Empirically supported psychosocial treatments for attention deficit hyperactivity disorder

Predictors of stress-related growth in parents of children with ADHD

This study was designed to investigate stress-related growth in 71 parents of children with ADHD, compared with 80 parents of non-clinical children. Adopting Tedeschi and Calhoun's (2004) theoretical framework for predicting personal growth, the study investigated the contribution of emotional intelligence (individual characteristics), social support (environmental factors), parental self-efficacy and perceptions of parenting as a challenge vs. a threat (cognitive processing). Results indicated that emotional intelligence was the main predictor of stress-related growth, particularly for parents of ADHD children, emphasizing that this personal trait is especially relevant to coping with on-going parental strain; whereas social support made a greater contribution to growth for the control group than for parents of children with ADHD. Path analysis confirmed our research model, suggesting that parents' sense of competence and of parenthood as a challenge vs. a threat mediates between emotional intelligence and social support on the one hand, and growth on the other.

Contrasting parents' and pediatricians' perspectives on shared decision-making in ADHD

OBJECTIVE

The goal was to compare how parents and clinicians understand shared decision-making (SDM) in attention-deficit/hyperactivity disorder (ADHD), a prototype for SDM in pediatrics.

METHODS

We conducted semi-structured interviews with 60 parents of children 6 to 12 years of age with ADHD (50% black and 43% college educated) and 30 primary care clinicians with varying experience. Open-ended interviews explored how pediatric clinicians and parents understood SDM in ADHD. Interviews were taped, transcribed, and then coded. Data were analyzed by using a modified grounded theory approach.

RESULTS

Parents and clinicians both viewed SDM favorably. However, parents described SDM as a partnership between equals, with physicians providing medical expertise and the family contributing in-depth knowledge of the child. In contrast, clinicians understood SDM as a means to encourage families to accept clinicians' preferred treatment. These findings affected care because parents mistrusted clinicians whose presentation they perceived as biased. Both groups discussed how real-world barriers limit the consideration of evidence-based options, and they emphasized the importance of engaging professionals, family members, and/or friends in SDM. Although primary themes did not differ according to race, white parents more commonly received support from medical professionals in their social networks.

CONCLUSIONS

Despite national guidelines prioritizing SDM in ADHD, challenges to implementing the process persist. Results suggest that, to support SDM in ADHD, modifications are needed at the practice and policy levels, including clinician training, incorporation of decision aids and improved strategies to facilitate communication, and efforts to ensure that evidence-based treatment is accessible.

Parental influence on children with attention-deficit/hyperactivity disorder: II. Results of a pilot intervention training parents as friendship coaches for children

We report findings from a pilot intervention that trained parents to be "friendship coaches" for their children with Attention-Deficit/Hyperactivity Disorder (ADHD). Parents of 62 children with ADHD (ages 6-10; 68% male) were randomly assigned to receive the parental friendship coaching (PFC) intervention, or to be in a no-treatment control group. Families of 62 children without ADHD were included as normative comparisons. PFC was administered in eight, 90-minute sessions to parents; there was no child treatment component. Parents were taught to arrange a social context in which their children were optimally likely to develop good peer relationships. Receipt of PFC predicted improvements in children's social skills and friendship quality on playdates as reported by parents, and peer acceptance and rejection as reported by teachers unaware of treatment status. PFC also predicted increases in observed parental facilitation and corrective feedback, and reductions in criticism during the child's peer interaction, which mediated the improvements in children's peer relationships. However, no effects for PFC were found on the number of playdates hosted or on teacher report of child social skills. Findings lend initial support to a treatment model that targets parental behaviors to address children's peer problems.

