationships between MP, parenting behaviors and children's self-regulation in 120 families with child ADHD (85% male; mean age = 11.93) and 105 control families (62% male; mean age = 11.98). Parents completed measures of MP (Interpersonal Mindfulness in Parenting Scale), parenting behaviors (parenting warmth, consistency, and anger assessed with the Longitudinal Study of Australian Children measures), psychological distress (Kessler 6), and children's self-regulation (Social Skills Improvement System-self-control subscale).

Results: When compared with controls, parents of children with ADHD reported significantly lower MP. Higher MP was associated with lower levels of parent psychological distress, higher levels of parenting warmth and consistency, lower levels of parenting anger, and higher child emotion self-regulation in both groups. In mediation analyses, MP was indirectly associated with child emotion self-regulation through lower parenting anger, with the model accounting for 55% of the variance in child self-regulation.

Conclusions: MP is a useful construct for understanding parent behaviors, and children's emotion self-regulation.
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http://dx.doi.org/10.1093/jpepsy/jsaa073DOI Listing
October 2020

Is 'minimally adequate treatment' really adequate? investigating the effect of mental health treatment on quality of life for children with mental health problems.

J Affect Disord 2020 11 20;276:327-334. Epub 2020 Jul 20.

Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Australia.

Background: Minimally adequate treatment (MAT) is intended to represent treatment minimally sufficient for common mental health problems. For children, MAT has been defined over a twelve-month period as either eight or more mental health visits, or four to seven visits plus relevant medication. MAT is used to identify those missing out on adequate care, but it is unknown whether MAT improves children's outcomes.

Methods: This paper examines whether MAT is associated with improved outcomes for children. It uses survey data from the nationally representative Longitudinal Study of Australian children on 596 children with mental health problems based on the Strengths and Difficulties Questionnaire at ages 8-15 years, linked to health service administrative data from 2012 to 2016. Statistical analysis examines the association of MAT with later quality of life (Pediatric Quality of Life Inventory), using a lagged dependent variable model to account for time-varying unobserved confounding.

Results: Compared to children with lower levels of treatment, those who received MAT between baseline and follow up had no statistically significant improvement in either quality of life or mental health symptoms.

Limitations: The observational data provide insight into real-world practice but require statistical methods to account for selection into treatment.

Conclusions: While clinical trials show mental health treatments can be efficacious, this study shows no evidence that children receiving MAT in routine practice have better outcomes. These findings demonstrate the need for better understanding of the nature and impact of children's mental health care as it is delivered and received in routine practice.
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http://dx.doi.org/10.1016/j.jad.2020.07.086DOI Listing
November 2020

Sleep problems, internalizing and externalizing symptoms, and domains of health-related quality of life: bidirectional associations from early childhood to early adolescence.

Sleep 2021 01;44(1)

Population Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia.

Study Objectives: To examine longitudinal, bidirectional associations among behavioral sleep problems, internalizing and externalizing symptoms, and domains of health-related quality of life (HRQoL) from early childhood to adolescence in a population sample of Australian children.

Method: Data were drawn from the Longitudinal Study of Australian Children, a national prospective cohort study with 4983 children participating in the Kindergarten cohort. Data were collected when children were aged 4-5, 6-7, 8-9, 10-11, and 12-13 years. At each study wave, the primary parent (97% mothers) reported on behavioral child sleep problems, internalizing and externalizing symptoms, and HRQoL domains (psychosocial and physical). Cross-lagged structural equation models were used to evaluate bidirectional associations.

Results: At nearly every age, behavioral sleep problems were associated with worse subsequent psychosocial and physical HRQoL. Despite bidirectional associations between mental health and HRQoL at many waves, HRQoL domains more strongly predicted later internalizing symptoms, while externalizing symptoms more strongly predicted later HRQoL. Many of the bidirectional associations among sleep, mental health, and HRQoL were found earlier in childhood.

Conclusions: Behavioral sleep problems may forecast later HRQoL psychosocial and physical impairments. Attending to both sleep problems and HRQoL could prevent the progression of internalizing conditions, while a focus on externalizing concerns could prevent the worsening of these symptoms, sleep problems, and HRQoL, particularly during the transition to school.
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http://dx.doi.org/10.1093/sleep/zsaa139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982136PMC
January 2021

A pilot randomised placebo-controlled trial of cannabidiol to reduce severe behavioural problems in children and adolescents with intellectual disability.

Br J Clin Pharmacol 2021 02 1;87(2):436-446. Epub 2020 Jul 1.

Monash University, Clayton, Victoria, Australia.

Aims: Severe behavioural problems (SBP) are a major contributor to morbidity in children with intellectual disability (ID). Medications used to treat SBP in ID are associated with a high risk of side effects. Cannabidiol has potential therapeutic effects in SBP. This pilot study aimed to investigate the feasibility of conducting a randomised placebo-controlled trial of cannabidiol to reduce SBP in children with ID.

