Psychosocial and combined treatments for ADHD

Clinical practice guidelines for attention-deficit/hyperactivity disorder: recent updates

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders found in children and adolescents. The American Academy of Pediatrics (AAP) first published a clinical practice guideline on ADHD in 2000, which was revised in 2011 and republished together with an accompanying process-of-care algorithm. More recently, the 2019 clinical practice guideline revision was published. Since the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), was released. In addition, the Society of Developmental and Behavioral Pediatrics (SDBP) recently released another clinical practice guideline for complex ADHD. Although there are nonessential changes reflected in these updates, a number of changes have still been made; for example, the DSM-5 criteria lowered the diagnostic threshold for ADHD in older teens and adults. Additionally, the criteria were revised to facilitate application to older teens and adults, and a comorbid diagnosis with autism spectrum disorder is now allowed. Meanwhile, the 2019 AAP guideline added the recommendation related to comorbid conditions with ADHD. Lastly, SDBP developed a complex ADHD guideline, covering areas such as comorbid conditions, moderate-to-severe impairment, treatment failure, and diagnostic uncertainty. In addition, other national ADHD guidelines have been published, as have European guidelines for managing ADHD during the coronavirus disease 2019 pandemic. To facilitate ADHD management in a primary care, it is important to provide and review clinical guidelines and recent updates. In this article, we will review and summarize the recent clinical guidelines and their updates.

The Effect of Parenting Programme on the Symptoms and the Family Functioning of Children with Attention Deficit and Hyperactivity Disorder Who Have Residual Symptoms Despite Medical Treatment

This study aims to determine the effects of the Parents Plus Children's Programme (PPCP) on children's symptoms of attention deficit and hyperactivity disorder (ADHD) and on family functionality and parenting stress. The children in the study were aged 6–11 years, and they had been diagnosed with ADHD and had residual symptoms despite effective dosage and timing of their medication. Forty-six couples, who with their children met the eligibility criteria, were enrolled and randomly allocated to the PPCP or the control group. The intervention involved a 9-week, 2 h a week, parenting group exercise. Those in the PPCP group improved significantly more over time on Conners’ Parent Rating Scale-Revised, Family Assessment Device, and Parent Stress Index than those in the control condition. The trial is the first clinical study involving the parents of children with ADHD that addresses residual symptoms and functional impairments that remain despite the administration of the maximum effective dose of pharmacological treatment.

Maternal depressive and anxiety symptoms and the risk of attention deficit hyperactivity disorder symptoms in offspring aged 17: Findings from the Raine Study

BACKGROUND

While previous studies have suggested that maternal anxiety and depressive symptoms are associated with increased risk of attention-deficit/hyperactivity disorder (ADHD) in their offspring in early and late childhood, studies exploring the risk in late adolescence are however lacking. This study aims to examine the association between maternal anxiety and depressive symptoms and the risk of ADHD symptoms in late adolescence (at age 17).

METHODS

We used data from the Raine Study. Maternal depressive and anxiety symptoms were measured when the child was 10 years of age using the Depression, Anxiety, and Stress Scale (DASS). Offspring ADHD symptoms at age 17 were assessed using the DSM-oriented scales of the child behavior checklist (CBCL). Log-binomial regression was used to explore the associations.

RESULTS

We found an increased risk of ADHD symptoms in offspring of mothers with comorbid anxiety and depressive symptoms when compared with offspring of mothers with no symptoms [RR 5.60 (95%CI 3.02-10.37)]. There was a nearly three-fold increase in the risk of ADHD symptoms in offspring of mothers with increased anxiety symptoms compared with offspring of mothers who were in the normal range [RR 2.84 (95%CI 1.18-6.83)]. No association was observed with maternal depressive symptoms.

CONCLUSION

This study found an increased risk of ADHD symptoms in the offspring of mothers with anxiety as well as comorbid anxiety and depressive symptoms but not among the offspring of mothers with depressive symptoms. Early screening and intervention for ADHD symptoms in offspring with maternal anxiety and comorbid anxiety and depressive symptoms are warranted.

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Attention-deficit/hyperactivity disorder (ADHD) is 1 of the most common neurobehavioral disorders of childhood and can profoundly affect children's academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for evaluation and diagnosis of pediatric ADHD in 2000; recommendations for treatment followed in 2001. The guidelines were revised in 2011 and published with an accompanying process of care algorithm (PoCA) providing discrete and manageable steps by which clinicians could fulfill the clinical guideline's recommendations. Since the release of the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders has been revised to the fifth edition, and new ADHD-related research has been published. These publications do not support dramatic changes to the previous recommendations. Therefore, only incremental updates have been made in this guideline revision, including the addition of a key action statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying process of care algorithm has also been updated to assist in implementing the guideline recommendations. Throughout the process of revising the guideline and algorithm, numerous systemic barriers were identified that restrict and/or hamper pediatric clinicians' ability to adopt their recommendations. Therefore, the subcommittee created a companion article (available in the Supplemental Information) on systemic barriers to the care of children and adolescents with ADHD, which identifies the major systemic-level barriers and presents recommendations to address those barriers; in this article, we support the recommendations of the clinical practice guideline and accompanying process of care algorithm.