Understanding attention-deficit/hyperactivity disorder from childhood to adulthood

Attention deficit/hyperactivity disorder (ADHD) is among the most common neurobehavioral disorders requiring treatment in children and adolescents. The disorder is often chronic, with prominent symptoms and impairment spanning into adulthood. It is often associated with co-occurring disorders, including disruptive, mood, anxiety, and substance abuse disorders. The diagnosis of ADHD is clinically established by review of symptoms and impairment. The biological underpinning of the disorder is supported by genetic, neuroimaging, neurochemistry, and neuropsychological data. All aspects of an individual's life need to be considered in the diagnosis and treatment of ADHD. Multimodal treatment includes educational, family, and individual support. Psychotherapy alone and in combination with medication is helpful for treating patients with ADHD and comorbid disorders. Pharmacotherapy, including stimulants, noradrenergic agents, α-agonists, and antidepressants, plays a fundamental role in the long-term management of ADHD.

Resilience in Families Living with a Child Diagnosed with Hyperactivity/Attention Deficit Disorder

There has been limited South African research to date on family resilience as well as on the resiliency of families living with children diagnosed with AD/HD. We aimed to explore and describe the factors that facilitate adjustment and adaptation in families after a child has been clinically diagnosed with AD/HD. The Resiliency Model of Family Stress, Adjustment and Adaptation served as a framework to conceptualize the families' adjustment and adaptation processes. The study was triangular in nature, with an exploratory, descriptive approach. Non-probability purposive sampling was used to gain participants for the study. A biographical questionnaire and seven structured questionnaires were used to gather data. The biographical data were analysed using descriptive statistics. Quantitative data were analysed by means of correlation analysis, and content analysis was used to analyse the qualitative data obtained from the open-ended question on the biographical questionnaire. While the results of the quantitative analysis and qualitative analysis yielded various results, some commonalities can be highlighted; social support, family time and routines, and incendiary (affirmative) communication. The study sample also demonstrated their ability to bounce back from the adversities that previous research consistently highlighted as difficulties in their context. The findings of the research can be incorporated into individual and family level interventions for families living with a child diagnosed with AD/HD.

Child and family therapy process: concordance of therapist and observational perspectives

The objective of this study is to examine the characteristics of outpatient mental health services delivered in community-based outpatient clinics, comparing information obtained from two different sources, therapists serving children and families, and observational coders viewing tapes of the same treatment sessions. Videotaped therapy sessions were rated by therapists and independent coders regarding goals and strategies pursued during each session. Sixty-three sessions were taped of outpatient care provided to 18 children and their caregivers by 11 therapists. Children were 4-13 years old and families were receiving services at least in part due to reported child behavior problems, confirmed by ratings from the Child Behavior Checklist and Conners Parent Rating Scale-Revised. Analyses assessed the frequency, type, and intensity of goals and strategies pursued in therapy sessions from both therapist and observational coders' perspectives. Reliability of observer ratings and correspondence between therapist and observer reports were also examined. The reliability of observational coding of goals and strategies was moderate to good, with 76% of 39 codes having ICCs of .5 or greater. Therapists reported pursuing 2.5 times more goals and strategies per session, on average, than identified by observational coders. Correspondence between therapists and coders about the occurrence of specific goals and strategies in treatment sessions was low, with 20.5% of codes having a Kappa of .4 or higher. Substantial differences exist in what therapists and independent coders report as occurring in outpatient treatment sessions. Both perspectives suggest major differences between the content of services provided in community-based outpatient clinics and the structure of evidence-based programs, which emphasize intense pursuit of a small number of goals and strategies in each treatment session. Implications of the findings for quality improvement efforts in community-based mental health care settings are discussed.

The influences of environmental enrichment, cognitive enhancement, and physical exercise on brain development: can we alter the developmental trajectory of ADHD?

Attention-deficit/Hyperactivity Disorder (ADHD) is characterized by a pervasive pattern of developmentally inappropriate inattentive, impulsive and hyperactive behaviors that typically begin during the preschool years and often persist into adulthood. The most effective and widely used treatments for ADHD are medication and behavior modification. These empirically-supported interventions are generally successful in reducing ADHD symptoms, but treatment effects are rarely maintained beyond the active intervention. Because ADHD is now generally thought of as a chronic disorder that is often present well into adolescence and early adulthood, the need for continued treatment throughout the lifetime is both costly and problematic for a number of logistical reasons. Therefore, it would be highly beneficial if treatments would have lasting effects that remain after the intervention is terminated. This review examines the burgeoning literature on the underlying neural determinants of ADHD along with research demonstrating powerful influences of environmental factors on brain development and functioning. Based upon these largely distinct scientific literatures, we propose an approach that employs directed play and physical exercise to promote brain growth which, in turn, could lead to the development of potentially more enduring treatments for the disorder.