Methods: This is a double-blind, placebo-controlled, two-armed, parallel-design, randomised controlled trial of cannabidiol in children aged 8-16 years with ID and SBP. Participants were randomised 1:1 to receive either 98% cannabidiol in oil (Tilray, Canada) or placebo orally for 8 weeks. The dose was up-titrated over 9 days to 20 mg/kg/day in two divided doses, with a maximum dose of 500 mg twice/day. The feasibility and acceptability of all study components were assessed.

Results: Eight children were randomised, and all completed the full study protocol. There were no serious adverse events or drop-outs. Protocol adherence for key study components was excellent: study visits 100%, medication adherence 100%, blood tests 92% and questionnaire completion 88%. Parents reported a high degree of acceptability with the study design. All parents reported they would recommend the study to other families with children with similar problems. There was an efficacy signal in favour of active drug.

Conclusions: The findings suggest that the study protocol is feasible and acceptable to patients with ID and SBP and their families.
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http://dx.doi.org/10.1111/bcp.14399DOI Listing
February 2021

Comorbid anxiety and irritability symptoms and their association with cognitive functioning in children with ADHD.

J Abnorm Child Psychol 2020 08;48(8):1035-1046

School of Psychology, Faculty of Health, Deakin University Geelong, Victoria, Australia.

Anxiety and irritability symptoms frequently co-occur in children with Attention-Deficit/Hyperactivity Disorder (ADHD). This study aims to investigate whether irritability and anxiety are uniquely associated with performance on measures of cognitive functioning in children with ADHD and whether these associations hold when accounting for confounding variables. Baseline data was used from a randomised controlled trial of cognitive behavioural therapy for anxiety in children with ADHD (N = 219, 8-13 years). Anxiety was assessed using the child- and parent-reported Spence Children's Anxiety Scale, while irritability was assessed using the parent-reported Affective Reactivity Index. Children completed the National Institutes of Health Toolbox - Cognition Battery. Higher symptoms of anxiety were uniquely associated with performance on the Dimensional Card Change Sort Test (β = -2.75, confidence interval (CI) [-4.97, -.52], p = .02) and the List Sort Working Memory Test (β = -2.57, CI [-4.43, -.70], p = .01), while higher symptoms of irritability were negatively associated with Picture Vocabulary Test (β = -2.00, CI [-3.83, -.16], p = .03). These associations did not survive correction for multiple comparisons. There was little evidence of an association between anxiety or irritability symptoms and cognitive functioning. Frequent co-occurrence of anxiety and irritability suggests clinicians working with children with ADHD should assess co-morbid symptom profiles to inform the provision of optimum care.
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http://dx.doi.org/10.1007/s10802-020-00658-zDOI Listing
August 2020

Peer Victimization and Poor Academic Outcomes in Adolescents With ADHD: What Individual Factors Predict Risk?

J Atten Disord 2021 Aug 24;25(10):1455-1465. Epub 2020 Apr 24.

Murdoch Children's Research Institute, Parkville, Victoria, Australia.

Examine individual factors associated with peer victimization (PV) in adolescents with attention-deficit/hyperactivity disorder (ADHD) and to examine the association between PV and educational outcomes. Participants were 121 adolescents ( = 13.62, = 1.03; 89% boys) with diagnosed ADHD. Using path analysis, we tested whether general adolescent factors (ADHD symptoms, comorbid autism spectrum disorder, cognitive and social functioning, and age) were associated with experiences of PV, and associations between PV and academic outcomes. Deficits in working memory (WM) and peer relationship problems were weakly and moderately associated with PV, respectively. PV was in turn was associated with adolescents' attitudes about school, academic competence, and academic achievement. Adolescents with poor social skills and/or WM difficulties who have ADHD may be particularly vulnerable to being victimized by peers. Failure to identify and manage PV during early adolescence may be connected to poor educational outcomes.
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http://dx.doi.org/10.1177/1087054720914387DOI Listing
August 2021

Does cannabidiol reduce severe behavioural problems in children with intellectual disability? Study protocol for a pilot single-site phase I/II randomised placebo controlled trial.

BMJ Open 2020 03 8;10(3):e034362. Epub 2020 Mar 8.

Health Services, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.

Introduction: Severe behavioural problems (SBPs) are a common contributor to morbidity and reduced quality of life in children with intellectual disability (ID). Current medication treatment for SBP is associated with a high risk of side effects. Innovative and safe interventions are urgently needed. Anecdotal reports and preliminary research suggest that medicinal cannabis may be effective in managing SBP in children with developmental disabilities. In particular, cannabidiol (CBD) may be a plausible and safe alternative to current medications. Families who are in urgent need of solutions are seeking cannabis for their ID children with SBP. However there is no evidence from randomised controlled trials to support the use of CBD for SBP. This pilot study aims to investigate the feasibility of conducting a randomised placebo-controlled trial of CBD to improve SBP in children with ID.

