Vibhore Prasad

ADHD in children and young people: prevalence, care pathways, and service provision

Attention-deficit hyperactivity disorder (ADHD) is a common childhood behavioural disorder. Systematic reviews indicate that the community prevalence globally is between 2% and 7%, with an average of around 5%. At least a further 5% of children have substantial difficulties with overactivity, inattention, and impulsivity that are just under the threshold to meet full diagnostic criteria for ADHD. Estimates of the administrative prevalence (clinically diagnosed or recorded) vary worldwide, and have been increasing over time. However, ADHD is still relatively under-recognised and underdiagnosed in most countries, particularly in girls and older children. ADHD often persists into adulthood and is a risk factor for other mental health disorders and negative outcomes, including educational underachievement, difficulties with employment and relationships, and criminality. The timely recognition and treatment of children with ADHD-type difficulties provides an opportunity to improve long-term outcomes. This Review includes a systematic review of the community and administrative prevalence of ADHD in children and adolescents, an overview of barriers to accessing care, a description of associated costs, and a discussion of evidence-based pathways for the delivery of clinical care, including a focus on key issues for two specific age groups-younger children (aged ≤6 years) and adolescents requiring transition of care from child to adult services.

Injury Among Children and Young Adults With Epilepsy

OBJECTIVE: To investigate whether children and young adults with epilepsy are at a greater risk of fracture, thermal injury, or poisoning than those without. METHODS: A cohort study was conducted by using the Clinical Practice Research Datalink (1987–2009), a longitudinal database containing primary care records. A total of 11 934 people with epilepsy and 46 598 without, aged between 1 and 24 years at diagnosis, were followed for a median (interquartile range) of 2.6 (0.8–5.9) years. The risk of fractures (including long bone fractures), thermal injuries, and poisonings (including medicinal and nonmedicinal poisonings) was estimated. RESULTS: Adjusting for age, gender, Strategic Health Authority region, deprivation, and calendar year at study entry (and, for medicinal poisonings, behavior disorder), people with epilepsy had an 18% increase in risk of fracture (hazard ratio [HR] = 1.18; 95% confidence interval [CI], 1.09–1.27), a 23% increase in risk of long bone fracture (HR = 1.23; 95% CI, 1.10–1.38), a 49% increase in risk of thermal injury (HR = 1.49; 95% CI, 1.27–1.75), and more than twice the risk of poisoning (HR = 2.47; 95% CI, 2.15–2.84), which was limited to poisoning from medicinal products (medicinal HR = 2.54; 95% CI, 2.16–2.99; nonmedicinal HR = 0.96; 95% CI, 0.61–1.52). CONCLUSIONS: Children and young adults with epilepsy are at a greater risk of fracture, thermal injury, and poisoning than those without. The greatest risk is from medicinal poisonings. Doctors and other health care professionals should provide injury and poison prevention advice at diagnosis and epilepsy reviews.

Parental poison prevention practices and their relationship with perceived toxicity: cross-sectional study

Objective: To describe poison prevention practices for a range of substances and explore the relationship between prevention practices and perceptions of toxicity. Design: Cross-sectional study using a validated postal questionnaire. Participants: Parents with children aged 12–35 months on 23 health visitors’ caseloads. Setting: Areas of various levels of deprivation in Nottingham, UK. Main outcome measures: Possession and storage of substances, putting substances away immediately after use, and perceptions of toxicity. Results: Dishwasher tablets (68%), toilet cleaner (71%), bleach (74%), oven cleaner (78%), oral contraceptives (80%), and essential oils (81%) were least likely to be stored safely. Children’s painkillers (69%), cough medicine (72%), and essential oils (77%) were least likely to be put away immediately after use. More than 50% of parents perceived antibiotics and oral contraceptives as harmful in small quantities and cough medicines as harmful only in large quantities. Six substances perceived by parents to be more harmful were more likely to be put away immediately after use. Parents perceiving dishwasher tablets (OR 1.96, 95% CI 1.05 to 3.66), essential oils (OR 2.80, 95% CI 1.35 to 5.81), turpentine (OR 14.54, 95% CI 2.75 to 76.95), and rat/ant killer (OR 15.33, 95% CI 2.01 to 116.82) as more harmful were more likely to store these substances safely. Conclusions: Parents’ perceptions of toxicity of substances were sometimes inaccurate. Perceived toxicity was associated with putting substances away immediately after use for six substances and with safe storage for four substances. The effect of addressing perceptions of toxicity on poison prevention practices requires evaluation.