The importance of friendship for youth with attention-deficit/hyperactivity disorder

It is well-established that youth with attention-deficit/hyperactivity disorder (ADHD) are often peer-rejected and rated by parents, teachers, and observers to have poor social skills, when compared to typically developing peers. Significantly less research, however, has been devoted to the experiences youth with ADHD have in their close friendships. The aim of this article is to draw attention to friendship as a distinct construct from peer rejection and social skills and to summarize what is known about youth with ADHD in their friendships. The potential for stable, high-quality friendships to buffer the negative outcomes typically conferred by peer rejection in this population is discussed. This article concludes with recommendations for interventions that specifically target improving the close friendships of youth with ADHD as a treatment strategy.

Ethnicity as a moderator of treatment effects on parent--child interaction for children with ADHD

OBJECTIVE

To examine ethnic differences in observed parenting and child behavior and the moderating effects of ethnicity on the relationship between treatment and parent and child behavior.

METHOD

Observations of 508 children with ADHD (ages 7-9) and their caregivers, collected during the Multimodal Treatment Study of ADHD, were analyzed using univariate and mixed-model ANOVAs.

RESULTS

Although baseline parenting practices differed by ethnic group, ethnicity did not moderate the relationship between treatment and either parenting or child behavior.

CONCLUSION

Consistent with data from normative samples, parents of children with ADHD differed by ethnicity in their utilization of certain parenting strategies. However, different ethnic groups did not differ on benefit received from treatments for ADHD, measured by parent and child behavior. Although ethnicity did not emerge as a moderator, ethnic minority family engagement in treatment may be increased by recognizing different parenting strategies and modifying interventions accordingly.

The importance of ADHD subtype classification for educational applications of DSM-V

OBJECTIVE

An examination of the academic achievement of children with ADHD by stimulant treatment status must consider this heterogeneity of the disorder. With the dissemination of the final wave of data, the Special Education Elementary Longitudinal Study presents an opportunity to examine the academic achievement of students with ADHD using a large, community-based, and nationally representative sample over 4 years.

METHOD

In Study 1, the association between stimulant treatment and academic achievement is examined over 4 years. In Study 2, the association between stimulant treatment and academic achievement is examined acknowledging the influence of subtype symptoms of ADHD using growth mixture modeling.

RESULTS

Results indicate significant differences in academic achievement according to long-term stimulant treatment status within each subtype symptom class.

CONCLUSION

Research should acknowledge the influence of subtype symptoms when examining outcomes such as academic achievement. The upcoming DSM-V should consider the results as indicating the educational relevance of ADHD subtype classification.

Practitioner review: Non-pharmacological treatments for ADHD: a lifespan approach

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a chronic and pervasive developmental disorder that is not restricted to the childhood years.

METHODS

This paper reviews non-pharmacological interventions that are available at present for preschoolers, school-age children, adolescents and adults.

RESULTS

The most appropriate intervention for preschoolers is parent training. For school-age children with moderate impairments there is some evidence to suggest that group parent training programmes and classroom behavioural interventions may suffice as a first-line treatment. For school-age children with severe impairments, interventions are more appropriate when combined with stimulant medication (i.e., integrated treatment packages are likely to be more successful than 'standalone' treatments). Multimodal interventions seem to be best suited for middle school/adolescent children, which most likely reflects that these interventions usually integrate home and school treatment strategies and often include an element of social skills training. Stimulant medication is generally the first line of treatment for adults but CBT has also been found to be effective at addressing the complex needs of this population.

