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Aims Early identification of patients likely to die after acetaminophen (APAP) poisoning remains challenging. We sought to compare the sensitivity and time to fulfilment (latency) of established prognostic criteria. Methods Three physician toxicologists independently classified every in-hospital death associated with APAP overdose from eight large Canadian cities over three decades using the Relative Contribution to Fatality scale from the American Association of Poison Control Centres. The sensitivity and latency were calculated for each of the following criteria: King's College Hospital (KCH), Model for End Stage Liver Disease (MELD) ≥33, lactate ≥3.5 mmol/L, phosphate ≥1.2 mmol/L 48+ hours post-ingestion, as well as combinations thereof. Results A total of 162 in-hospital deaths were classified with respect to APAP as follows: 26 Undoubtedly, 40 Probably, 27 Contributory, 14 Probably not, 25 Clearly not, and 30 Unknown. Cases from the first three classes (combined into n = 93 "APAP deaths") typically presented with supratherapeutic APAP concentrations, hepatotoxicity, acidaemia, coagulopathy and/or encephalopathy, and began antidotal treatment a median of 12 hours (IQR 3.4-30 h) from the end of ingestion. Among all patients deemed "APAP deaths", meeting either KCH or lactate criteria demonstrated the highest sensitivity (94%; 95% CI 86-98%), and the shortest latency from hospital arrival to criterion fulfilment (median 4.2 h; IQR 1.0-16 h). In comparison, the MELD criterion demonstrated a substantially lower sensitivity (55%; 43-66%) and longer latency (52 h; 4.4-∞ h, where "∞" denotes death prior to criterion becoming positive). Conclusions Meeting either KCH or serum lactate criteria identifies most patients who die from acetaminophen poisoning at or shortly after hospital presentation.

This paper By Ward et al. (Journal of Child Psychology and Psychiatry, 2019) in the issue of the JCPP, is an excellent example of preparing a new programme for parents with children at high risk of present and future behaviour problems. It was to be delivered in a very deprived population in a township in South Africa. We discuss the paper but also raise questions about developing new programmes when they are already successful programmes available and discuss whether it is time for programme developers to meet to discuss what works best and for whom.

International practice guidelines recommend medication and behavioral intervention as evidenced-based treatments for attention deficit hyperactivity disorder (ADHD). Currently in Japan, the availability of non pharmacological interventions for ADHD is limited. We report the results of a pilot and a proof-of-concept study for a new behavioral intervention for Japanese mothers of children with ADHD. The pilot study delivered a standard six-session behavioral intervention and two parent-support sessions. Participants approved the group format and requested additional support to change parenting practices and behavioral strategies targeting ADHD symptoms. For the proof-of-concept study, the intervention was revised to include five sessions of pre intervention support followed by six sessions of the New Forest Parent Training Programme (NFPP), an evidence based intervention for ADHD. The revised intervention, NFPP-Japan, was associated with reductions in the mothers’ reports of children's ADHD symptoms and aggression, more effective parenting practices, and reduced parenting stress. The pilot and proof-of-concept studies indicate that it is possible to successfully modify Western behavioral interventions for Japanese mothers and to justify a randomized controlled trial evaluation of the NFPP-Japan, which is currently underway.

Background The importance of early intervention approaches for the treatment of attention-deficit hyperactivity disorder (ADHD) has been increasingly acknowledged. Parenting programmes (PPs) are recommended for use with preschool children with ADHD. However, low ‘take-up’ and high ‘drop-out’ rates compromise the effectiveness of such programmes within the community. Methods This qualitative study examined the views of 25 parents and 18 practitioners regarding currently available PPs for preschool children with ADHD-type problems in the UK. Semi-structured interviews were undertaken to identify both barriers and facilitators associated with programme access, programme effectiveness, and continued engagement. Results and conclusions Many of the themes mirrored previous accounts relating to generic PPs for disruptive behaviour problems. There were also a number of ADHD-specific themes. Enhancing parental motivation to change parenting practice and providing an intervention that addresses the parents' own needs (e.g. in relation to self-confidence, depression or parental ADHD), in addition to those of the child, were considered of particular importance. Comparisons between the views of parents and practitioners highlighted a need to increase awareness of parental psychological barriers among practitioners and for better programme advertising generally. Clinical implications and specific recommendations drawn from these findings are discussed and presented.