Methods And Analysis: This is a single-site, double-blind, parallel-group, randomised, placebo-controlled pilot study of 10 participants comparing 98% CBD oil with placebo in reducing SBP in children aged 8-16 years with ID. Eligible participants will be randomised 1:1 to receive either CBD 20 mg/kg/day or placebo for 8 weeks. Data will be collected regarding the feasibility and acceptability of all study components, including recruitment, drop-out rate, study visit attendance, protocol adherence and the time burden of parent questionnaires. Safety outcomes and adverse events will be recorded. All data will be reported using descriptive statistics. These data will inform the design of a full scale randomised controlled trial to evaluate the efficacy of CBD in this patient group.

Ethics And Dissemination: This protocol has received ethics approval from the Royal Children's Hospital ethics committee (Human Research Ethics Committee no. 38236). Results will be disseminated through peer-reviewed journals, professional networks, conferences and social media.

Trial Registration Number: ACTRN12618001852246.
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http://dx.doi.org/10.1136/bmjopen-2019-034362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7064134PMC
March 2020

Patterns of long-term ADHD medication use in Australian children.

Arch Dis Child 2020 06 14;105(6):593-597. Epub 2020 Jan 14.

Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.

Objective: Adherence to attention-deficit/hyperactivity disorder (ADHD) medication treatment is often suboptimal. This can compromise patient outcomes. We aimed to describe the patterns of ADHD medication use in Australian children, and characteristics associated with patterns of use.

Design: Dispensing data were analysed for all redeemed prescriptions of methylphenidate, dexamphetamine and atomoxetine between May 2002 and March 2015 from waves 1 to 6 of the Longitudinal Study of Australian Children (n=4634, age 4-5 years at wave 1). Medication coverage was defined as the proportion of time between the first and the last redeemed prescriptions in which the child was taking medication. Associations between predictor variables (child sex, ADHD symptom severity, age at first prescription, family socioeconomic status (SES), single parent status, parent education and parent mental health) and medication coverage were examined using regression analyses.

Results: 166 (3.6%) children had ever redeemed a prescription for an ADHD medication. Boys had higher odds of having taken ADHD medication than girls (OR=3.9; 95% CI 2.7 to 5.7). The mean medication coverage was 59.8%. Medication coverage was lower in children from families of lower SES (β=4.0; 95% CI 0.2 to 7.8, p=0.04). Medication coverage was relatively high in the first year of prescription, then decreased progressively, only increasing again after 5 or 6 years of treatment.

Conclusions: Children with ADHD from socially disadvantaged families were less likely to receive medication consistently. Prescribers need to continue to support families over many years to ensure medication is used consistently for children with ADHD.
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http://dx.doi.org/10.1136/archdischild-2019-317997DOI Listing
June 2020

Does the treatment of anxiety in children with Attention-Deficit/Hyperactivity Disorder (ADHD) using cognitive behavioral therapy improve child and family outcomes? Protocol for a randomized controlled trial.

BMC Psychiatry 2019 11 13;19(1):359. Epub 2019 Nov 13.

Murdoch Children's Research Institute, Parkville, Vic, Australia.

Background: Up to 60% of children with Attention-Deficit/Hyperactivity Disorder (ADHD) meet diagnostic criteria for at least one anxiety disorder, including Social, Generalized and/or Separation Disorder. Anxiety in children with ADHD has been shown to be associated with poorer child and family functioning. Small pilot studies suggest that treating anxiety in children with ADHD using cognitive-behavioral therapy (CBT) has promising benefits. In a fully powered randomized controlled trial (RCT), we aim to investigate the efficacy of an existing CBT intervention adapted for children with ADHD and comorbid anxiety compared with usual care.

Methods: This RCT is recruiting children aged 8-12 years (N = 228) from pediatrician practices in Victoria, Australia. Eligibility criteria include meeting full diagnostic criteria for ADHD and at least one anxiety disorder (Generalized, Separation or Social). Eligible children are randomized to receive a 10 session CBT intervention (Cool Kids) versus usual clinical care from their pediatrician. The intervention focuses on building child and parent skills and strategies to manage anxiety and associated impairments including cognitive restructuring and graded exposure. Minor adaptations have been made to the delivery of the intervention to meet the needs of children with ADHD including increased use of visual materials and breaks between activities. The primary outcome is change in the proportion of children meeting diagnostic criteria for an anxiety disorder at 5 months randomization. This will be assessed via diagnostic interview with the child's parent (Anxiety Disorders Interview Schedule for Children V) conducted by a researcher blinded to intervention condition. Secondary outcomes include a range of child (e.g., anxiety symptoms, ADHD severity, behavior, quality of life, sleep, cognitive functioning, school attendance) and parent (e.g., mental health, parenting behaviors, work attendance) domains of functioning assessed at 5 and 12 months post-randomization. Outcomes will be analyzed using logistic and mixed effects regression.

