Leah Kuntz

A recent study sought to understand the relationship between dietary patterns of children and their 

Investigators examined 2 different age groups of children from Spain: 259 preschoolers aged 3 to 6 years old (57 with ADHD and 202 controls) and 475 elementary-school-age children, aged 10 to 12 years old (213 with ADHD and 262 controls). ADHD was assessed in accordance with the DSM-5. Eating data were collected using a food consumption frequency questionnaire. Three types of eating patterns were identified: Western-like, sweet, and healthy.

Western pattern consists of eggs, processed meat, seafood, savory cereals, potatoes, legumes, sodas, and cooked vegetables. Sweet pattern consists of dairy desserts, sweet cereals, preserved fruit, and sweets. 

 consists of nuts, fish (white and oily), raw vegetables, fresh fruit, and olive oil.

The children and adolescents with ADHD were negatively associated with the healthy pattern (

 < 0.001) and positively associated with the Western-like diet (

 = 0.004). Furthermore, children with inattentive presentation showed lower adherence (12.2%) to a healthy pattern than that of the control group (39.9%) (

 < 0.001). The control group had the highest adherence to the Healthy pattern. However, the two groups had a similar adherence to the sweet dietary pattern.

Previous research explored the association between 

 and the Mediterranean diet—a dietary pattern that includes fiber-rich food such as fruits and vegetables, healthy fatty acids, proteins, and more.

 According to 2 studies, there was less healthy eating and lower adherence to the Mediterranean diet in children and adolescents with ADHD than that in controls.

“We hypothesize that children with ADHD have a low-quality diet with a lower intake of fruits and vegetables than that of their peers without the disorder, and that this shows up specifically in children with combined or hyperactive–impulsive (H–I) ADHD presentations. Moreover, we hypothesize that food consumption generally differs from the established recommendations by dietary guidelines,” wrote the authors.

The authors concluded that there is an association between ADHD and dietary habits, and children with inattentive presentation may be at increased risk of unhealthy eating habits.

This article was originally published by sister publication Psychiatric Times.

1. Rojo-Marticella M, Arija V, Alda JÁ, et al. 

Do children with attention-deficit/hyperactivity disorder follow a different dietary pattern than that of their control peers?

2. Rios-Hernandez A, Alda JA, Farran-Codina A, et al. 

The Mediterranean diet and ADHD in children and adolescents.

3. San Mauro Martín I, Blumenfeld Olivares JA, Garicano Vilar E, et al. 

Nutritional and environmental factors in attention-deficit hyperactivity disorder (ADHD): a cross-sectional study.

Articles

A recent study found a negative association between children with attention-deficit/hyperactivity disorder (ADHD) and health eating patterns. 

Exploring the link between kids with ADHD and unhealthy eating

TikTok, the global sensation: is this app harmless fun or dangerous? Following the start of a nationwide investigation into the video platform’s negative impacts, 

 sat down with Jaclyn Halpern, PsyD, from Washington Behavioral Medicine Associates to talk all about it.

Q: State attorneys general from several states have launched a nationwide investigation into TikTok and its possible harmful effects on young users’ mental health. What does the medical literature/research show about TikTok and its impact?

 Research specific to social media and TikTok is relatively new, and it continues to emerge. Some research shows that those with attentional difficulties may experience more struggles with social media. Other research has concluded that children with complex mental health and environmental stressors or trauma may see at least temporary increases in emotional symptoms after social media use.

Social problems based in personal values and ethics impacted by social media use have also been found. However, data is limited, causation has yet to be clearly established, personal factors impacting positive and negative outcomes are unclear, and long-term impact has yet to be fully studied given that social media use and related research is relatively new. Additionally, studies on individual platforms like TikTok, as opposed to social media as a whole, are very limited. Given that research is mixed, not definitive, and in its very early stages and while there is clear cause for concern, there are likely both positive and negative outcomes resulting from social media use.

Q: Has research shown it’s more harmful to boys or girls?

 I have not encountered definitive research suggesting Tik Tok is more harmful based on gender.

Q: About 1 billion users are on TikTok. Do you think it’s become too large to control at this point? Is that part of the problem?

 TikTok is indeed a large platform. While there are parental controls available, not all parents have the knowledge to protect their children from inappropriate content. Though there is a restricted mode, the size of the site may well allow inappropriate content to slip through.

Additionally, not all subject matter can be properly filtered, and what families find appropriate for one child may be inappropriate for another. Given this, the size of TikTok makes it likely that any child using the platform will be exposed to inaccurate information, and something potentially upsetting, harmful, or traumatizing, even with parental monitoring and careful use.