Attention-Deficit/Hyperactivity Disorder (ADHD) is characterized by problems with attention, impulsivity, and hyperactivity. The diagnosis derives from 18 symptoms indexing these behavioural domains [American Psychiatric Association (APA), DSM-IV-TR, 2000]. There is substantial continuity in maintaining a diagnosis of ADHD from childhood to adolescence (Faraone, Biederman, & Mick, 2006); however the phenotypic expression is highly variable within the diagnosed group and across time (Barkley, 2006; Nigg, 2006). Current diagnostic formulations distinguish between symptoms of inattention and those of hyperactivity-impulsivity. Three ADHD subtypes are recognized in the DSM-IV: the predominantly inattentive type, the predominantly hyperactive-impulsive type, and the combined type (where patients meet criteria on both the inattention and the hyperactive/impulsivity domains). This formulation is currently under review as part of the deliberation of the DSM-5 panel. Indeed, this current characterization remains controversial (Barkley, 2001; Diamond, 2005; Hinshaw, 2001; Lahey, 2001; Milich, Balentine, & Lynam, 2001). Here we focus on factor models of co-occurrence among ADHD symptoms. Two major types of factor models, correlated factor models and hierarchical models, have been used to examine coherence and distinctness among ADHD symptom domains. Hierarchical models provide a way to simultaneously conceptualize both the coherence and separability of symptoms from separate domains. These models include a single general factor accounting for covariation among all symptoms along with separate, specific factors of inattention, hyperactivity, and impulsivity that vary orthogonally from the general factor. These models are also termed as bifactor models in the statistical literature. Hierarchical models are different from correlated factor models that only have factors for the symptom domains of inattention and hyperactivity and/or impulsivity (see Figure 1). Several studies have shown hierarchical models with a general factor as having a better fit than correlated models for reported symptoms of ADHD (e.g., Dumenci, McConaghy, & Achenbach, 2004; Gibbins et al., in press; Martel, Von Eye, & Nigg, 2010; Toplak et al., 2009). These papers span clinical and community samples, and child, adolescent, and adult samples with ADHD. A one-factor model has also been considered, but thus far it has no empirical support (Dumenci et al., 2004). Figure 1 Generic example of a correlated two-factor model for 10 observed symptoms Hierarchical models explicitly acknowledge the common covariation among all ADHD symptoms, which is consistent with the conceptualization of ADHD as a single disorder. There are several lines of evidence suggesting that there is substantial commonality between the domains of inattention and hyperactivity-impulsivity. Inattentive symptoms tend to be more highly correlated with hyperactivity and impulsivity than with other domains of psychopathology (Adams, Kelley, & McCarthy, 1997; Conners, 2008; Strickland et al., 2011), with the exception of oppositional defiant disorder in some studies (Lahey et al., 2008). Current models of ADHD also highlight how the symptom domains of inattention, hyperactivity, and impulsivity likely interact to give rise to the heterogeneous expression of ADHD (Nigg & Casey, 2005; Sagvolden, Johansen, Aase, & Russell, 2005; Sonuga-Barke, 2005; Sonuga-Barke, Sergeant, Nigg, & Willcutt, 2008). To replicate and extend these findings, the current study examined different factor models in a large sample of ADHD patients recruited from a broad age range and from diverse national groupings. We were thus able to test whether a hierarchical model held for the whole sample and whether it also was invariant across different age groups and nationalities. A developmental perspective is important to integrate into models of individual ADHD symptoms, such that a single set of