Discussion: The results from this study will provide evidence on whether treating comorbid anxiety in children with ADHD using a CBT approach leads to improvements in anxiety and/or broader functional outcomes.

Trial Registration: This trial was prospectively registered: Current Controlled Trials ISRCTN59518816 (https://doi.org/10.1186/ISRCTN59518816). The trial was first registered 29/9/15 and last updated 15/1/19.
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http://dx.doi.org/10.1186/s12888-019-2276-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854614PMC
November 2019

The Relationship Between Maternal Stress and Boys' ADHD Symptoms and Quality of Life: An Australian Prospective Cohort Study.

J Pediatr Nurs 2020 Jan - Feb;50:e33-e38. Epub 2019 Oct 22.

Community Health Services Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.

Purpose: This study prospectively examined the role of maternal stress in boys' attention deficit hyperactivity disorder (ADHD) symptoms and quality of life (QoL).

Methods: Children with ADHD (5-13 years) were recruited from 21 pediatric practices and followed up 12 months later (n = 166). Maternal stress was examined at baseline, and boys' ADHD symptoms and QoL were examined at baseline and 12 months later. Linear regressions examined whether baseline maternal stress predicted child ADHD symptoms and QoL 12 months later in a series of adjusted models that accounted for child age, ADHD medication use, neighborhood disadvantage, comorbidities and baseline ADHD symptoms or QoL (full model).

Results: In the unadjusted model, maternal stress at baseline was significantly associated with more severe parent-reported ADHD symptoms at 12 months, accounting for 5.7% of the variance in ADHD symptoms, but this association was attenuated after adjustments in the full model. Baseline maternal stress was associated with poorer QoL at 12 months in boys in the unadjusted model, accounting for 12.4% of the variance, which remained significant in the full adjusted model.

Conclusions: Maternal stress is associated with lowered QoL in boys, and may pose a risk for boys' later QoL.

Practice Implications: Stress management interventions with mothers of children with ADHD experiencing heightened stress are warranted, and are likely to have a positive impact on mothers as well as children.
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http://dx.doi.org/10.1016/j.pedn.2019.09.029DOI Listing
December 2020

Impact of a behavioral intervention, delivered by pediatricians or psychologists, on sleep problems in children with ADHD: a cluster-randomized, translational trial.

J Child Psychol Psychiatry 2019 11 11;60(11):1230-1241. Epub 2019 Jun 11.

Centre for Community Child Health, The Royal Children's Hospital, Parkville, VIC, Australia.

Background: We have demonstrated the efficacy of a brief behavioral intervention for sleep in children with ADHD in a previous randomized controlled trial and now aim to examine whether this intervention is effective and cost-effective when delivered by pediatricians or psychologists in community settings.

Methods: Translational, cluster-randomized trial of a behavioral intervention versus usual care from 19th January, 2015 to 30th June, 2017. Participants (n = 361) were children aged 5-13 years with ADHD and parent report of a moderate/severe sleep problem who met criteria for American Academy of Sleep Medicine criteria for chronic insomnia disorder, delayed sleep-wake phase disorder, or were experiencing sleep-related anxiety. Participants were randomized at the level of the pediatrician (n = 61) to intervention (n = 183) or usual care (n = 178). Families in the intervention group received two consultations with a pediatrician or a psychologist covering sleep hygiene and tailored behavioral strategies.

Results: In an intention-to-treat analysis, at 3 and 6 months respectively, the proportion of children with moderate to severe sleep problems was lower in the intervention (28.0%, 35.8%) compared with usual care group (55.4%, 60.1%; 3 month: risk ratio (RR): 0.51, 95% CI 0.37, 0.70, p < .001; 6 month: RR: 0.58; 95% CI 0.45, 0.76, p < .001). Intervention children had improvements across multiple Children's Sleep Habits Questionnaire subscales at 3 and 6 months. No benefits of the intervention were observed in other domains. Cost-effectiveness of the intervention was AUD 13 per percentage point reduction in child sleep problem at 3 months.

Conclusions: A low-cost brief behavioral sleep intervention is effective in improving sleep problems when delivered by community clinicians. Greater sample comorbidity, lower intervention dose or insufficient clinician supervisions may have contributed to the lack benefits seen in our previous trial.
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http://dx.doi.org/10.1111/jcpp.13083DOI Listing
November 2019

Mental health difficulties across childhood and mental health service use: findings from a longitudinal population-based study.

