Cynthia Wilson Garvan

Parent and Teacher SNAP-IV Ratings of Attention Deficit Hyperactivity Disorder Symptoms: Psychometric Properties and Normative Ratings from a School District Sample.

To examine Swanson, Nolan, and Pelham—IV (SNAP-IV) psychometric properties, parent (N = 1,613) and teacher (N = 1,205) data were collected from a random elementary school student sample in a longitudinal attention deficit hyperactivity disorder (ADHD) detection study. SNAP-IV reliability was acceptable. Factor structure indicated two ADHD factors and an oppositional defiant disorder (ODD) factor. Parent and teacher scores varied by gender and poverty status (d = .49-.56) but not age; only teacher scores varied by race (d = .25-.55). Screening and diagnostic utility was evaluated with likelihood ratios (LRs) and posttest probabilities. Parent SNAP-IV scores above 1.2 increased probability of concern (LR > 10) and above 1.8, of ADHD diagnosis (LR > 3). Teacher hyperactivity/impulsivity scores above 1.2 and inattention scores above 1.8 increased probabilities of concern only (LR = 4.2 and >5, respectively). Higher teacher scores for African American children and race differences in measurement models require future study.

Anteroposterior skeletal and dental changes after early Class II treatment with bionators and headgear.

In this study we examined anteroposterior cephalometric changes in children enrolled in a randomized controlled trial of early treatment for Class II malocclusion. Children, aged 9.6 +/- 0.8 years at the start of study, were randomly assigned to control (n = 81), bionator (n = 78), and headgear/biteplane (n = 90) treatments. Cephalograms were obtained initially, after Class I molars were obtained or 2 years had elapsed, after an additional 6 months during which treated subjects were randomized to retention or no retention and after a final 6 months without appliances. Calibrated examiners, blinded to group, used Johnstons analysis to measure anteroposterior cephalometric changes. Statistical analysis was used to determine annual skeletal and dental changes during treatment, retention, and follow-up, and overall. Our data reveal that both bionator and head-gear treatments corrected Class II molar relationships, reduced overjets and apical base discrepancies, and caused posterior maxillary tooth movement. The skeletal changes, largely attributable to enhanced mandibular growth in both headgear and bionator subjects, were stable a year after the end of treatment, but dental movements relapsed.

Barriers to detection, help-seeking, and service use for children with ADHD symptoms.

This study describes 4 help-seeking steps among children at high risk for attention deficit hyperactivity disorder (ADHD), and identifies barriers to ADHD symptom detection and treatment. Using a district-wide stratified random sample of 1615 elementary school students screened for ADHD risk, predictors of 4 help-seeking steps among a high-risk group (n=389) and parent-identified barriers to care among children with unmet need for ADHD care (n=91) were assessed. Study findings indicate that although 88% of children were recognized as having a problem, only 39% had been evaluated, 32% received an ADHD diagnosis, and 23% received current treatment. Older children and those with more severe behavior problems were more likely to be perceived by their parents as having a problem. Additionally, gender and ethnic disparities in the subsequent help-seeking process emerged. Boys had over 5 times the odds than girls of receiving an evaluation, an ADHD diagnosis, and treatment. Compared to African American youth, Caucasian children had twice the odds of taking these help-seeking steps. For those children with unmet need for ADHD care, poverty predicted lower treatment rates and was associated with the most pervasive barriers. The gap between parental problem recognition and seeking services suggests that thresholds for parental recognition of a child behavior problem and for seeking ADHD services may be different. Future research examining the help-seeking process for ADHD should include a qualitative component to explore the potential mechanisms for gender and ethnic differences.

Adolescent Outcomes of Childhood Attention-Deficit/Hyperactivity Disorder in a Diverse Community Sample

OBJECTIVE To describe adolescent outcomes of childhood attention-deficit/hyperactivity disorder (ADHD) in a diverse community sample. METHOD ADHD screening of a school district sample of 1,615 students aged 5 to 11 years was followed by a case-control study 8 years later. High-risk youths meeting full (n = 94) and subthreshold (n = 75) DSM-IV ADHD criteria were matched with demographically similar low-risk peers (n = 163). Outcomes domains included symptom, functional impairment, quality of life, substance use, educational outcomes, and juvenile justice involvement. RESULTS In all, 44% of youths with childhood ADHD had not experienced remission. Compared with unaffected peers, adolescents with childhood ADHD were more likely to display oppositional defiant disorder (odds ratio [OR] = 12.9, 95% confidence interval [CI] 5.6-30.0), anxiety/depression (OR = 10.3, 95% CI 2.7-39.3), significant functional impairment (OR = 3.4, 95% CI 1.7-6.9), reduced quality of life (OR = 2.5, 95% CI 1.3-4.7), and involvement with the juvenile justice system (OR = 3.1, 95% CI 1.0-9.1). Subthreshold ADHD, but not full ADHD, increased the risk of grade retention, whereas both conditions increased the risk of graduation failure. Oppositional defiant disorder (ODD), but not childhood ADHD, increased the risk of cannabis and alcohol use. None of the adolescent outcomes of childhood ADHD were moderated by gender, race or poverty. CONCLUSIONS ADHD heralds persistence of ADHD and comorbid symptoms into adolescence, as well as significant risks for functional impairment and juvenile justice involvement. Subthreshold ADHD symptoms typically do not qualify affected students for special educational interventions, yet increase the risk for adverse educational outcomes. Findings stress the importance of early ADHD recognition, especially its comorbid presentation with ODD, for prevention and intervention strategies.