Q: During the pandemic, TikTok became the forefront for trends: baking bread, whipped coffee, dances. Are there any potential positives you see in the app? Has it helped sort of bring us together?

 Absolutely. There are a range of benefits that can come from using TikTok and other social media platforms. This includes allowing people to interact over their interests; learn a new hobby; promote their businesses and creations; share content that is playful, fun, or educational; peacefully mobilize around social and political issues; establish a sense of identity; and even learn about other cultures. Positive TikTok content can be empowering and educational. Particularly during the pandemic, it became a source of both entertainment and connection for many. This was critical to the well-being of many during a time of isolation and fear.

Q: On the flipside, have things like the TikTok dances contributed to the oversexualization of young people’s bodies?

 It is reasonable to conclude that some of the content on TikTok, including some of the dances, may lead to oversexualization of young people’s bodies. Oversexualization of children by media in general is a long-standing concern, particularly for females. These concerns are based in standards of beauty and sexuality portrayed by the bodies and styles of models and performers, as well as song lyrics, dances, music videos, and portrayals of children and teens in videos, TV, and movies. Recent press and publicized anecdotes also suggest a potential negative impact on body image for all genders. To fully understand oversexualization caused by TikTok, specific research on the impact of dances and other potentially sexual content available on the platform is needed.

Q: Representative Cathy McMorris Rodgers of Washington, the senior Republican on the House Energy and Commerce Committee, has said that: “TikTok threatens the safety, mental health, and well-being of our kids.”

Do you think this opinion is in any way related to adults’ lack of understanding and fear of this new method of engaging for their kids?

 Based on the research currently available, there is evidence that adults’ lack of understanding and fear are factors when making judgments about the negative impacts of TikTok and other social media platforms. However, there is also reason for concern given the content available on TikTok, differences in ethics and values surrounding TikTok’s content, the pressures children and teens may feel based on TikTok’s content, and the possibility of encountering an online predator when using the app. Ultimately, research has begun to show both risks and positives for youth using TikTok and other social media platforms.

Q: The focus is on TikTok here, but what about Instagram, Snapchat, and other forms of social media? What does the current medical literature say about their harmful effects, and are they not similar to TikTok in their promotion of things like eating disorder content?

 There is a critical need for research on the impact of individual platforms and content. Current research has shown a mix of both positive and negative outcomes resulting from social media use. As with TikTok, there is early research suggesting both positive (eating disorder recovery) and negative (pro-anorexia and pro-bulimia) impacts of eating disorder content on multiple social media platforms.

Q: One social media influencer in Germany may have contributed to what researchers are calling a “mass social media-induced illness,” in which patients were presenting with Tourette symptoms and tics closely resembling the social media influencer’s tics.

Apps like TikTok may help spread awareness of mental illness, but do you think it also contributes to self-diagnosis?

 Yes, absolutely. That said, self-diagnosis can be both positive and negative. For some, self-diagnosis opens the door to better self-understanding and improved self-esteem, and may lead to seeking medical diagnosis and support. For others, self-diagnosis may be detrimental and even dangerous, particularly if the conclusions drawn are inaccurate or based in faulty information.

Q: Finally, what advice would you give to any mental health clinicians talking to children and adolescents and their parents about social media?

 Mental health clinicians should continue to monitor the research on social media use in order to make accurate recommendations when talking to children, adolescents, and their parents. They should consider individual factors, and help families weigh the pros and cons of social media use, including the pros and cons of different social media platforms. Additionally, mental health clinicians should encourage parents to explore parental controls that might be effective and appropriate for their families. They should also encourage families to discuss appropriate monitoring of their child’s social media use, based on the family’s values and individualized needs.

1. Associated Press. California among states launching probe into TikTok’s effect on kids’ health. KTLA. March 2, 2022. Accessed March 4, 2022. 

https://ktla.com/news/california/california-among-states-launching-probe-into-tiktoks-effect-on-kids-health/

2. Kuntz L. Tourette’s or mass sociogenic illness? You decide. 

https://www.psychiatrictimes.com/view/tourettes-or-mass-sociogenic-illness-you-decide

TikTok has over 1 billion users and dominates youth culture. Is it damaging their mental health?

What TikTok could mean for adolescent mental health

Recently, investigators conducted a narrative literature review of affective disorders and sleep difficulties in children and young people, seeking to understand the relationship between sleep and both depression and bipolar disorder.