Br J Psychiatry 2020 07;217(1):364-369

Professor of Child and Adolescent Psychiatry, Faculty of Health and Medical Sciences, University of Adelaide, Australia.

Background: Over the past 20 years the prevalence of child and adolescent mental disorders in high-income countries has not changed despite increased investment in mental health services. Insufficient contact with mental health services may be a contributing factor; however, it is not known what proportion of children have sufficient contact with health professionals to allow delivery of treatment meeting minimal clinical practice guidelines, or how long children experience symptoms prior to receiving treatment.

Aims: To investigate the level of mental healthcare received by Australian children from age 4 years to 14 years.

Method: Trajectories of mental health symptoms were mapped using the Strengths and Difficulties Questionnaire. Health professional attendances and psychotropic medications dispensed were identified from linked national Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme records.

Results: Four trajectories of mental health symptoms were identified (low, high-decreasing, moderate-increasing and high-increasing). Most children with mental health symptoms had few MBS mental health attendances, and only a minority received care meeting study criteria for minimally adequate treatment. Children in the high-increasing and moderate-increasing trajectories were more likely to access care, yet there was no evidence of improvement in symptoms.

Conclusions: It is important that children and adolescents with mental health problems receive treatment that meets minimal practice guidelines. Further research is needed to identify the quality of care currently provided to children with mental health difficulties and how clinicians can be best funded and supported to provide care meeting minimal practice guidelines.

Declaration Of Interests: None.
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http://dx.doi.org/10.1192/bjp.2019.32DOI Listing
July 2020

An examination of the association between anxiety and social functioning in youth with ADHD: A systematic review.

Psychiatry Res 2019 03 14;273:402-421. Epub 2019 Jan 14.

Deakin University Geelong, Deakin Child Study Centre, School of Psychology, Faculty of Health, Victoria, Australia; Centre for Community Child Health, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia. Electronic address:

Although up to 50% of children with Attention-Deficit/Hyperactivity Disorder (ADHD) meet criteria for an anxiety disorder, it is unclear how comorbid anxiety influences social functioning for this population. Understanding the factors associated with social functioning in ADHD is important given the limited efficacy of existing social skills interventions for this population. This systematic review aimed to determine the association between anxiety and social functioning (social problems, peer status, and social skills/ competence) in children and adolescents with ADHD. A standardised search protocol was used, identifying 4807 articles for screening with 31 included in the final review. Anxiety symptom severity was associated with lower levels of social skills and higher levels of social problems in young people with ADHD. However, few differences emerged when defining anxiety based on diagnostic measures. Although the results varied considerably amongst studies, a number of key variables emerged that influenced the associations between anxiety and social functioning including the type of reporter and sample characteristics such as age, sex, ADHD subtype and other mental health comorbidities. These findings have implications for social functioning interventions in ADHD given the role of anxiety symptoms in predicting poorer social functioning.
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http://dx.doi.org/10.1016/j.psychres.2019.01.039DOI Listing
March 2019

Maternal postnatal mental health and offspring symptoms of ADHD at 8-9 years: pathways via parenting behavior.

Eur Child Adolesc Psychiatry 2019 Jul 16;28(7):923-932. Epub 2018 Nov 16.

Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Melbourne, 3052, Australia.

Exposure to maternal mental health problems during pregnancy and the first year of life has been associated with the development of ADHD. One pathway through which maternal mental health may influence children's outcomes is via its effects on parenting. This study aimed to investigate the mediating role of parenting behavior in the pathway between maternal postnatal distress and later symptoms of ADHD in the child. Biological mothers living with their children participating in the Longitudinal Study of Australian Children with data available from waves 1 (child age 3-12 months) and 5 (child age 8-9 years) were included in the current study (n = 3456). Postnatal distress was assessed by parent report at wave 1. Parenting warmth, hostility and consistency were assessed by parent report at wave 5. ADHD status at wave 5 was ascertained by parent report of the child having a diagnosis of ADHD/ADD or by elevated ADHD symptoms by both parent and teacher report. There was evidence of an indirect pathway from maternal postnatal distress to child ADHD at age 8-9 years via parenting hostility, but not through parenting warmth or consistency, even after accounting for concurrent maternal mental health. Our findings highlight the importance of early identification and intervention for maternal postnatal distress, as treatment may prevent mothers from developing hostile parenting practices and also disrupt the pathway to ADHD in their offspring.
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http://dx.doi.org/10.1007/s00787-018-1254-5DOI Listing
July 2019

The Cranky Thermometers: Visual analogue scales measuring irritability in youth.

J Adolesc 2018 04 2;64:146-154. Epub 2018 Mar 2.

Centre for Developmental Psychiatry & Psychology, Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Building #1, Ferntree Gully Rd, Notting Hill, Victoria, 3168, Australia.