factors could parsimoniously explain the changes that occur over development. Age differences in scores from ADHD measures may reflect true differences in the constructs being measured or may simply reflect measurement differences due to age. Therefore, establishing measurement invariance across age groups is important. The behavioural presentation of ADHD changes considerably from childhood to adolescence. For instance, the expression of hyperactivity seems to decrease from childhood to adolescence and inattention commonly appears later in development than hyperactivity and impulsivity (Biederman et al., 2000; Hart et al., 1995; Larsson et al., 2006; Nigg, 2006). This developmental change introduces complex issues with respect to diagnosis. Subtypes have been used to characterize these different symptom presentations, and the instability of ADHD subtypes in developmental samples has also been well demonstrated (Lahey, Pelham, Loney, Lee, & Willcutt, 2005; Todd et al., 2008). Some of this instability of subtypes may be attributable to measurement variability (Lahey et al., 2005; Valo & Tannock, 2010); however some of this variability would be expected from a developmental perspective, which would presume that children’s symptom presentations change over the course of development. What is needed is a coherent model that can represent these shifts and changes in symptoms. In addition to the question of developmental change and continuity in ADHD symptoms, the current sample also had the unique characteristic of having recruited participants from seven European countries and Israel by 12 different research centers. Most studies examining cross-national samples have been concerned with whether there are comparable rates of prevalence across different countries (Faraone, Sergeant, Gillberg, & Biederman, 2003; Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007) rather than consistency in symptom patterns across countries. In addition to testing the five different factor models in the full sample, invariance analyses were also conducted to examine consistency of the best overall model across countries. Thus, in the current study we first estimated five different factor models to determine which model best accounted for ADHD symptoms pooling all ages and locations using a sample of children and adolescents with ADHD and their siblings. The five factor structures included: a) a one-factor model of inattention/ hyperactivity/impulsivity; b) a non-hierarchical two-factor model with correlated inattention and hyperactivity/impulsivity factors (the correlated 2-factor model); c) a non-hierarchical three-factor model with correlated inattention, hyperactivity, and impulsivity factors (the correlated 3-factor model); d) a hierarchical model of a general ADHD factor with two specific factors of inattention and hyperactivity/impulsivity (the hierarchical 2-factor model); and e) a hierarchical model of a general ADHD factor with three specific factors of inattention, hyperactivity, and impulsivity (the hierarchical 3-factor model). Based on previous research, we expected that a hierarchical model with a general ADHD factor would provide the best fit to observed ADHD symptoms in both the ADHD and sibling samples and across instruments and informants. We then examined whether these modeled relationships among symptoms are equivalent across different groups by formally assessing measurement invariance in the ADHD group. Group differences in observed scores on measurement instruments can be attributed to true differences on the constructs being measured only if measurement invariance or equivalence holds across groups (e.g., Widaman & Reise, 1997). Based on the best fitting model, we conducted invariance analyses to determine whether the measurement parameters relating the constructs implied by the model to the observed symptoms are equivalent across age groups and locations in the ADHD group.

