Faculty Bibliography

Attention-deficit/hyperactivity disorder (ADHD) was once thought to be solely a childhood condition. Now it is well established that it can persist into adulthood, with an estimated worldwide prevalence of around 2.5%. Additionally, up to 70% of individuals with childhood-onset ADHD continue to experience impairing symptoms as adults, even if they no longer meet the criteria for a formal diagnosis. The validity of adult ADHD initially faced strong criticism. Today, empirical research supports its descriptive validity (identifying characteristic signs and symptoms), predictive validity (concerning specific outcomes, courses, and responses to treatment), and concurrent validity (evidence related to its underlying causes and biological mechanisms). Despite this progress, unresolved questions and ongoing debates about adult ADHD persist. This paper summarizes current empirical evidence, alongside uncertainties and controversies, regarding the definition, epidemiology, diagnosis, etiology, neurobiology, and management of ADHD in adults. Crucially, we also include perspectives from individuals with lived experience of this condition, highlighting their views on unmet needs and priorities for improving care. Key uncertainties and controversies on adult ADHD include: a) the possibility of late-onset ADHD; b) the significance of emotional dysregulation as a core symptom; c) the definition and characterization of functional impairment; d) the persistence of comorbid psychiatric and somatic conditions after accounting for confounders; e) the relevance of executive dysfunction in the definition of the condition; f) the use of objective diagnostic measures; g) the long-term effects of treatments; and h) the role of non-pharmacological interventions. Further research on adult ADHD is urgently needed. Funding for studies on this condition lags behind that for childhood ADHD and other mental disorders in adulthood. Hopefully, efforts by clinicians, researchers and other stakeholders will ultimately help ensure that adults with ADHD are better understood, supported, and empowered to thrive.

Maternal mental health during the perinatal period has been linked to the development of infant emotion regulation capacity, largely through its impact on caregiver-infant interactions during the first year of life. The majority of studies have focused on the effects of maternal depression, even though maternal anxiety is more prevalent and its effects on infant outcomes are less well understood. The current study aims to 1) explore differences in infant affect and regulatory behaviors across two commonly implemented infant stress-induction paradigms and 2) evaluate the differential effects of depression and anxiety on infant regulatory behaviors. Six-month-old infants and their mothers (N = 126) completed two tasks remotely in the home: the Arm Restraint task and the Still-Face Paradigm. Maternal depression and anxiety symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS) subscales. Within-person results indicated no significant associations among infant regulatory behaviors nor infant reactivity across the two paradigms. Additionally, no significant associations were found between maternal mental health and infant regulatory behaviors during the Still-Face Paradigm. However, higher EPDS composite scores were associated with fewer infant avoidance behaviors during the Arm Restraint task, and this result was driven by items on the anxiety subscale. These findings suggest that infant regulatory behaviors may differ depending on task used and may also be influenced by subclinical levels of maternal anxiety, but not maternal depression.

OBJECTIVE:This study aimed at identifying moderators of efficacy of stimulants against placebo to inform personalized recommendations for treatment in preschool children (< 6 years) with attention-deficit/hyperactivity disorder (ADHD). METHOD/METHODS:We acquired individual-level participant data from two randomized placebo-controlled trials (RCTs) of preschool ADHD: MAPPA (8-week methylphenidate, 102 participants, Brazil) and SPD489-347 (6-week lisdexamfetamine, 148 participants, US). We evaluated the moderator and predictor effects of baseline demographic (age, sex, race, ethnicity, maternal educational level) and baseline clinical (ADHD symptom severity, intelligence quotient, number of psychiatric comorbidities) characteristics, as available, on endpoint ADHD symptom severity scores. Data from each study were analyzed separately with linear mixed-effects model for repeated measures. For categorical variables, we also computed treatment effects (i.e., stimulants versus placebo) within subgroups and, when possible, pooled them alongside subgroup data from PATS (5-week methylphenidate, 165 participants, US) in random-effects meta-analyses. RESULTS:Stimulants had greater efficacy against placebo in White children compared to Black children considering data from US studies. Older age was not a moderator of greater efficacy of stimulants against placebo, nor was it associated with worse ADHD symptom severity at endpoint. Greater baseline ADHD symptom severity was associated with higher ADHD symptom severity at endpoint independently of the assigned treatment group. CONCLUSION/CONCLUSIONS:Race, but not older age or baseline ADHD symptom severity, may moderate the efficacy of stimulants for preschool ADHD. Given the post hoc nature of subgroup analyses, the findings should be interpreted as exploratory and viewed as hypothesis for confirmation in future studies.