Monica Comsa, FRACP, Child and Adolescent Mental Health Service, Cumbria Northumberland, Tyne and Wear NHS Foundation Trust, UK, and colleagues found that parasomnias, narcolepsy, and sleep-related movement disorders are associated with depression in children and adolescents. Additionally, children and adolescents with depression can present with a number of sleep difficulties, which are also associated with several other issues, such as higher depression severity, greater fatigue, suicidal ideation, physical complaints, pain, and decreased concentration.

On the other hand, insomnia, obstructive sleep apnea, and circadian rhythm disorders are associated with both depression and bipolar disorder in children and adolescents. Sleep difficulties can occur before, during, and after an episode of depression or bipolar disorder.

“Sleep disturbances among adolescents with bipolar disorder can affect the severity of depressive and manic symptoms, are a poor prognostic indicator, and have been associated with social and academic impairment,” said Comsa and colleagues.

These sleep difficulties may be the result of medication. According to the investigators, antidepressants and antipsychotics can directly affect sleep architecture, and clinicians should be cognizant of this problem when prescribing and might instead consider nonpharmacological interventions. These interventions for sleep problems might minimize the risk of relapse in affective disorders.

Investigators suggested a multi-modal approach to target both the affective and specific sleep disorders is the ideal treatment plan: “Psychoeducation, consistent sleep-wake schedules and tailored interventions for addressing sleep problems should play an important role in the prevention and treatment of mental health difficulties, at any age. Concomitantly addressing sleep problems can lead to an increased remission rate of depression.”

More research is required to understand the impact of combined interventions on clinical outcomes, concluded investigators.

“Of most importance is the impact of specific treatment for sleep disorders on the long-term outcome of affective disorders. Clinicians need to know if better nights reliably lead to better days.”

1. Comsa M, Anderson KN, Sharma A, et al. The relationship between sleep and depression and bipolar disorder in children and young people. 

Sleep, depression, and bipolar disorder: what's the connection?

 Looking for the connections between sleep, depression, and bipolar disorder in kids and teens

Steven Pliszka, MD, chair of The American Professional Society of ADHD [attention-deficit/hyperactivity disorder] and Related Disorders (APSARD) annual program committee, joined Jeffrey Newcorn, MD, APSARD president, in welcoming attendees to their virtual 2022 Annual Meeting, noting the conference was putting attendees “on the ground floor of exciting developments in the field.” Pliszka said the conference would highlight issues in genetics, neuroimaging, psychological variables, and environmental variables. “I think we’re moving to really integrating all these different aspects so we can think much more broadly about where ADHD fits into psychopathology in general,” he added. “And it will get us thinking more about new ways to intervene and to treat people.”

The 4-day meeting was held January 13 to 16, 2022. In-depth coverage can be found online at 

www.psychiatrictimes.com/conferences/apsard

As separate groups, college students with ADHD and college students who identify as a sexuality and gender minority (SGM) have increased risk for functional impairments, psychiatric comorbidities, and risky behaviors.

 According to Destiny Orantes, PhD, from Syracuse University, and colleagues, previous research had not considered if these outcomes are further increased in SGM students who have ADHD. Orantes shared findings from their recent research in a poster presentation.

The study assessed functional impairments, psychiatric comorbidities, and engagement in risky behaviors in 4 groups: (1) SGM students with ADHD, (2) SGM students without ADHD, (3) non-SGM students with ADHD, and (4) non-SGM students without ADHD. Data from the American College Health Association-National College Health Assessment 2019-2021 III were used. The researchers also sought to examine the prevalence of ADHD in SGM college students.

They found ADHD prevalence increased in SGM populations: 15% compared with 8% in non-SGM individuals. Additionally, SGM students with ADHD reported the highest levels of functional impairments, substance use, and psychiatric comorbidities.

The research results suggest, Orantes said, that future studies should consider the underlying reasons for SGM students having high rates of ADHD, and how best to reduce these negative outcomes. Specifically, treatment plans should take into account the separate difficulties students face from their ADHD diagnosis and their SGM identities, as well as how best to target the risky behaviors and comorbidities.

1. Auerbach RP, Mortier P, Bruffaerts R, et al; WHO WMH-ICS Collaborators. 

Mental disorder comorbidity and suicidal thoughts and behaviors in the World Health Organization World Mental Health Surveys International College Student initiative.

“The [APSARD] task force was launched in relation to the amazing societal changes that are happening...in association with the awareness that equity means creating fair, equitable opportunities for all of us,” Martin Katzman, MD, FRCP(C), APSARD Health Equity Task Force chair, told attendees. “We’re hoping to build connections within the APSARD community, to enhance diversity of the organization, and to reach out across boundaries as well as to partner within all of our communities to raise awareness and to increase opportunities for treatment for populations that may not get the same access to treatment.”

