Abigail Russell

The Association Between Socioeconomic Disadvantage and Attention Deficit/Hyperactivity Disorder (ADHD): A Systematic Review

This systematic review examines associations between parental socioeconomic disadvantage and childhood attention deficit/hyperactivity disorder (ADHD). Socioeconomic status (SES) was measured by parental income, education, occupation and marital status. Results were mixed by measure of SES with no one aspect being differentially related to ADHD. 42 studies were included in the review, of which 35 found a significant univariate association between socioeconomic disadvantage and ADHD. Meta-analyses of dimensions of SES and their association with ADHD indicate that children in families of low SES are on average 1.85–2.21 more likely to have ADHD than their peers in high SES families. In spite of substantial between-study heterogeneity, there is evidence for an association between socioeconomic disadvantage and risk of ADHD measured in different ways. This is likely mediated by factors linked to low SES such as parental mental health and maternal smoking during pregnancy.

Socioeconomic Associations with ADHD: Findings from a Mediation Analysis

Background Children from disadvantaged socioeconomic backgrounds are at greater risk of a range of negative outcomes throughout their life course than their peers; however the specific mechanisms by which socioeconomic status relates to different health outcomes in childhood are as yet unclear. Aims The current study investigates the relationship between socioeconomic disadvantage in childhood and attention deficit/hyperactivity disorder (ADHD), and investigates putative mediators of this association in a longitudinal population-based birth cohort in the UK. Methods Data from the Avon Longitudinal Study of Parents and Children was used (n = 8,132) to explore the relationship between different measures of socioeconomic status at birth-3 years and their association with a diagnosis of ADHD at age 7. A multiple mediation model was utilised to examine factors occurring between these ages that may mediate the association. Results Financial difficulties, housing tenure, maternal age at birth of child and marital status were significantly associated with an outcome of ADHD, such that families either living in financial difficulty, living in council housing, with younger or single mothers’ were more likely to have a child with a research diagnosis of ADHD at age 7. Financial difficulties was the strongest predictor of ADHD (OR 2.23 95% CI 1.57-3.16). In the multiple mediation model, involvement in parenting at age 6 and presence of adversity at age 2-4 mediated 27.8% of the association. Conclusions Socioeconomic disadvantage, conceptualised as reported difficulty in affording basic necessities (e.g. heating, food) has both direct and indirect impacts on a child’s risk of ADHD. Lower levels of parent involvement mediates this association, as does presence of adversity; with children exposed to adversity and those with less involved parents being at an increased risk of having ADHD. This study highlights the importance of home and environmental factors as small but important contributors toward the aetiology of ADHD.

Clinical effectiveness and cost-effectiveness of collaborative care for depression in UK primary care (CADET): a cluster randomised controlled trial

BACKGROUND Collaborative care is effective for depression management in the USA. There is little UK evidence on its clinical effectiveness and cost-effectiveness. OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of collaborative care compared with usual care in the management of patients with moderate to severe depression. DESIGN Cluster randomised controlled trial. SETTING UK primary care practices (n = 51) in three UK primary care districts. PARTICIPANTS A total of 581 adults aged ≥ 18 years in general practice with a current International Classification of Diseases, Tenth Edition depressive episode, excluding acutely suicidal people, those with psychosis, bipolar disorder or low mood associated with bereavement, those whose primary presentation was substance abuse and those receiving psychological treatment. INTERVENTIONS Collaborative care: 14 weeks of 6-12 telephone contacts by care managers; mental health specialist supervision, including depression education, medication management, behavioural activation, relapse prevention and primary care liaison. Usual care was general practitioner standard practice. MAIN OUTCOME MEASURES Blinded researchers collected depression [Patient Health Questionnaire-9 (PHQ-9)], anxiety (General Anxiety Disorder-7) and quality of life (European Quality of Life-5 Dimensions three-level version), Short Form questionnaire-36 items) outcomes at 4, 12 and 36 months, satisfaction (Client Satisfaction Questionnaire-8) outcomes at 4 months and treatment and service use costs at 12 months. RESULTS In total, 276 and 305 participants were randomised to collaborative care and usual care respectively. Collaborative care participants had a mean depression score that was 1.33 PHQ-9 points lower [n = 230; 95% confidence interval (CI) 0.35 to 2.31; p = 0.009] than that of participants in usual care at 4 months and 1.36 PHQ-9 points lower (n = 275; 95% CI 0.07 to 2.64; p = 0.04) at 12 months after adjustment for baseline depression (effect size 0.28, 95% CI 0.01 to 0.52; odds ratio for recovery 1.88, 95% CI 1.28 to 2.75; number needed to treat 6.5). Quality of mental health but not physical health was significantly better for collaborative care at 4 months but not at 12 months. There was no difference for anxiety. Participants receiving collaborative care were significantly more satisfied with treatment. Differences between groups had disappeared at 36 months. Collaborative care had a mean cost of £272.50 per participant with similar health and social care service use between collaborative care and usual care. Collaborative care offered a mean incremental gain of 0.02 (95% CI -0.02 to 0.06) quality-adjusted life-years (QALYs) over 12 months at a mean incremental cost of £270.72 (95% CI -£202.98 to £886.04) and had an estimated mean cost per QALY of £14,248, which is below current UK willingness-to-pay thresholds. Sensitivity analyses including informal care costs indicated that collaborative care is expected to be less costly and more effective. The amount of participant behavioural activation was the only effect mediator. CONCLUSIONS Collaborative care improves depression up to 12 months after initiation of the intervention, is preferred by patients over usual care, offers health gains at a relatively low cost, is cost-effective compared with usual care and is mediated by patient activation. Supervision was by expert clinicians and of short duration and more intensive therapy may have improved outcomes. In addition, one participant requiring inpatient treatment incurred very significant costs and substantially inflated our cost per QALY estimate. Future work should test enhanced intervention content not collaborative care per se. TRIAL REGISTRATION Current Controlled Trials ISRCTN32829227. FUNDING This project was funded by the Medical Research Council (MRC) (G0701013) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.