Are topical antibiotics an alternative to oral antibiotics for children with acute otitis media and ear discharge

#### What you need to know Acute otitis media (AOM) is a common reason for childhood primary care visits and antibiotic prescription in the United Kingdom.1 2 Many randomised controlled trials (RCTs) have shown that symptoms settle within a few days, irrespective of antibiotic use,3 with one systematic review reporting that ear pain takes eight days to resolve fully in 90% of children.4 However observational data and an individual patient data meta-analysis showed that, among children with AOM, those with ear discharge have a worse prognosis5 and a more prolonged duration of ear pain or fever than those without ear discharge.6 Current guidance from the UK National Institute for Health and Care Excellence recommends that general practitioners consider immediately prescribing oral antibiotics for children presenting with AOM and ear discharge.7 However, oral antibiotics commonly have side effects such as diarrhoea, vomiting, and rashes3 and increase the risk of antimicrobial resistance.8 For children with AOM and ear discharge, topical antibiotics are a possible alternative because they put less selective resistance pressure on bacteria and eardrum perforation allows direct entry of the antibiotic into the middle ear, without exposing children to systemic side effects.9 However the risk of ototoxicity is debated.10 11 To our knowledge, no RCTs or relevant systematic reviews of the effectiveness of topical antibiotics for children with AOM and ear discharge have been published. ### Oral antibiotics By contrast, individual patient data meta-analysis evidence shows that oral antibiotics are more effective than …

Barriers to medication entitlements after diagnosis of ADHD – Authors' reply

www.thelancet.com/psychiatry Vol 5 January 2018 19 not be minimised, the problem is a global one impacting on the health of children and young people across the world. Data from countries such as Australia highlight that this is not only an issue for children and young people with ADHD but is a wider problem across child and adolescent mental health with barriers to care for both pharmacological and nonpharmacological interventions. 2 Although cost is likely to be an important barrier in many situations, there are, of course, many other factors at play. Further research is required to tease these barriers out more clearly and then to develop and implement specific strategies to resolve them, as was done so effectively in Ireland.

Attention-deficit/hyperactivity disorder: variation by socioeconomic deprivation

Background In England, there is a discrepancy between the prevalence of attention-deficit/hyperactivity disorder (ADHD) ascertained from medical records and community surveys. There is also a lack of data on variation in recorded prevalence by deprivation and geographical region; information that is important for service development and commissioning. Methods Cohort study using data from the Clinical Practice Research Datalink comprising 5196 children and young people aged 3–17 years with ADHD and 490 016 without, in 2012. Results In 2012, the recorded prevalence of ADHD was 1.06% (95% CI 1.03 to 1.09). Prevalence in the most deprived areas was double that of the least deprived areas (prevalence rate ratio 2.58 (95% CI 2.36 to 2.83)), with a linear trend from least to most deprived areas across all regions in England. Conclusions The low prevalence of ADHD in medical records may indicate considerable underdiagnosis. Higher rates in more disadvantaged areas indicate greater need for services in those areas.

Using the plan–do–study–act (PDSA) cycle to make change in general practice

As new members of the team, GP trainees can provide a fresh perspective on practice systems. They are, therefore, ideally placed to enact change within practices. However, GP trainees may feel ill-equipped to suggest and deliver change to their practices. This article will explore the concept of change management using the plan–do–study–act cycle and consider how to initiate change by providing a structure to guide the process.

355 The risk of injuries in children with Attention deficit-hyperactivity disorder (ADHD) in England

Background Attention deficit-hyperactivity disorder (ADHD) is a common in children with a prevalence of 5%. Injuries are common and are a leading cause of morbidity and mortality in England and worldwide. ADHD may be associated with an increased risk of injuries but accurate and detailed risk estimates are lacking. Methods A cohort study was conducted using primary care and hospital records from the Clinical Practice Research Datalink (CPRD) (1998 to 2012). All children with ADHD (aged 3 to 17 years) were frequency-matched, by age band, to up to twenty children without ADHD. Hazard ratios for (long bone) fractures, thermal injuries and poisonings were estimated using Cox regression and adjusted for age, sex, strategic health authority region, area-level deprivation quintile (measured using Index of Multiple Deprivation) and the calendar year when the child entered the study. Results There were 15,737 children with and 291,894 without ADHD. 84.6% with ADHD were boys compared to 50.7% without ADHD. The adjusted risk of fractures in children with ADHD was 28% greater than in children without (HR = 1.28 (1.22 to 1.35)). The adjusted risk of thermal injuries in children with ADHD was more than double the risk in children without (HR = 2.04 (1.80 to 2.31)). The adjusted risk of poisonings was nearly 4 times greater in children with ADHD compared to children without (HR = 3.99 (3.58 to 4.44)). The adjusted risk of long bone fractures was similar to the risk of any fractures (HR = 1.23 (1.16 to 1.31)). Conclusions Children with ADHD are at a greater risk of fractures, thermal injuries and poisonings than children without. All services involved in the care and education of children with ADHD should be aware of the risks. The estimated risks of injury should be communicated to children and their parents at the time of diagnosis, medication reviews and follow-up visits.