This study assessed the psychometric properties of two visual analogue scales of irritability, known as the Cranky Thermometers (CT), in both an Australian community secondary-school sample (N = 164) and a sample of adolescents with a depressive disorder (N = 127). The first scale Cranky Now measures current irritability, and the second, Cranky Two Weeks, measures peak irritability within the last two weeks. CT scores were significantly higher in adolescents with major depressive disorder than in the school sample and showed improvement following treatment for depression. Positive associations were found between CT and irritability scores as determined by Kiddie Schedule for Affective Disorders and Schizophrenia (not irritable, sub-threshold, threshold irritability) and Affective Reactivity Index scores. Results suggest that the CTs are rapidly administered, have promising psychometric properties and demonstrate utility in measuring irritability in clinical and community settings.
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http://dx.doi.org/10.1016/j.adolescence.2018.02.008DOI Listing
April 2018

Sleep problems and daytime sleepiness in children with ADHD: Associations with social, emotional, and behavioral functioning at school, a cross-sectional study.

Behav Sleep Med 2019 Jul-Aug;17(4):411-422. Epub 2017 Oct 13.

a Department of Pediatrics, The University of Melbourne , Parkville , Victoria , Australia.

: Sleep problems and daytime sleepiness are common in children with attention-deficit hyperactivity disorder (ADHD) and are associated with poor parent-reported functional outcomes. However, the potential impact of sleep problems or daytime sleepiness on the school functioning of children with ADHD remains unknown. We aimed to determine if sleep problems and daytime sleepiness were associated with the social, emotional, and behavioral school-based functioning of children with ADHD and comorbid sleep problems. : Children aged 5-13 years with ADHD and a moderate-severe sleep problem (confirmed using American Academy of Sleep Medicine diagnostic criteria) were recruited from 43 pediatric practices across Victoria and Queensland, Australia (257). Parent-rated sleep problems were assessed using the Children's Sleep Habits Questionnaire (CSHQ) and teacher-rated daytime sleepiness using the Teacher's Daytime Sleepiness Questionnaire. Teacher-rated social, emotional, and behavioral school functioning was assessed using three scales (peer problems, emotional problems, and conduct problems) from the Strength and Difficulties Questionnaire. Data was analyzed using Pearson correlations and linear regression models. : Teacher-rated daytime sleepiness was associated with higher levels of emotional (β = 0.39; 95% CI = 0.25-0.52) and behavioral problems (β = 0.47; CI = 0.36-0.58) in adjusted models. While total sleep duration and parent-rated sleep problems were not associated with daytime sleepiness or school functioning, the CSHQ subscale was correlated with teacher-rated daytime sleepiness (= 0.21; < 0.01). : Daytime sleepiness (possibly as an indicator of sleep quality) may be a better predictor of school functioning in children with ADHD who have concomitant sleep problems than total sleep duration or parent-rated sleep problems.
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http://dx.doi.org/10.1080/15402002.2017.1376207DOI Listing
December 2019

Sleep problems in children with attention-deficit hyperactivity disorder: associations with parenting style and sleep hygiene.

Eur Child Adolesc Psychiatry 2017 Sep 16;26(9):1129-1139. Epub 2017 May 16.

Murdoch Childrens Research Institute, Parkville, VIC, Australia.

We aimed to examine the association between sleep problems and parenting and sleep hygiene in children with attention-deficit/hyperactivity disorder (ADHD). Participants included 5-13-year-old children with DSM 5 defined ADHD and a parent-reported moderate-to-severe sleep problem (N = 361). Sleep was assessed using the parent-reported Children's Sleep Habits Questionnaire. Parents also completed checklists assessing sleep hygiene, parenting consistency, and parenting warmth. Linear regression established prediction models controlling for confounding variables including child age and sex, ADHD symptom severity, comorbidities, medication use, and socio-demographic factors. More consistent parenting was associated with decreased bedtime resistance (β = -0.16) and decreased sleep anxiety (β = -0.14), while greater parental warmth was associated with increased parasomnias (β = +0.18) and sleep anxiety (β = +0.13). Poorer sleep hygiene was associated with increased bedtime resistance (β = +0.20), increased daytime sleepiness (β = +0.12), and increased sleep duration problems (β = +0.13). In conclusion, sleep hygiene and parenting are important modifiable factors independently associated with sleep problems in children with ADHD. These factors should be considered in the management of sleep problems in children with ADHD.
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http://dx.doi.org/10.1007/s00787-017-1000-4DOI Listing
September 2017

ADHD Symptoms and Quality of Life Across a 12-Month Period in Children With ADHD: A Longitudinal Study.

J Atten Disord 2019 11 1;23(13):1675-1685. Epub 2017 May 1.

1 Murdoch Childrens Research Institute, Parkville, Australia.

Objective: To describe the relationship between ADHD symptom severity and quality of life (QoL) across three time points over a 12-month period and investigate whether sleep modifies this relationship.