CONCLUSION

Current research has largely ignored that ADHD is a developmental disorder that spans the preschool to adult years. Most studies focus on young school-age children and outside of this age group there is a dearth of controlled trials that provide conclusive evidence. As children mature the mode and agent of intervention will shift to reflect the developmental needs and circumstances of the individual.

Stimulant treatment reduces lapses in attention among children with ADHD: the effects of methylphenidate on intra-individual response time distributions

Recent research has suggested that intra-individual variability in reaction time (RT) distributions of children with ADHD is characterized by a particularly large rightward skew that may reflect lapses in attention. The purpose of the study was to provide the first randomized, placebo-controlled test of the effects of the stimulant methylphenidate (MPH) on this tail and other RT distribution characteristics. Participants were 49 9- to 12-year-old children with ADHD. Children participated in a 3-day double-blind, placebo-controlled medication assessment during which they received long-acting MPH (Concerta), with the nearest equivalents of 0.3 and 0.6 mg/kg t.i.d. immediate-release MPH. Children completed a simple two-choice speeded discrimination task on and off of medication. Mode RT and deviation from the mode were used to examine the peak and skew, respectively, of RT distributions. MPH significantly reduced the peak and skew of RT distributions. Importantly, the two medication effects were uncorrelated suggesting that MPH works to improve both the speed and variability in responding. The improvement in variability with stimulant treatment is interpreted as a reduction in lapses in attention. This, in turn, may reflect stimulant enhancement of self-regulatory processes theorized to be at the core of ADHD.

Behavioral parent training as an adjunct to routine care in children with attention-deficit/hyperactivity disorder: moderators of treatment response

OBJECTIVE

To investigate predictors and moderators of outcome of behavioral parent training (BPT) as adjunct to ongoing routine clinical care (RCC), versus RCC alone.

METHODS

We randomly assigned 94 referred children (4-12 years) with attention-deficit/hyperactivity disorder (ADHD) to BPT plus RCC or RCC alone. Outcome was based on parent-reported behavioral problems and ADHD symptoms. Predictor/moderator variables included children's IQ, age, and comorbidity profile, and maternal ADHD, depression, and parenting self-efficacy.

RESULTS

Superior BPT treatment effects on behavioral problems and ADHD symptoms were present in children with no or single-type comorbidity-anxiety/depression or oppositional defiant disorder (ODD)/conduct disorder (CD)-and when mothers had high parenting self-efficacy, but absent in children with broad comorbidity (anxiety/depression and ODD/CD) and when mothers had low parenting self-efficacy. In older children ADHD symptoms tended to decrease more through BPT than in younger children.

CONCLUSIONS

Adjunctive BPT is most useful when mothers have high parenting self-efficacy and in children with no or single-type comorbidity.

The Community Parent Education Program (COPE): treatment effects in a clinical and a community-based sample

The present study is the first European evaluation of the Canadian parent training programme called Community Parent Education Program (COPE). In addition, it is the first to examine the effects of the COPE programme in different types of clinical and nonclinical samples. The main findings were that COPE was found to be effective in reducing conduct problems, hyperactivity/impulsivity, daily problem behaviours, parental stress, and lack of perceived parental control. However, the programme was not effective in reducing inattention, social competence deficits, or peer problems. Interestingly, the significant group effects were a result of significant differences between the two nonclinical intervention groups and the waiting-list control group, whereas the clinical intervention group did not differ significantly from the control group with regard to either child or parental variables. This points to the importance of evaluating parent training programmes in groups with different levels of severity so that parents are offered the type of training programme most suitable for their child's needs.

Is neurofeedback an efficacious treatment for ADHD? A randomised controlled clinical trial

BACKGROUND

For children with attention deficit/hyperactivity disorder (ADHD), a reduction of inattention, impulsivity and hyperactivity by neurofeedback (NF) has been reported in several studies. But so far, unspecific training effects have not been adequately controlled for and/or studies do not provide sufficient statistical power. To overcome these methodological shortcomings we evaluated the clinical efficacy of neurofeedback in children with ADHD in a multisite randomised controlled study using a computerised attention skills training as a control condition.