IMPORTANCE/UNASSIGNED:The comparative effectiveness of 2 transitions of care programs for improving health status and reducing readmissions among patients hospitalized with heart failure is unknown. OBJECTIVE/UNASSIGNED:To compare the effectiveness adding mobile integrated health (MIH) to a transitions of care coordinator for improving health status and reducing 30-day all-cause readmissions among patients discharged after heart failure. DESIGN, SETTINGS, AND PARTICIPANTS/UNASSIGNED:The Mighty-Heart randomized clinical trial included Medicare- or Medicaid-enrolled adult (≥18 years) patients hospitalized with heart failure in 11 New York City (New York) hospitals between January 2021 and September 2024. Participants were randomized 1:1 to MIH or TOCC. TOCC provided a follow-up call by a nurse 48 to 72 hours after discharge. MIH included the same TOCC postdischarge call, and added ongoing nurse care coordination, community paramedic home visits, and facilitated synchronous telehealth with emergency medicine physicians. Data analysis occurred between September 2024 and June 2025. INTERVENTIONS/UNASSIGNED:Receiving MIH plus TOCC or TOCC alone during the first 30 days after hospital discharge. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Coprimary outcomes were health status at 30 days measured with the Kansas City Cardiomyopathy Questionnaire Overall Summary score, and 30-day all-cause hospital readmission, with heart failure-specific readmissions as a secondary outcome. RESULTS/UNASSIGNED:Among 2003 participants (median [IQR] age, 67 [58-78] years; 1040 female [52%]), no adjusted differences were observed in the Kansas City Cardiomyopathy Questionnaire Overall Summary score at 30 days between MIH and TOCC groups (mean difference, 1.83; 95% CI, -0.75 to 4.40; P = .16). Exploratory analysis showed a significant age-by-treatment interaction effect, with younger participants who received MIH having larger improvement in health status (β: 4.40; 95% CI, 1.01 to 7.79). There were no significant differences in overall 30-day readmissions between study groups (20.3% vs 20.4%; odds ratio, 0.99; 95% CI, 0.83 to 1.19; P = .95). CONCLUSIONS AND RELEVANCE/UNASSIGNED:This randomized clinical trial found that MIH conferred no additional benefit on health status or 30-day readmissions for postacute patients with heart failure compared to TOCC alone. Preliminary subgroup analyses suggest potential variations in MIH effects by age and sex; therefore, further research is warranted. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT04662541.