This paper outlines the presentation, aetiology and treatment of attention deficit hyperactivity disorder (ADHD) in pre-school children. A review of current parenting training interventions demonstrates that there is good evidence for their efficacy in reducing symptoms of ADHD in pre-school children, and three interventions are evaluated: The new forest parent training programme (NFPP); the triple P - positive parenting programme and the incredible years parent training programme (IY). The evaluation of the NFPP provides strong evidence demonstrating its effectiveness for pre-school children with ADHD, while the efficacy of the Triple - P and the IY programme have, to date, only been demonstrated on children with conduct problems and co-morbid ADHD. It is suggested that parent training should be the first choice treatment for pre-school children presenting signs of ADHD, and medication introduced only for those children where parent training is not effective. Few moderators of outcome have been identified for these interventions, with the exception of parental ADHD. Barriers to intervention and implementation fidelity will need to be addressed to achieve high levels of attendance, completion and efficacy. The IY programme is a good model for addressing fidelity issues and for overcoming barriers to intervention. The future directions for parent training are also discussed.

BackgroundParenting empathy, the understanding by parents, and the sharing in their child's perspective, represents an important element of competent parenting. The present study tested the hypotheses that maternal empathy might be lower where mothers or their children display symptoms of psychopathology. MethodMothers (N=268) of school-aged children completed questionnaires on child-directed empathy and egoistic personal distress and their own and their child's symptoms of psychopathology across a number of broadly defined domains. ResultsChild conduct problems were associated with decreased child-directed empathy and increased maternal egoistic distress. Maternal aggressive characteristics and maternal ADHD symptoms were each associated with increased egoistic personal distress. ConclusionThe findings indicate that symptoms of psychopathology in children and adults are associated with deficits in empathy and increased maternal egoistic personal distress. The implications of the findings for responsive parenting and child social behaviour are discussed.

Mother and child ADHD symptoms both have a negative effect on parenting. Little is known about how these characteristics interact. In a recent paper, we reported two studies that suggested that maternal ADHD ameliorated the negative effects of child ADHD on negative parenting supporting a similarity-fit hypothesis. The aim of the current paper is to extend this analysis to a sample of mothers and fathers. The study examined the association between child and adult ADHD symptoms on child-specific parenting practices in 278 mothers and 85 fathers from a population-based sample of school-age children. As in the previous study, high levels of ADHD symptoms in mothers ameliorated the negative effects of child ADHD on parenting - supporting the similarity-fit hypothesis. Fathers demonstrated the opposite effect with high levels of ADHD exacerbating the effects of child ADHD - supporting a similarity-misfit hypothesis. The study confirms the important role played by parental ADHD symptoms in parenting while highlighting differences between mothers and fathers in this regard.

Background: Effective implementation of parent training programmes for preschool Attention-Deficit/Hyperactivity Disorder type is constrained by barriers limiting take-up and effective engagement by ‘hard to reach’ and ‘difficult to treat’ families. Method: We describe an evidence-driven adaptation and piloting of an existing empirically supported preschool ADHD parenting programme to address these problems. Results: The New Forest Parenting programme was changed substantially in terms of length; content and delivery on the basis of information gathered from the literature, from parents and practitioners, further modifications were made after the pilot study. Conclusions: The adapted-NFPP is currently being assessed for efficacy in a large multicentre randomized controlled trial.

In this paper we examine the characteristics of preschool attention deficit hyperactivity disorder (ADHD) from both mental disorder and developmental psychopathology points of view. The equivalence of preschool and school-aged hyperactivity as a behavioral dimension is highlighted together with the potential value of extending the use of the ADHD diagnostic category to the preschool period where these behaviours take an extreme and impairing form (assuming age appropriate diagnostic items and thresholds can be developed). At the same time, the importance of identifying pathways between risk and later ADHD is emphasized. Developmental discontinuity and heterogeneity are identified as major characteristics of these pathways. We argue that models that distinguish among different developmental types of early-emerging problems are needed. An illustrative taxonomy of four developmental pathways implicating preschool hyperactivity is presented to provide a framework for future research.

Background: The effectiveness of parent training (PT) when delivered as part of specialist tier-two services for preschool AD/HD children has been recently demonstrated. Aims: To assess the effectiveness of the same PT programme when delivered as part of routine primary care by non-specialist nurses. Method: A sample of 89 3-year-old children with preschool AD/HD took part in a controlled trial of an eight-week (one hour a week), health visitor delivered, PT package. Children, allocated randomly to PT (n = 59) and waiting list control (WLC; n = 30) groups, were compared. Results: PT did not reduce AD/HD symptoms. Maternal well-being decreased in both PT and WLC groups. Conclusions: While PT is an effective intervention for preschool AD/HD when delivered in specialized settings, these benefits do not appear to generalize when programme are delivered as part of routine primary care by non-specialist nurses.