METHODS

102 children with ADHD, aged 8 to 12 years, participated in the study. Children performed either 36 sessions of NF training or a computerised attention skills training within two blocks of about four weeks each (randomised group assignment). The combined NF treatment consisted of one block of theta/beta training and one block of slow cortical potential (SCP) training. Pre-training, intermediate and post-training assessment encompassed several behaviour rating scales (e.g., the German ADHD rating scale, FBB-HKS) completed by parents and teachers. Evaluation ('placebo') scales were applied to control for parental expectations and satisfaction with the treatment.

RESULTS

For parent and teacher ratings, improvements in the NF group were superior to those of the control group. For the parent-rated FBB-HKS total score (primary outcome measure), the effect size was .60. Comparable effects were obtained for the two NF protocols (theta/beta training, SCP training). Parental attitude towards the treatment did not differ between NF and control group.

CONCLUSIONS

Superiority of the combined NF training indicates clinical efficacy of NF in children with ADHD. Future studies should further address the specificity of effects and how to optimise the benefit of NF as treatment module for ADHD.

Parent-child interaction therapy for Puerto Rican preschool children with ADHD and behavior problems: a pilot efficacy study

This study evaluates the initial efficacy of the Parent-Child Interaction Therapy (PCIT) for Puerto Rican preschool children aged 4-6 years with a diagnosis of attention-deficit/hyperactivity disorder (ADHD), combined or predominantly hyperactive type, and significant behavior problems. Thirty-two families were randomly assigned to PCIT (n = 20) or a 3.5-month waiting-list condition (WL; n = 12). Participants from both groups completed pretreatment and posttreatment assessments. Outcome measures included child's ADHD symptoms and behavior problems, parent or family functioning, and parents' satisfaction with treatment. ANCOVAs with pretreatment measures entered as covariates were significant for all posttreatment outcomes, except mother's depression, and in the expected direction (p < .01). Mothers reported a highly significant reduction in pretreatment hyperactivity and inattention and less aggressive and oppositional-defiant behaviors, conduct problems assessed as problematic, parenting stress associated with their child's behavior, and an increase in the use of adequate parenting practices. For the WL group, there were no clinically significant changes in any measure. Treatment gains obtained after treatment were maintained at a 3.5-month follow-up assessment. PCIT seems to be an efficacious intervention for Puerto Rican families who have young children with significant behavior problems.

Are there placebo effects in the medication treatment of children with attention-deficit hyperactivity disorder?

Placebos have been shown to produce significant positive changes in several health and mental health problems, referred to as placebo effects. Although it is well established that stimulant medication is an empirically supported treatment for children with attention-deficit hyperactivity disorder (ADHD), little is known about the role of placebos in the medication treatment of children with ADHD. This article reviews existing studies that evaluate whether placebos produce significant changes in children with ADHD. Published literature and the author's own empirical work were used to evaluate whether placebo effects are present in the medication treatment of children with ADHD. There is little evidence that placebos produce significant changes in the behavior or cognition of elementary school-age children with ADHD. However, there may be significant placebo effects in adults who evaluate children with ADHD. Evidence suggests that parents and teachers tend to evaluate children with ADHD more positively when they believe the child has been administered stimulant medication and they tend to attribute positive changes to medication even when medication has not actually been administered. Several viable mechanisms for these placebo effects are suggested.

Psychosocial treatments for preschool-aged children with Attention-Deficit Hyperactivity Disorder

This article reviews the research literature on psychosocial treatments for preschool-aged children with Attention-Deficit Hyperactivity Disorder (ADHD) in the context of the developmental and contextual needs of this population (e.g., increased parenting demands, differences in classroom structure, and the child's emerging developmental capacities). Discussion of the findings and limitations of existing studies is provided for parent-training approaches, classroom management strategies, and multimodal treatments. Although the empirical base is quite small for ADHD-specific samples, parent-training interventions have the greatest overall support for improving behavioral outcomes, with a variety of different approaches having shown effectiveness. Very few studies of classroom management and multimodal interventions have been conducted in this age group; however, initial data show promising results for teacher training and consultation interventions. The body of research suggests that the most effective treatments for clinical samples of preschoolers with ADHD and their families may be individually delivered, developmentally appropriate, and multimodal.