IMPORTANCE/UNASSIGNED:Studies suggest developmental concerns for infants born during the COVID-19 pandemic, but evidence on its impact on toddler behavioral and emotional well-being remains limited. OBJECTIVE/UNASSIGNED:To assess whether birth timing relative to the COVID-19 pandemic is associated with toddler internalizing and externalizing problems. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This retrospective cohort study utilized Environmental Influences on Child Health Outcomes (ECHO) cohort data collected between September 27, 2009, and July 21, 2023. Children were divided into 3 groups: the prepandemic group, who were born and assessed before March 13, 2020; the pandemic-assessed group, who were born before March 13, 2020, but assessed after that date; and the pandemic-born group, who were born and assessed on or after March 13, 2020. Data were collected from 9 ECHO cohort sites across the United States and Puerto Rico. EXPOSURE/UNASSIGNED:The COVID-19 pandemic, designated as starting on March 13, 2020. MAIN OUTCOME AND MEASURE/UNASSIGNED:Parent-reported internalizing and externalizing symptoms on the Preschool Child Behavior Checklist (CBCL 1½-5) at age 18 to 39 months. RESULTS/UNASSIGNED:The 3438 children (mean [SD] age, 2.33 years [5.38 months]; 1770 [51.5%] male; 537 [16.2%] Black, 1722 [50.1%] Hispanic; and 1538 [44.7%] White) were divided into 3 groups: 1323 in the prepandemic group (mean [SD] age, 2.41 years [5.66 months]); 1690 in the pandemic-assessed group (mean [SD] age, 2.32 years [5.16 months]); and 425 in the pandemic-born group (mean [SD] age, 2.14 years [4.47 months]). Both the pandemic-assessed group (unadjusted β = -1.51; 95% CI, -2.27 to -0.75; adjusted β = -1.73; 95% CI, -2.48 to -0.99) and the pandemic-born group (unadjusted β = -2.03; 95% CI, -3.13 to -0.93; adjusted β = -1.90; 95% CI, -2.99 to -0.80) had lower levels of internalizing problems compared with the prepandemic (ie, historical) group. Similarly, both the pandemic-assessed (unadjusted β = -1.74; 95% CI, -2.46 to -1.02; adjusted β = -1.81; 95% CI, -2.53 to -1.09) and the pandemic-born group (unadjusted β = -3.16; 95% CI, -4.20 to -2.12; adjusted β = -3.17; 95% CI, -4.22 to -2.12) each had lower levels of externalizing problems compared with the prepandemic group. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this study, toddlers with prenatal and postnatal as well as those with only postnatal COVID-19 pandemic exposure showed fewer internalizing and externalizing problems than those born and assessed prior to the onset of the pandemic. These findings underscore the need for further research to identify protective factors that may buffer the impact of the pandemic on child behavior.

The use of complementary, alternative and integrative medicine (CAIM) is highly prevalent among autistic individuals, with up to 90% reporting having used CAIM at least once in their lifetime. However, the evidence base for the effects of CAIM for autism remains uncertain. Here, to fill this gap, we conducted an umbrella review of meta-analyses exploring the effects of CAIM in autism across the lifespan and developed a web platform to disseminate the generated results. Five databases were searched (up to 31 December 2023) for systematic reviews with meta-analyses exploring the effects of CAIM in autism. Independent pairs of investigators identified eligible papers and extracted relevant data. Included meta-analyses were reestimated using a consistent statistical approach, and their methodological quality was assessed with AMSTAR-2. The certainty of evidence generated by each meta-analysis was appraised using an algorithmic version of the GRADE framework. This process led to the identification of 53 meta-analytic reports, enabling us to conduct 248 meta-analyses exploring the effects of 19 CAIMs in autism. We found no high-quality evidence to support the efficacy of any CAIM for core or associated symptoms of autism. Although several CAIMs showed promising results, they were supported by very low-quality evidence. The safety of CAIMs has rarely been evaluated, making it a crucial area for future research. To support evidence-based consideration of CAIM interventions for autism, we developed an interactive platform that facilitates access to and interpretation of the present results ( https://ebiact-database.com ).

STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVE:Due to proximity of the surgical site to important respiratory structures, patients may undergo delayed extubation after adult cervical deformity (ACD) surgery to manage postoperative airway edema/obstruction. Herein, we evaluate relevant relationships with delayed extubation. SUMMARY OF BACKGROUND DATA/BACKGROUND:Delayed extubation is an underreported perioperative occurrence, with only a few studies conducting case-by-case reviews of prolonged intubation. METHODS:Operative ACD patients with baseline (BL) were grouped based on whether they experienced delayed extubation (DE), or leaving the OR while still intubated, versus those who were extubated successfully in the OR (non-DE). Means comparison and regression analyses identified predictors of delayed extubation and associations with peri-operative complications and outcomes. RESULTS:82 patients met inclusion criteria (mean age 62.4±13.0 y, 52.4% female, Edmonton frailty score: 5.10±2.97, ACFI score: 0.30±0.16, CCI: 1.41±1.73). 14 patients left the OR intubated, and 1(1.2%) required reintubation. DE cohort demonstrated greater Edmonton frailty scores (P=0.017) and smoking histories (P=0.031). Intraoperatively, there was a significant difference EBL (P=0.021) and rate of transfusions (DE: 27.3% v non-DE: 4.8%, P=0.12). Upper instrumented vertebra (UIV) was not associated with DE, while lower LIV increased the likelihood of DE (OR 1.1, P=0.029). Post-operatively, as expected, there was a significant difference in rate of SICU admissions (DE: 90.9% v. non-DE: 49.2%, P=0.01), although no significant differences in LOS. Greater cSVA and MGS correction from baseline was associated with increased likelihood of delayed extubation (OR 1.1, CI 95% 1.05-1.17, P<.001; OR 1.14, CI 95% 1.05-1.24, P=0.003). Furthermore, delayed extubation was a significant predictor of increased VR-Physical Component Scores (P=0.013) at 6W, and DE cohort demonstrated significantly higher VR-PCS and VR-MCS Scores at 6W (P=0.01, both). CONCLUSIONS:Baseline frailty and larger radiographic correction can be associated with delayed extubation, which can impact quality of life perioperatively. Considerations like minimizing intraoperative blood loss and degree of correction could minimize delayed extubation.

