Background: To examine the prospective association between multivitamin supplementation during pregnancy and biomarker measures of maternal plasma folate and vitamin B 12 levels at birth and child's Autism Spectrum Disorder (ASD) risk. Methods: This report included 1257 mother-child pairs, who were recruited at birth and prospectively followed through childhood at the Boston Medical Center. ASD was defined from diagnostic codes in electronic medical records. Maternal multivitamin supplementation was assessed via questionnaire interview; maternal plasma folate and B 12 were measured from samples taken 2-3 days after birth. Results: Moderate (3-5 times/week) self-reported supplementation during pregnancy was associated with decreased risk of ASD, consistent with previous findings. Using this as the reference group, low (≤2 times/week) and high (>5 times/week) supplementation was associated with increased risk of ASD. Very high levels of maternal plasma folate at birth (≥60.3 nmol/L) had 2.5 times increased risk of ASD [95% confidence interval (CI) 1.3, 4.6] compared to folate levels in the middle 80th percentile, after adjusting for covariates including MTHFR genotype. Similarly, very high B 12 (≥536.8 pmol/L) showed 2.5 times increased risk (95% CI 1.4, 4.5). Conclusion: There was a 'U shaped' relationship between maternal multivitamin supplementation frequency and ASD risk. Extremely high maternal plasma folate and B 12 levels at birth were associated with ASD risk. This hypothesis-generating study does not question the importance of consuming adequate folic acid and vitamin B 12 during pregnancy; rather, raises new questions about the impact of extremely elevated levels of plasma folate and B 12 exposure in-utero on early brain development.

Limited health literacy has been associated with a range of adverse health outcomes including decreased use of preventive health services, poorer disease-specific outcomes for certain chronic conditions and increased risk of hospitalisation and mortality. Although the majority of research has been conducted in the adult population, there is a small and growing body of research on this subject in the paediatric literature. In this article, we will review the research on health literacy, consider the range of other communication skills associated with limited health literacy and explore strategies to improve patient-provider communication for clinicians who care for families with limited health-literacy skills.

OBJECTIVES: Although many attention-deficit/hyperactivity disorder (ADHD) care models have been studied, few have demonstrated individual-level symptom improvement. We sought to test whether complementing basic collaborative care with interventions that address common reasons for symptom persistence improves outcomes for children with inattention and hyperactivity/impulsivity. METHODS:We conducted a randomized comparative effectiveness trial of 2 care management systems for 6-to 12-year-old children being evaluated for ADHD (n = 156). All participants received care management with decision support. Care managers in the enhanced care arm also were trained in motivational and parent management techniques to help parents engage in their child's treatment, address their own mental health needs, and manage challenging child behaviors. We used multivariable models to assess inattention, hyperactivity/impulsivity, oppositionality, and social skills over 1 year.RESULTS: Both treatment arms generated guideline concordant diagnostic processes in 94% of cases; 40% of children had presentations consistent with ADHD. For the entire sample, there were no differences in symptom trajectories between study arms; mean differences in change scores at 12 months were -0.14 (95% confidence interval -0.34 to 0.07) for inattention; -0.13 (-0.31 to 0.05) for hyperactivity/impulsivity; -0.09 (-0.28 to 0.11) for oppositionality; and 3.30 (-1.23 to 7.82) for social skills. Among children with ADHD-consistent presentations, enhanced arm participants experienced superior change scores for hyperactivity/impulsivity of -0.36 (-0.69 to -0.03), oppositionality -0.40 (-0.75 to -0.05), and social skills 9.57 (1.85 to 17.28).CONCLUSIONS: Among children with ADHD-consistent presentations, addressing barriers to engagement with care and challenging child behaviors has potential to improve the effectiveness of collaborative care. WHAT'S KNOWN ON THIS SUBJECT:Collaborative care is known to be an effective system to manage child behavioral health conditions in the primary care setting. WHAT THIS STUDY ADDS:Among urban children with attention-deficit/hyperactivity disorder, using lay care managers to address barriers to engagement with care and challenging child behaviors has the potential to improve the effectiveness of conventional collaborative care. Dr Silverstein conceptualized and designed the study, oversaw its implementation, and drafted the initial manuscript; Drs Hironaka and Walter conceptualized and designed the study, oversaw its clinical implementation, reviewed and revised the entire manuscript, and assisted in the interpretation of analyses; Dr Feinberg assisted in conceptualizing and designing the study, oversaw its clinical implementation at one site, assisted in the interpretation of analyses, and reviewed and revised the manuscript; Ms Sandler managed the data for the project, assisted in preparing the analyses, and reviewed and revised the manuscript; Ms Pellicer supervised the care managers for the project, and reviewed and...