Versorgungsstudie zum Marburger Konzentrationstraining (MKT) bei Grundschulkindern mit Symptomen einer Aktivitäts- und Aufmerksamkeitsstörung

In der vorliegenden Versorgungsstudie wurden die Effekte des „Marburger Konzentrationstraining“ (MKT, Krowatschek, 2000 ) untersucht. 125 Grundschulkinder im Alter von 6 – 11 Jahren mit unterschiedlich stark ausgeprägten Symptomen einer Aktivitäts- und Aufmerksamkeitsstörung und ihre Eltern nahmen an dem in Kleingruppen durchgeführten kognitiv-behavioralen Training teil. Die ADHS-Symptome der Kinder wurden vor der Intervention, direkt danach und drei Monate nach Abschluss derselben erhoben. Im jeweiligen Vorher-Nachher-Vergleich ergab sich ein Rückgang der Symptomatik im Elternurteil direkt nach dem Training. Bei der Follow-up-Befragung zeigte sich eine weitere signifikante Verringerung der Unaufmerksamkeitssymptome. Zusätzlich wurde erhöhte Selbstständigkeit der Kinder in der Hausaufgabensituation sowohl während des Trainings als auch in den drei Monaten danach berichtet. Es zeigt sich hier also ein positiver Effekt einer relativ niederschwelligen und kurzzeitigen Intervention.

A pilot study of the feasibility and efficacy of the Strategies to Enhance Positive Parenting (STEPP) program for single mothers of children with ADHD

OBJECTIVE

The Strategies to Enhance Positive Parenting (STEPP) program was developed to address putative factors related to poor engagement in and outcomes following traditional behavioral parent training (BPT) for single mothers of children diagnosed with ADHD.

METHOD

Twelve single mothers of children with ADHD were enrolled in an initial investigation of the feasibility and preliminary efficacy of the 9-week STEPP program.

RESULTS

Results indicated that the STEPP program was effective in reducing problematic child behavior and improving parental stress and psychopathology at posttreatment. The STEPP program resulted in high rates of treatment attendance and completion and consumer satisfaction with the program. However, results also indicated that the STEPP program did not improve childrens' overall psychosocial impairment and resulted in small effect size findings across measures.

CONCLUSION

The results of the pilot study are encouraging but indicate a need to improve the potency and delivery of certain aspects of the STEPP program.

Impact of attention-deficit/hyperactivity disorder on the patient and family: results from a European survey

BACKGROUND

Children with attention-deficit/hyperactivity disorder (ADHD) often experience problems with education, interaction with others and emotional disturbances. Families of ADHD children also suffer a significant burden, in terms of strain on relationships and reduced work productivity. This parent survey assessed daily life for children with ADHD and their families.

METHOD

This pan-European survey involved the completion of an on-line questionnaire by parents of children (6-18 years) with ADHD (ADHD sample) and without ADHD (normative population sample). Parents were questioned about the impact of their child's ADHD on everyday activities, general behaviour and family relationships.

RESULTS

The ADHD sample comprised 910 parents and the normative population sample 995 parents. 62% of ADHD children were not currently receiving medication; 15% were receiving 6-8 hour stimulant medication and 23% 12-hour stimulant medication. Compared with the normative population sample, parents reported that ADHD children consistently displayed more demanding, noisy, disruptive, disorganised and impulsive behaviour. Significantly more parents reported that ADHD children experienced challenges throughout the day, from morning until bedtime, compared with the normative population sample. Parents reported that children with ADHD receiving 12-hour stimulant medication experienced fewer challenges during early afternoon and late afternoon/early evening than children receiving 6-8 hour stimulant medication; by late evening and bedtime however, this difference was not apparent. ADHD was reported to impact most significantly on activities such as homework, family routines and playing with other children. All relationships between ADHD children and others were also negatively affected, especially those between parent and child (72% of respondents). Parents reported that more children with ADHD experienced a personal injury in the preceding 12 months, including those requiring the attention of healthcare professionals. Although 68% of parents were satisfied with their child's current treatment, 35-40% stated that their child's ADHD symptoms needed to be more effectively treated during the afternoon and evening.