OBJECTIVE:To examine the effects of drug treatment for attention deficit/hyperactivity disorder (ADHD) on suicidal behaviours, substance misuse, accidental injuries, transport accidents, and criminality. DESIGN/METHODS:Emulation of target trials. SETTING/METHODS:Linkage of national registers in Sweden, 2007-20. PARTICIPANTS/METHODS:People aged 6-64 years with a new diagnosis of ADHD, who either started or did not start drug treatment for ADHD within three months of diagnosis. MAIN OUTCOME MEASURES/METHODS:First and recurrent events of five outcomes over two years after ADHD diagnosis: suicidal behaviours, substance misuse, accidental injuries, transport accidents, and criminality. RESULTS:90.1 per 1000 person years; incidence rate ratio 0.98, 0.96 to 1.01). The reduced rates were more pronounced among individuals with previous events, with incidence rate ratios ranging from 0.79 (0.72 to 0.86) for suicidal behaviours to 0.97 (0.93 to 1.00) for accidental injuries. For recurrent events, drug treatment for ADHD was significantly associated with reduced rates of all five outcomes, with incidence rate ratios of 0.85 (0.77 to 0.93) for suicidal behaviours, 0.75 (0.72 to 0.78) for substance misuse, 0.96 (0.92 to 0.99) for accidental injuries, 0.84 (0.76 to 0.91) for transport accidents, and 0.75 (0.71 to 0.79) for criminality. CONCLUSIONS:Drug treatment for ADHD was associated with beneficial effects in reducing the risks of suicidal behaviours, substance misuse, transport accidents, and criminality but not accidental injuries when considering first event rate. The risk reductions were more pronounced for recurrent events, with reduced rates for all five outcomes. This target trial emulation study using national register data provides evidence that is representative of patients in routine clinical settings.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Unaccompanied migrant youths often confront traumatic experiences elevating their risk for mental health symptoms. However, United States-based research on mental health services for this population, particularly Indigenous youths, is limited. Objectives were to examine mental health screening and referral, characteristics associated with referrals, and clinical rationale for screening result/referral discordance. METHODS:All unaccompanied migrant youths with pediatric intake visits at a healthcare-legal clinic between 3/2020-2/2023 were included (N=100). Retrospective cohort data were extracted from medical chart and program registry, including pediatricians' rationale for referrals. Chi-square and t-tests were used to compare rates of screening, evaluation, and discordant referrals by sociodemographic characteristics. Logistic regression was used to identify associations with mental health referral. Exploratory analyses examined referrals by Indigenous group. RESULTS:Youths had a mean (SD) age of 17.5 (2.5) years, most were assigned male at birth (66 [66%]), from Central America (83 [83%]), and one-third were Indigenous. Odds of mental health referral were higher for youths who were assigned female at birth (adjusted OR, 3.00 [95% confidence interval, 1.13-7.87), non-Indigenous (adjusted OR, 2.73; 95% confidence interval, 1.01-7.40), and reported more trauma types (adjusted OR, 1.38; 95% confidence interval, 1.02-1.87). One-third of referrals were for trauma or mental health symptoms identified by pediatricians, but not screeners. CONCLUSION/CONCLUSIONS:Most unaccompanied migrant youths had mental health referrals, one-third of which were for mental health symptoms undetected by screeners at pediatric visit. Findings highlight sociodemographic differences in mental health referrals, with non-Indigenous and female youths having higher odds of referral.