The predictors of persistent DSM-IV disorders in 3-year follow-ups of the British Child and Adolescent Mental Health Surveys 1999 and 2004.

BACKGROUND The identification of the factors that influence the persistence of psychiatric disorder may assist practitioners to focus on young people who are particularly prone to poor outcomes, but population-based samples of sufficient size are rare. METHOD This secondary analysis combined data from two large, population-based cross-sectional surveys in Great Britain (1999 and 2004) and their respective follow-ups (2002 and 2007), to study homotypic persistence among the 998 school-age children with psychiatric disorder at baseline. Psychiatric disorder was measured using the Development and Well-Being Assessment applying DSM-IV criteria. Factors relating to the child, family, and the severity and type of psychopathology at baseline were analysed using logistic regression. RESULTS Approximately 50% of children with at least one psychiatric disorder were assigned the same diagnostic grouping at 3-year follow-up. Persistent attention-deficit/hyperactivity disorder and anxiety were predicted by poor peer relationship scores. Persistent conduct disorder was predicted by intellectual disability, rented housing, large family size, poor family function and by severer baseline psychopathology scores. CONCLUSIONS Homotypic persistence was predicted by different factors for different groups of psychiatric disorders. Experimental research in clinical samples should explore whether these factors also influence response to interventions.

A Systematic Review and Synthesis of Qualitative Research: The Influence of School Context on Symptoms of Attention Deficit Hyperactivity Disorder.

This systematic review and synthesis of qualitative research explored contextual factors relevant to non-pharmacological interventions for attention deficit hyperactivity disorder (ADHD) in schools. We conducted meta-ethnography to synthesise 34 studies, using theories of stigma to further develop the synthesis. Studies suggested that the classroom context requiring pupils to sit still, be quiet and concentrate could trigger symptoms of ADHD, and that symptoms could then be exacerbated through informal/formal labelling and stigma, damaged self-perceptions and resulting poor relationships with staff and pupils. Influences of the school context on symptoms of ADHD were often invisible to teachers and pupils, with most attributions made to the individual pupil and/or the pupil’s family. We theorise that this ‘invisibility’ is at least partly an artefact of stigma, and that the potential for stigma for ADHD to seem ‘natural and right’ in the context of schools needs to be taken into account when planning any intervention.

The relationship between financial difficulty and childhood symptoms of attention deficit/hyperactivity disorder: a UK longitudinal cohort study

PurposeAttention deficit/hyperactivity disorder (ADHD) is associated with socioeconomic status (SES), in that children who grow up in low SES families are at an increased risk of ADHD symptoms and diagnosis. The current study explores whether different levels of ADHD symptoms are associated with prior changes in the SES facet of financial difficulty.MethodsUsing the Avon Longitudinal Study of Parents and Children (ALSPAC), we examined symptoms of ADHD measured by the Strengths and Difficulties Questionnaire (SDQ) hyperactivity subscale in relation to parent-reported changes in financial difficulty, grouped into four repeated measures at four time points across childhood; (n = 6416). A multilevel mixed-effects linear regression model with an unstructured covariance matrix was used to test whether different patterns of financial difficulty were associated with subsequent changes in ADHD symptoms.ResultsFamilies who had no financial difficulty had children with a lower average ADHD symptom score than groups who experienced financial difficulty. Children whose families stayed in financial difficulty had higher mean ADHD symptom scores than all other groups (No difficulty mean SDQ hyperactivity 3.14, 95% CI 3.07, 3.21, In difficulty mean SDQ hyperactivity 3.39, 95% CI 3.28, 3.45, p < 0.001). Increasing or decreasing financial difficulty predicted mean symptom scores lower than those of the in difficulty group and higher than the no difficulty group.ConclusionsOur findings contribute to the building evidence that SES may influence the severity and/or impairment associated with the symptoms of ADHD, however the effects of SES are small and have limited clinical significance.

Educational Practitioners' Beliefs and Conceptualisation about the Cause of ADHD: A Qualitative Study.

Objectives: Educational practitioners play an important role in the referral and treatment of children with attention-deficit/hyperactivity disorder (ADHD). This study aimed to explore how educational practitioners conceptualise their beliefs about the causes of symptoms of ADHD. Method: Forty-one educational practitioners from schools in the United Kingdom participated in focus groups or individual interviews. Data were analysed using thematic analysis. Results: Practitioners’ beliefs fell into two categories: biological and environmental. Practitioners conceptualised the causes of ADHD in lay-theoretical models: a ‘True’ ADHD model considered that symptoms of ADHD in many cases were due to adverse environments; and a model whereby a biological predisposition is the root of the cause of the child’s symptoms. Conclusion: Differential beliefs about the causes of ADHD may lead to practitioners blaming parents for a child’s behaviour and discounting ADHD as a valid condition. This has implications for the effective support of children with ADHD in schools.