CONCLUSION

This parent survey highlights the breadth of problems experienced by ADHD children and the impact throughout the day on both activities and relationships. Therefore, there is a need for treatment approaches that take into account the 24-hour impact of the disorder and include all-day coverage with effective medication.

Attention deficit/hyperactivity disorder: a review and update

Attention deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and pervasive childhood disorder characterized by developmentally inappropriate activity level, impulsivity, and inability to sustain attention and concentration. Core symptoms of the disorder are associated with impairment in multiple domains of functioning and often coexist with other psychiatric disorders, the most prevalent being oppositional defiant disorder, conduct disorder, depression, and anxiety disorders. Concerns have been expressed about the overdiagnosis of ADHD, an upsurge in prescription of stimulant medication, and wide variations in practice patterns related to diagnosis and treatment of children with ADHD among primary care providers. Clinical research and expert consensus guidelines over the past decade have increasingly clarified the most effective approaches to diagnosis and treatment of the disorder. Hence, the purpose of this article was to provide primary care providers with the most current, evidence-based information on the assessment and treatment of children with ADHD.

Psychopharmacological and other treatments in preschool children with attention-deficit/hyperactivity disorder: current evidence and practice

OBJECTIVE

This article reviews rational approaches to treating attention-deficit/hyperactivity disorder (ADHD) in preschool children, including pharmacological and nonpharmacological treatments. Implications for clinical practice are discussed.

DATA SOURCES

We searched MEDLINE, PsychINFO, Cumulative Index to Nursing & Allied Health, Educational Resources Information Center, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects for relevant literature published in English from 1967 to 2007 on preschool ADHD. We also reviewed the references cited in identified reports.

STUDY SELECTION

Studies were reviewed if the sample included at least some children younger than 6 years of age or attending kindergarten, the study participants had a diagnosis of ADHD or equivalent symptoms, received intervention aimed at ADHD symptoms, and included a relevant outcome measure.

DATA EXTRACTION

Studies were reviewed for type of intervention and outcome relevant to ADHD and were rated for the level of evidence for adequacy of the data to inform clinical practice.

CONCLUSIONS

The current level of evidence for adequacy of empirical data to inform clinical practice for short-term treatment of ADHD in preschool children is Level A for methylphenidate and Level B for parent behavior training, child training, and additive-free elimination diet.

Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder

Pelham, Wheeler, and Chronis (1998) reviewed the treatment literature on attention-deficit/hyperactivity disorder (ADHD) and concluded behavioral parent training (BPT) and behavioral classroom management (BCM) were well-established treatments for children with ADHD. This review updates and extends the finding of the prior review. Studies conducted since the 1998 review were identified and coded based on standard criteria, and effect sizes were calculated where appropriate. The review reinforces the conclusions of Pelham, Wheeler, and Chronis regarding BPT and BCM. Further, the review shows that intensive peer-focused behavioral interventions implemented in recreational settings (e.g., summer programs) are also well-established. The results of this update are discussed in the context of the existing treatment literature on ADHD. Implications for practice guidelines are suggested, as are directions for future research.