Amy Glasofer, DPN, RN, nurse scientist with Virtua, shared an analysis of 41 studies relating to ADHD, race, ethnicity, and disparity; Catherine Dingley, PhD, RN, FNP, FAAN, associate professor in the Nursing Department of the University of Las Vegas, Nevada, also worked on the project.

They found 66.7% of studies noted Black children were significantly less likely than white children to be diagnosed with ADHD, and 65% of Black children with ADHD were significantly less likely than white children to receive medication. In addition, compared to white children, she noted Black children were more likely to discontinue medication and more likely to experience gaps in treatment; less likely to receive an α2 agonist alone; and more likely to receive significantly lower doses of stimulant. The findings suggest that, although diagnostic disparities have been reduced over time, treatment disparities still exist for minority children with ADHD.

1. Katzman M, Higgins N, Glasofer A, et al. Introducing the APSARD Health Equity Task Force. Presented at 2022 APSARD Conference. January 14, 2022.

“ADHD in preschool children is a valid and reliable condition,” reported Ann Childress, MD, president of the Center for Psychiatry and Behavioral Medicine, Inc, in Las Vegas, Nevada.

According to the 2014 National Survey of Diagnosis and Treatment of ADHD and Tourette’s, 30% of children diagnosed with ADHD receive their diagnosis before age 6; 16% receive the diagnosis at 4 years or younger.

 Impairment can be great for these patients, Childress said. For example, an epidemiological review of preschoolers diagnosed with ADHD found more than 40% had been suspended from school or daycare and about 16% had been expelled.

 In comparison, less than 1% of young children without ADHD were suspended.

The actions of young children with ADHD pose safety risks to themselves due the higher levels of hyperactive impulsivity, she said. “These are kids who are running out in traffic. They’re jumping off of things and breaking bones. They’re doing things that are dangerous, and they really need treatment for their safety,” she explained.

Childress reviewed efficacy and safety data for a number of common medications, noting some small behavior improvements as a result of the study medications. However, medications were associated with adverse events, including insomnia, gastrointestinal issues, irritability, sedation, and repetitive behaviors and thoughts. She also noted not all of these medications have been approved for the youngest patients.

Fortunately, there is good evidence for the efficacy of nonpharmacological interventions for preschoolers with ADHD, Childress reported. The New Forest Therapy, Helping the Noncompliant Child, and the Incredible Years series were among the programs she noted that have demonstrated efficacy. Furthermore, she spoke highly of parent training models that foster the implementation of positive reinforcement to promote positive behaviors; ignoring low-level provocative behaviors; and responding in a clear, consistent, and safe manner to unacceptable behaviors.

“You have to carefully consider both developmental aspects and comorbidity when you’re establishing a diagnosis, and the medication efficacy and tolerability profile may not look as good in the little guys as it does in older children,” she concluded.

1. Visser SN, Zablotsky B, Holbrook JR, et al. 

Diagnostic experiences of children with attention-deficit/hyperactivity disorder.

The epidemiology and diagnostic issues in preschool attention-deficit/hyperactivity disorder: a review.

Catch up on all the latest in ADHD from the The American Professional Society of ADHD (attention-deficit/hyperactivity disorder) and Related Disorders (APSARD) virtual 2022 Annual Meeting. 

ADHD highlights from the 2022 ASPARD meeting

The US Food and Drug Administration (FDA) has approved Otsuka and Lundbeck’s supplemental new drug application (sNDA) of brexpiprazole for the treatment of schizophrenia in pediatric patients aged 13 to 17 years.

The FDA previously granted Priority Review for the sNDA. In 2015, brexpiprazole was approved in the US for the treatment of 

 in adults and for adjunctive treatment of 

“This approval further bolsters the mental health community’s efforts and resources to address a critical unmet need within the pediatric schizophrenia population,” said Robert McQuade, PhD, president of the McQuade Center for Strategic Research and Development, and chief strategic officer at Otsuka Pharmaceutical Development & Commercialization. “We will continue to raise awareness about schizophrenia in adolescents and educate this important community on the availability of effective treatment options.”

The mechanism of action for brexpiprazole is not fully understood; however, studies of brexpiprazole’s efficacy observed 

 at serotonin 5-HT1A and dopamine D2 receptors, and antagonist activity at serotonin 5-HT2A receptors—for which, brexpiprazole exhibits high affinity.

“Brexpiprazole appears to be a viable option for treating an acute exacerbation of schizophrenia requiring hospitalization or adjunctive treatment of major depressive disorder in patients who showed an inadequate response to 1 to 3 antidepressants,” wrote Lauren A. Diefenderfer, PharmD, BCPP, and Courtney Iuppa, PharmD, BCPP, back in 2017.