Type and Severity of Cognitive Decline in Older Adults after Noncardiac Surgery

Background:The authors investigated type and severity of cognitive decline in older adults immediately and 3 months after noncardiac surgery. Changes in instrumental activities of daily living were examined relative to type of cognitive decline. Methods:Of the initial 417 older adults enrolled in the study, 337 surgery patients and 60 controls completed baseline, discharge, and/or 3-month postoperative cognitive and instrumental activities of daily living measures. Reliable change methods were used to examine three types of cognitive decline: memory, executive function, and combined executive function/memory. SD cutoffs were used to grade severity of change as mild, moderate or severe. Results:At discharge, 186 (56%) patients experienced cognitive decline, with an equal distribution in type and severity. At 3 months after surgery, 231 patients (75.1%) experienced no cognitive decline, 42 (13.6%) showed only memory decline, 26 (8.4%) showed only executive function decline, and 9 (2.9%) showed decline in both executive and memory domains. Of those with cognitive decline, 36 (46.8%) had mild, 25 (32.5%) had moderate, and 16 (20.8%) had severe decline. The combined group had more severe impairment. Executive function or combined (memory and executive) deficits involved greater levels of functional (i.e., instrumental activities of daily living) impairment. The combined group was less educated than the unimpaired and memory groups. Conclusion:Postsurgical cognitive presentation varies with time of testing. At 3 months after surgery, more older adults experienced memory decline, but only those with executive or combined cognitive decline had functional limitations. The findings have relevance for patients and caregivers. Future research should examine how perioperative factors influence neuronal systems.

Parental explanatory models of ADHD: gender and cultural variations.

This study describes parents’ explanatory models of Attention Deficit Hyperactivity Disorder (ADHD) and examines model variation by child characteristics. Children with ADHD (N = 182) were identified from a school district population of elementary school students. A reliable coding system was developed for parental responses obtained in ethnographic interviews in order to convert qualitative into numerical data for quantitative analysis. African-American parents were less likely to connect the school system to ADHD problem identification, expressed fewer worries about ADHD-related school problems, and voiced fewer preferences for school interventions than Caucasian parents, pointing to a potential disconnect with the school system. More African-American than Caucasian parents were unsure about potential causes of and treatments for ADHD, indicating a need for culturally appropriate parent education approaches.

Correlations of oral bacterial arginine and urea catabolism with caries experience

BACKGROUND/AIM Alkali generation by oral bacteria plays a key role in plaque pH homeostasis and may be a major impediment to the development of dental caries. To determine if the capacity of oral samples to produce ammonia from arginine or urea was related to caries experience, the arginine deiminase system (ADS) and urease activity in saliva and dental plaque samples were measured in 45 adult subjects. METHODS The subjects were divided into three groups according to caries status; 13 caries-free (CF) individuals (decayed, missing, and filled teeth = 0); 21 caries-active (CA) individuals (decayed teeth >or= 4); and 11 caries-experienced (CE) individuals (decayed teeth = 0; missing and filled teeth > 0). Real-time polymerase chain reaction was used to quantify the proportion of certain acid- or alkali-producing organisms in the samples. RESULTS The amount of ammonia generated from the test substrates by plaque samples was generally higher than that produced by salivary samples in all groups. Significantly higher levels of salivary ADS activity and plaque urease activity were observed in CF subjects compared to CA subjects (P = 0.0004 and P = 0.014, respectively). The proportions of Streptococcus mutans from saliva and dental plaque of CA subjects were significantly higher than those from the CF group (P = 0.0153 and P = 0.0009, respectively). In the CA group, there was an inverse relationship between urease activity and the levels of S. mutans (P < 0.0001). CONCLUSION This study supports the theory that increased caries risk is associated with reduced alkali-generating capacity of the bacteria colonizing the oral cavity; providing compelling evidence to further our understanding of oral alkali-generation in health and disease.