The effects of incentives on visual-spatial working memory in children with attention-deficit/hyperactivity disorder

Working memory is one of several putative core neurocognitive processes in attention-deficit/hyperactivity disorder (ADHD). The present work seeks to determine whether visual-spatial working memory is sensitive to motivational incentives, a laboratory analogue of behavioral treatment. Participants were 21 children (ages 7-10) with a diagnosis of ADHD-combined type. Participants completed a computerized spatial span task designed to assess storage of visual-spatial information (forward span) and manipulation of the stored information (backward span). The spatial span task was completed twice on the same day, once with a performance-based incentive (trial-wise feedback and points redeemable for prizes) and once without incentives. Participants performed significantly better on the backward span when rewarded for correct responses, compared to the no incentive condition. However, incentives had no effect on performance during the forward span. These findings may suggest the use of motivational incentives improved manipulation, but not storage, of visual-spatial information among children with ADHD. Possible explanations for the differential incentive effects are discussed, including the possibility that incentives prevented a vigilance decrement as task difficulty and time on task increased.

The transition to middle school is associated with changes in the developmental trajectory of ADHD symptomatology in young adolescents with ADHD

The attention deficit hyperactivity disorder (ADHD) symptom presentation of young adolescents with ADHD was examined in association with the transition to middle school. This study used data collected in the Multimodal Treatment Study of ADHD, which included children between 7 and 9 years of age with a diagnosis of ADHD (n = 258) and grade- and sex-matched controls (n = 112). The trajectory of ADHD symptoms before, during, and after the transition to middle school was modeled using hierarchical linear modeling. A clear developmental reduction in ADHD symptomatology was observed for all three ADHD symptom domains. For young adolescents with ADHD, the transition to middle school was associated with a disruption in the developmental decline of inattention, hyperactivity, and impulsivity symptoms as measured by parent ratings. This effect was also observed for teacher ratings of inattention and hyperactivity. These results support the assertion that the environmental changes associated with transitioning to middle school coincide with a transient reversal in ADHD symptom decline among children with ADHD.

Use of Stimulus Fading and Functional Assessment to Treat Pill Refusal With an 8-Year-Old Boy Diagnosed With ADHD

Pharmacological treatments improve functioning for many of the core problems characteristic of attention deficit/hyperactivity disorder (ADHD). Pharmacological treatment is also useful when delivered in combination with behavior management procedures. However, many children find swallowing pills and capsules difficult, and many refuse treatment outright. There are limited resources available to parents confronted with their children's pill refusal behaviors, especially when these difficulties are not because of skills- or anxiety-related problems. This study describes the use of stimulus fading and functional assessment to eliminate pill refusal with an 8-year-old boy diagnosed with ADHD. The study is a replication and extension of procedures described by Anderson, Ruggiero, and Adams to facilitate pill swallowing for a child diagnosed with HIV. Completely independent pill swallowing was achieved after 12 sessions of stimulus fading supplemented by a functional behavioral assessment. Functional assessment suggested that pill refusal behavior was related to positive (attention) and negative (avoidance) reinforcement.

Attention deficit hyperactivity disorder in preschool children

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with a childhood onset of symptoms and impairment. Although it is most frequently identified during elementary school years, epidemiologic data suggest that the onset of ADHD frequently occurs earlier, with presentation as young as 3 years of age. Early identification, however, allows consideration of appropriate interventions. Many data are available on safe and efficacious treatment options for school-aged children who have ADHD; however, little is known about the use of these modalities in preschoolers and, ultimately, the long-term effects of early treatment. Recognition of the preschool presentation of ADHD, appropriate differential diagnosis, and identification of comorbid conditions, and a developmental perspective on the course and potential outcomes of the disorder may guide treatment planning. Newly available data on the safety and efficacy of pharmacotherapy and psychosocial intervention for preschoolers who have ADHD may help clinicians make treatment decisions for these young children and their families.

Psychosocial interventions in attention deficit hyperactivity disorder

This brief overview of psychosocial treatment approaches to attention deficit hyperactivity disorder (ADHD) concentrates on the two that receive the greatest research support, parent training in child behavior management and teacher training in classroom management. Cognitive-behavioral training of children who have ADHD has little evidence of efficacy and group social skills training has mixed or limited evidence of effectiveness. Research should focus on more theoretically driven psychosocial treatment approaches, on potential side effects or adverse events associated with this form of intervention, and on the complex pathways that affect impairment in major life activities that could guide subsequent treatment design for such impairments.