The sNDA submission was based on an extrapolation analysis utilizing data from 3 groups of prior research: 1) studies among adult patients, 2) pharmacokinetic results from adult and pediatric trials, and 3) 6-month data from the ongoing open-label, long-term trial among adolescent patients with schizophrenia.

“We are proud to offer a treatment option for adolescents with schizophrenia who are navigating the complexities of their health during a transitional time in their lives – we hope this will help make a meaningful difference in reducing their schizophrenia symptoms so they can be their best,” said Johan Luthman, executive vice president of research and development at Lundbeck.

1. Otsuka and Lundbeck announce FDA approval of supplemental new drug application for REXULTI® (brexpiprazole) to treat schizophrenia in pediatric patients ages 13-17. News release. BioSpace. January 6, 2022. 

https://www.biospace.com/article/releases/otsuka-and-lundbeck-announce-fda-approval-of-supplemental-new-drug-application-for-rexulti-brexpiprazole-to-treat-schizophrenia-in-pediatric-patients-ages-13-17/

2. Diefenderfer LA, Iuppa C. Brexpiprazole: a review of a new treatment option for schizophrenia and major depressive disorder. 

The supplemental new drug application of brexpiprazole for the treatment of schizophrenia in pediatric patients aged 13 to 17 received US Food and Drug Administration (FDA) approval. 

FDA approves treatment for schizophrenia in pediatric patients 

“Adolescence is a critical period, with increased risk for cannabis and, in particular, high tetrahydrocannabinol (THC) potency cannabis use. This may represent a public health crisis,” Christopher J. Hammond, MD, PhD, shared with attendees of the 

In his presentation, “Impact of THC on Adolescents: Neurodevelopment,” Hammond shared that chronic adolescent THC exposure across animal and human studies is associated with disruptions or alterations in brain development. Furthermore, it is associated with adverse mental health outcomes, including depression and anxiety.

“Contrary to a lot of what the popular media messaging has communicated to us, data across studies of young people show that adolescents that use cannabis regularly and who cut down or stop using cannabis show reductions in depression and anxiety and improvements in cognition,” said Hammond.

Abstinence from cannabis for 3 to 4 weeks could reduce anxiety and depression, improve sleep, and boost cognition in adolescent regular cannabis users.

Cannabis is the most commonly used federally illicit drug by US youth, and it accounts for more than 75% of teen admissions to substance use treatment. About 1.4 million adolescents try cannabis for the first time each year.

Early onset of cannabis use, according to Hammond, could lead to a number of health issues, including major depressive disorder, alcohol use disorders, substance use disorders, suicidality, anxiety disorders, bipolar disorders, psychosis, and delinquent behaviors.

“There appears to be a relatively consistent pattern of findings showing that adolescent cannabis use is associated in a dose dependent manner with poor outcomes in academic and occupational functioning, cognition, and psychiatric and substance use outcomes, and that these may be worse for young people with mental health problems,” said Hammond.

Adolescent cannabis use could also lead to potential long-term brain effects, like dysfunction in white matter tracts, altered brain waves, and decreased brain blood flow. These effects are larger and more consistent with earlier age of onset and heavy use.

“As more data comes in, we can further update and inform this field, but using the data as it exists now is important,” concluded Hammond.

1. Jacobus J, Squeglia LM, Escobar S, et al. 

Changes in marijuana use symptoms and emotional functioning over 28-days of monitored abstinence in adolescent marijuana users.

Reductions in cannabis use are associated with mood improvement in female emerging adults.

3. Hanson KL, Winward JL, Schweinsburg AD, et al. 

Longitudinal study of cognition among adolescent marijuana users over three weeks of abstinence.

4. Hammond CJ, Chaney A, Hendrickson B, Sharma P. 

Cannabis use among U.S. adolescents in the era of marijuana legalization: a review of changing use patterns, comorbidity, and health correlates.

5. Morgan CJ, Gardener C, Schafer G, et al. 

Sub-chronic impact of cannabinoids in street cannabis on cognition, psychotic-like symptoms and psychological well-being.

6. Arterberry BJ, Padovano HT, Foster KT, et al. 

Higher average potency across the United States is associated with progression to first cannabis use disorder symptom.

7. DiForti M, Quattrone D, Freeman TP, et al. 

The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study.

8. Hines LA, Freeman TP, Gage SH, et al. 

Association of high-potency cannabis use with mental health and substance use in adolescence.

Chronic adolescent exposure to THC and cannabis could lead to adverse mental health outcomes and impacted brain functioning.