Diffusion Tensor Imaging of Frontal White Matter and Executive Functioning in Cocaine-Exposed Children

BACKGROUND. Although animal studies have demonstrated frontal white matter and behavioral changes resulting from prenatal cocaine exposure, no human studies have associated neuropsychological deficits in attention and inhibition with brain structure. We used diffusion tensor imaging to investigate frontal white matter integrity and executive functioning in cocaine-exposed children. METHODS. Six direction diffusion tensor images were acquired using a Siemens 3T scanner with a spin-echo echo-planar imaging pulse sequence on right-handed cocaine-exposed (n = 28) and sociodemographically similar non-exposed children (n = 25; mean age: 10.6 years) drawn from a prospective, longitudinal study. Average diffusion and fractional anisotropy were measured in the left and right frontal callosal and frontal projection fibers. Executive functioning was assessed using two well-validated neuropsychological tests (Stroop color-word test and Trail Making Test). RESULTS. Cocaine-exposed children showed significantly higher average diffusion in the left frontal callosal and right frontal projection fibers. Cocaine-exposed children were also significantly slower on a visual-motor set-shifting task with a trend toward lower scores on a verbal inhibition task. Controlling for gender and intelligence, average diffusion in the left frontal callosal fibers was related to prenatal exposure to alcohol and marijuana and an interaction between cocaine and marijuana exposure. Performance on the visual-motor set-shifting task was related to prenatal cocaine exposure and an interaction between cocaine and tobacco exposure. Significant correlations were found between test performance and fractional anisotropy in areas of the frontal white matter. CONCLUSIONS. Prenatal cocaine exposure, alone and in combination with exposure to other drugs, is associated with slightly poorer executive functioning and subtle microstructural changes suggesting less mature development of frontal white matter pathways. The relative contribution of postnatal environmental factors, including characteristics of the caregiving environment and stressors associated with poverty and out-of-home placement, on brain development and behavioral functioning in polydrug-exposed children awaits further research.

Brain penetration effects of microelectrodes and DBS leads in STN or GPi

Objective: To determine how intraoperative microelectrode recordings (MER) and intraoperative lead placement acutely influence tremor, rigidity, and bradykinesia. Secondarily, to evaluate whether the longevity of the MER and lead placement effects were influenced by target location (subthalamic nucleus (STN) or globus pallidus interna (GPi)). Background: Currently most groups who perform deep brain stimulation (DBS) for Parkinson disease (PD) use MER, as well as macrostimulation (test stimulation), to refine DBS lead position. Following MER and/or test stimulation, however, there may be a resultant “collision/implantation” or “microlesion” effect, thought to result from disruption of cells and/or fibres within the penetrated region. These effects have not been carefully quantified. Methods: 47 consecutive patients with PD undergoing unilateral DBS for PD (STN or GPi DBS) were evaluated. Motor function was measured at six time points with a modified motor Unified Parkinson Disease Rating Scale (UPDRS): (1) preoperatively, (2) immediately after MER, (3) immediately after lead implantation/collision, (4) 4 months following surgery—off medications, on DBS (12 h medication washout), (5) 6 months postoperatively—off medication and off DBS (12 h washout) and (6) 6 months—on medication and off DBS (12 h washout). Results: Significant improvements in motor scores (p<0.05) (tremor, rigidity, bradykinesia) were observed as a result of MER and lead placement. The improvements were similar in magnitude to what was observed at 4 and 6 months post-DBS following programming and medication optimisation. When washed out (medications and DBS) for 12 h, UPDRS motor scores were still improved compared with preoperative testing. There was a larger improvement in STN compared with GPi following MER (p<0.05) and a trend for significance following lead placement (p<0.08) but long term outcome was similar. Conclusion: This study demonstrated significant acute intraoperative penetration effects resulting from MER and lead placement/collision in PD. Clinicians rating patients in the operating suite should be aware of these effects, and should consider pre- and post-lead placement rating scales prior to activating DBS. The collision/implantation effects were greater intraoperatively with STN compared with GPi, and with greater disease duration there was a larger effect.

Child Temperament, ADHD, and Caregiver Strain: Exploring Relationships in an Epidemiological Sample

OBJECTIVE To investigate the relationship between child-reported dimensions of temperament and attention-deficit/ hyperactivity disorder (ADHD), as well as other indicators of child psychopathology, including disruptive disorders, depression, and anxiety. It also examined whether difficult child temperament scores independently predicted caregiver strain. METHOD A school-district-wide, two-phase screening design (response rate 70% for phase 2) identified elementary school children at high risk for ADHD. Two hundred high-risk children and their parents completed standardized instruments to assess child temperament, diagnoses of disruptive disorders, childrens symptoms of anxiety and depression, and caregiver strain. Relationships were examined using analysis of variance, correlations, and multivariate prediction models, adjusting for child sociodemographic characteristics and psychopathology. All estimates were weighted for sampling design and differential participation. RESULTS Combined subtype ADHD was associated with lower scores on task orientation and higher scores on general activity level. Depressive symptoms correlated significantly with all but one difficult temperament dimension, in a pattern consistent with clinical symptoms of depression. Child temperament did not vary by ADHD treatment status. Among these high-risk children, maternal caregiver strain experiences were increased by male gender, inattention symptoms, and oppositional defiant disorder, but not by difficult temperament scores. CONCLUSION This study provides support for Graham and Stevensons hypothesis of continuity between specific temperament traits and certain child psychiatric disorders, namely ADHD and depressive disorders.