Method: Children aged 5 to 13 years with ADHD were recruited from 21 pediatric practices across Victoria, Australia ( N = 392). Child QoL (parent-report) and ADHD symptoms (both parent- and teacher-report) were assessed at three time points (0, 6, and 12 months), and sleep was assessed at baseline (parent-report). Data were analyzed using Pearson's correlations and autoregressive cross-lagged panel models.

Results: Parent-reported ADHD symptoms predicted poorer QoL at each subsequent time point ( r = -.10 to -.13), and a small bidirectional relationship was observed between teacher-reported ADHD symptoms and QoL from 6 to 12 months. Sleep moderated the relationship between ADHD symptoms and QoL.

Conclusion: Clinicians need to look beyond core ADHD symptoms to other factors that may be influencing QoL in children with ADHD.
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http://dx.doi.org/10.1177/1087054717707046DOI Listing
November 2019

Prenatal Risk Factors and the Etiology of ADHD-Review of Existing Evidence.

Curr Psychiatry Rep 2017 Jan;19(1)

Murdoch Childrens Research Institute, Parkville, VIC, Australia.

While it is well accepted that attention-deficit/hyperactivity disorder (ADHD) is a highly heritable disorder, not all of the risk is genetic. It is estimated that between 10 and 40% of the variance associated with ADHD is likely to be accounted for by environmental factors. There is considerable interest in the role that the prenatal environment might play in the development of ADHD with previous reviews concluding that despite demonstration of associations between prenatal risk factors (e.g. prematurity, maternal smoking during pregnancy) and ADHD, there remains insufficient evidence to support a definite causal relationship. This article provides an update of research investigating the relationship between prenatal risk factors and ADHD published over the past 3 years. Recently, several epidemiological and data linkage studies have made substantial contributions to our understanding of this relationship. In particular, these studies have started to account for some of the genetic and familial confounds that, when taken into account, throw several established findings into doubt. None of the proposed prenatal risk factors can be confirmed as causal for ADHD, and the stronger the study design, the less likely it is to support an association. We need a new benchmark for studies investigating the etiology of ADHD whereby there is an expectation not only that data will be collected prospectively but also that the design allows the broad range of genetic and familial factors to be accounted for.
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http://dx.doi.org/10.1007/s11920-017-0753-2DOI Listing
January 2017

Do early internalizing and externalizing problems predict later irritability in adolescents with attention-deficit/hyperactivity disorder?

Aust N Z J Psychiatry 2017 Apr 20;51(4):393-402. Epub 2016 Aug 20.

1 Centre for Community Child Health, Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia.

Objective: Irritable mood is common in children with attention-deficit/hyperactivity disorder. Research to date has primarily comprised cross-sectional studies; thus, little is known about the antecedents of irritability. Furthermore, existing cross-sectional studies generally focus on the association between irritability and comorbidities and do not examine broader aspects of functioning. Finally, previous research has neglected to include child-report of irritability. This study aimed to address these gaps using data from a longitudinal study of children with attention-deficit/hyperactivity disorder.

Method: Children aged 5-13 years (mean = 10.2; standard deviation = 1.9) with attention-deficit/hyperactivity disorder were recruited from pediatric practices across Victoria, Australia. This study reports on those who had reached adolescence (12 years or older, mean = 13.8; standard deviation = 1.2) at the 3-year follow-up ( n = 140). Internalizing and externalizing problems were measured using the Strengths and Difficulties Questionnaire. At follow-up, parent-reported and adolescent self-reported irritability was assessed using the Affective Reactivity Index. Parent and adolescent outcomes measured at follow-up included attention-deficit/hyperactivity disorder symptom severity, sleep, behavior and parent mental health.

Results: Children with externalizing problems at age 10 had higher parent-reported irritability (β = 0.31, 95% confidence interval = [0.17,-0.45], p = 0.001) in adolescence. Cross-sectional analyses found that irritability was associated with increased attention-deficit/hyperactivity disorder symptom severity and sleep problems; poorer emotional, behavioral and social functioning; and poorer parent mental health.

Conclusion: Our findings highlight the importance of assessing for and managing early conduct problems in children with attention-deficit/hyperactivity disorder, as these predict ongoing irritability which, in turn, is associated with poorer functioning across a number of domains.
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http://dx.doi.org/10.1177/0004867416659365DOI Listing
April 2017

Correlates of Anxiety in 6- to 8-Year-Old Children With ADHD: A Community-Based Study.

J Atten Disord 2018 03 28;22(5):425-434. Epub 2016 Mar 28.

1 Murdoch Childrens Research Institute, Parkville, Victoria, Australia.

Objective: The aim of this study was to identify the child and parent/family correlates of anxiety in a community-based sample of children with ADHD.