Background It has been suggested that much of the medical and midwifery student curricula on normal pregnancy and birth could be taught as a co-operative effort between obstetric and midwifery staff. One important element of a successful combined teaching strategy would involve a determination of the extent to which the students themselves identify common learning objectives. Aim The aim of the present study was to survey medical and midwifery students about how they perceived their respective learning roles on the delivery suite. Methods A descriptive cross-sectional survey study was undertaken. The study venue was an Australian teaching and tertiary referral hospital in obstetrics and gynaecology. Survey participants were medical students who had just completed a 10 week clinical attachment in obstetrics and gynaecology during the 5th year of a six year undergraduate medical curriculum and midwifery students undertaking a one year full-time (or two year part-time) postgraduate diploma in midwifery. Results Of 130 and 52 questionnaires distributed to medical and midwifery students, response rates of 72% and 52% were achieved respectively. The key finding was that students reported a lesser role for their professional colleagues than they identified for themselves. Some medical students lacked an understanding of the role of midwives as 8%, 10%, and 23% did not feel that student midwives should observe or perform a normal birth or neonatal assessment respectively. Of equal concern, 7%, 22%, 26% and 85% of student midwives did not identify a role for medical students to observe or perform a normal birth, neonatal assessment or provide advice on breastfeeding respectively. Summary Medical and midwifery students are placed in a competitive framework and some students may not understand the complementary role of their future colleagues. Interdisciplinary teaching may facilitate co-operation between the professions and improve working relationships.

Objectives: To collect mothers' reports of the range of behaviours used by them in the management of their children's difficult behaviour. Design: A cross-sectional study using an interview with both semi-structured and open-ended question routes. Sampling frame: The population of mothers with 10-year-old children living in the New Forest region of Hampshire, UK. Methods: Mothers (n = 67), selected from the sampling frame, were interviewed about the range of parenting behaviours they used in the management of their children's difficult behaviour. Results: Mothers reported a wide range of behaviours. Both authoritative (e.g. reasoning was mentioned by 42%) and authoritarian (e.g. the use of physical punishment was mentioned by 37%) behaviours were mentioned frequently. Although the different behaviours within these domains were intercorrelated, there was little overlap between the two domains. The use of praise for good behaviour seemed to be independent of other behaviours. There was no association between mothers' parenting behaviours and the behaviour problems of their children. Conclusions: These data suggest that parenting takes many forms, with variations of behaviour across the 'normal' range being unlikely to represent a significant risk to children's development. Public funding for parenting education should be targeted at those children who are at significant risk from extreme forms of parenting.

Parents were asked which sources of advice families with difficult children should seek. The results suggested a similar hierarchy of agencies for both boys and girls with emotional and behavioural problems. Teachers, doctors, child psychiatrists and health visitors all received strong positive ratings, books about children with problems received moderate positive ratings, religious leaders received the strongest negative ratings and grandparents and friends received neutral ratings. Implications for service provision are discussed.

A case of unusual reactions consisting of involuntary abnormal facial movements in a child following exposure to the 5-HT3 receptor antagonists for prophylaxis against chemotherapy-induced vomiting is presented. Potential mechanisms for these reactions are discussed.

The Politics of Cultural Performance. David Parkin. Lionel Caplan. and Humphrey Fisher. eds. Providence, RI: Berghahn Books, 1996. 294 pp.

The incidence of elevated serum creatine kinase (CK) and pyruvate kinase (PK) activities was compared in 20 definite carriers of Duchenne muscular dystrophy (DMD), 47 possible carriers, and 42 female controls. When adult age was not regarded as a variable, 70% of the definite carriers had elevated PK, 55% had elevated CK, and 75% had elevated PK or elevated CK or both, 38% of the possible carriers had elevated PK, 19% had elevated CK, and 40% had elevated PK or elevated CK or both. The detection efficiency of the CK test was influenced by the age of the subjects: the upper normal limit of serum CK in the adult controls was at the minimum between 21 and 35 years of age, and CK activity in some carriers declined from elevated to normal levels with increasing age. With these considerations, 70% of definite carriers had elevated CK and 80% had elevated PK and/or CK; 34% of the possible carriers had elevated CK and 43% had elevated PK and/or CK. On the basis of the PK and CK measurements, only 16 of 24 possible carrier mothers were likely to be DMD carriers, implying that the other 8 were non-carrier mothers of new mutant sons.