Method: Children (6-8 years) with ADHD ( n = 179) and controls ( n = 212) were assessed for ADHD and anxiety using the Diagnostic Interview Schedule for Children IV. Potential child and parent/family correlates were measured through direct assessments, and parent- and teacher-reported questionnaires. Associations were examined using univariate and multivariate logistic regression analyses.

Results: One in four children with ADHD ( n = 44) met criteria for an anxiety disorder, compared with one in 20 controls ( n = 10). Anxiety was common in both boys and girls with ADHD. The strongest correlates of anxiety in multivariate analyses were ADHD subtype, primary caregiver psychosocial distress, and neighborhood socioeconomic disadvantage.

Conclusion: Anxiety is common in children with ADHD. This study provides insight into the potential parent/family stressors that may increase risk for anxiety in children with ADHD.
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http://dx.doi.org/10.1177/1087054716638510DOI Listing
March 2018

The bidirectional relationship between sleep problems and internalizing and externalizing problems in children with ADHD: a prospective cohort study.

Sleep Med 2016 Jan 23;17:45-51. Epub 2015 Oct 23.

Community Child Health, Murdoch Childrens Research Institute, 50 Flemington Road, Parkville, Victoria, Australia; Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, Victoria, Australia; The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, Australia; School of Psychology, Deakin University, Burwood Highway, Burwood, Victoria, Australia.

Background: Behavioral sleep problems are common in children with attention deficit hyperactivity disorder (ADHD), and longitudinal studies have found sleep problems to be both a predictor and outcome of internalizing and externalizing problems. We investigated the potential bidirectional relationship between sleep problems and internalizing/externalizing problems.

Methods: Children with ADHD, aged 5-13 years, were recruited from 21 pediatric practices across Victoria, Australia (N = 270). Across a 12-month period, at three time points, parents reported on their child's sleep problems (Children's Sleep Habits Questionnaire) and emotional and behavioral functioning (Strengths and Difficulties Questionnaire). Data were analyzed using autoregressive cross-lagged panel models.

Results: Sleep problem severity and emotional/behavioral problem severity were very stable across the 12-month period. Sleep problems at baseline predicted emotional problems at six months (r = 0.17, p < 0.01), and emotional problems at baseline predicted sleep problems at six months (r = 0.07, p < 0.05). However, there was no predictive relationship between sleep problems and emotional problems from 6-12 months. No bidirectional relationship was observed between sleep problems and conduct problems.

Conclusions: In children with ADHD, there is weak evidence of a bidirectional relationship between sleep problems and emotional problems. These symptoms are also very stable over time; therefore, the best treatment approach to improve overall functioning may be to target both sleep and emotional functioning in these children.
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http://dx.doi.org/10.1016/j.sleep.2015.09.019DOI Listing
January 2016

Comorbidity and correlates of disruptive mood dysregulation disorder in 6-8-year-old children with ADHD.

Eur Child Adolesc Psychiatry 2016 Mar 30;25(3):321-30. Epub 2015 Jun 30.

Murdoch Childrens Research Institute, Parkville, VIC, Australia.

This study aimed to characterize the nature and impact of disruptive mood dysregulation disorder (DMDD) in children with attention-deficit/hyperactivity disorder (ADHD) including its co-occurrence with other comorbidities and its independent influence on daily functioning. Children with ADHD (6-8 years) were recruited through 43 Melbourne schools, using a 2-stage screening (parent and teacher Conners 3 ADHD index) and case-confirmation (Diagnostic Interview Schedule for Children, Version IV; [DISC-IV]) procedure. Proxy DMDD diagnosis was confirmed via items from the oppositional defiant disorder (ODD) and major depressive disorder modules of the DISC-IV. Outcome domains included comorbid mental health disorders, academic functioning, social functioning, child and family quality of life, parent mental health, and parenting behaviors. Unadjusted and adjusted linear and logistic regression were used to compare children with comorbid ADHD and DMDD and children with ADHD without DMDD. Thirty-nine out of 179 children (21.8 %) with ADHD had comorbid DMDD. Children with ADHD and DMDD had a high prevalence of ODD (89.7 %) and any anxiety disorder (41.0 %). Children with ADHD and DMDD had poorer self-control and elevated bullying behaviors than children with ADHD without DMDD. Children with ADHD and DMDD were similar to children with ADHD in the other domains measured when taking into account other comorbidities including ODD. One in five children with ADHD in their second year of formal schooling met criteria for DMDD. There was a very high diagnostic overlap with ODD; however, the use of a proxy DMDD diagnosis containing items from the ODD module of the DISC-IV may have artificially inflated the comorbidity rates. DMDD added to the burden of ADHD particularly in the area of social functioning.
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http://dx.doi.org/10.1007/s00787-015-0738-9DOI Listing
March 2016