Group cognitive behavioral therapy for children and adolescents with ADHD

The present study analyzed the use of group CBT protocol to treat ADHD by comparing two types of treatment, unimodal (medication only) and multimodal (medication combined with CBT), in terms of their effects on cognitive and behavioral domains, social skills, and type of treatment effect by ADHD subtype. Participants were 60 children with ADHD, subtypes inattentive and combined, aged 7 to 14, 48 boys. Combined treatment included 20 CBT sessions while all children were given Ritalin LA® 20 mg. Cognitive and behavioral outcome measures showed no differences between treatment groups. On social skills, multimodal showed more improvement in frequency indicators on empathy, assertiveness, and self-control subscales and in the difficulty on assertiveness and self-control subscales. Using a group CBT protocol for multimodal ADHD treatment may improve patient adherence and ADHD peripheral symptoms.

Racial and Ethnic Differences in ADHD Treatment Quality Among Medicaid-Enrolled Youth

OBJECTIVES

We estimated racial/ethnic differences in attention-deficit/hyperactivity disorder (ADHD) care quality and treatment continuity among Medicaid-enrolled children.

METHODS

Using Medicaid data from 9 states (2008 to 2011), we identified 172 322 youth (age 6 to 12) initiating ADHD medication. Outcome measures included: (1) adequate follow-up care in the (a) initiation and (b) continuation and maintenance (C&M) treatment phases; (2) combined treatment with medication and psychotherapy (versus medication alone); (3) medication discontinuation; and (4) treatment disengagement (ie, discontinued medication and received no psychotherapy). Logistic regressions controlled for confounding measures.

RESULTS

Among those initiating medication, three-fifths received adequate follow-up care in the initiation and C&M phases, and under two-fifths received combined treatment. Compared with whites, African American youth were less likely to receive adequate follow-up in either phase (P < .05), whereas Hispanic youth were more likely to receive adequate follow-up in the C&M phase (P < .001). African American and Hispanic youth were more likely than whites to receive combined treatment (P < .05). Over three-fifths discontinued medication, and over four-tenths disengaged from treatment. Compared with whites, African American and Hispanic children were 22.4% and 16.7% points more likely to discontinue medication, and 13.1% and 9.4% points more likely to disengage from treatment, respectively (P < .001).

CONCLUSIONS

Care quality for Medicaid-enrolled youth initiating ADHD medication is poor, and racial/ethnic differences in these measures are mixed. The most important disparities occur in the higher rates of medication discontinuation among minorities, which translate into higher rates of treatment disengagement because most youth discontinuing medication receive no psychotherapy.

Occupational Therapy for Children with Attention Deficit Hyperactivity Disorder (ADHD), Part 1: A Delineation Model of Practice

An occupational therapy delineation model of practice is presented, which guides a multidimensional understanding of the psychopathology of attention deficit hyperactivity disorder (ADHD) and its management. Previous research has established that occupational therapists lack detailed training or theory in this field. The delineation model of practice is based on a literature review, clinical experience and a consensus study carried out with occupational therapists to determine their priorities for the evaluation of, and intervention with, children with ADHD.

Part 1 of this article presents the model and examines its implications for evaluation and intervention at the levels of child, task and environment. A family-centred assessment and treatment package, based on the delineation model, is described. Part 2 of this article will report the results of a multicentre study, which was designed to evaluate the effectiveness of this package.

Connectivity Analysis and Feature Classification in Attention Deficit Hyperactivity Disorder Sub-Types: A Task Functional Magnetic Resonance Imaging Study

Attention deficit hyperactivity disorder (ADHD) is a pervasive neuropsychiatric disorder. Patients with different ADHD subtypes show different behaviors under different stimuli and thus might require differential approaches to treatment. This study explores connectivity differences between ADHD subtypes and attempts to classify these subtypes based on neuroimaging features. A total of 34 patients (13 ADHD-IA and 21 ADHD-C subtypes) underwent functional magnetic resonance imaging (fMRI) with six task paradigms. Connectivity differences between ADHD subtypes were assessed for the whole brain in each task paradigm. Connectivity measures of the identified regions were used as features for the support vector machine classifier to distinguish between ADHD subtypes. The effectiveness of connectivity measures of the regions were tested by predicting ADHD-related Diagnostic and Statistical Manual of Mental Disorders (DSM) scores. Significant connectivity differences between ADHD subtypes were identified mainly in the frontal, cingulate, and parietal cortices and partially in the temporal, occipital cortices and cerebellum. Classifier accuracy for distinguishing between ADHD subtypes was 91.18 % for both gambling punishment and emotion task paradigms. Linear prediction under the two task paradigms showed significant correlation with DSM hyperactive/impulsive score. Our study identified important brain regions from connectivity analysis based on an fMRI paradigm using gambling punishment and emotion task paradigms. The regions and associated connectivity measures could serve as features to distinguish between ADHD subtypes.

Treatment of Attention Deficit/Hyperactivity Disorder among Children with Special Health Care Needs

OBJECTIVES

To describe the parent-reported prevalence of treatments for attention deficit/hyperactivity disorder (ADHD) among a national sample of children with special health care needs (CSHCN), and assess the alignment of ADHD treatment with current American Academy of Pediatrics guidelines.

STUDY DESIGN

Parent-reported data from the 2009-2010 National Survey of Children with Special Health Care Needs allowed for weighted national and state-based prevalence estimates of medication, behavioral therapy, and dietary supplement use for ADHD treatment among CSHCN aged 4-17 years with current ADHD. National estimates were compared across demographic groups, ADHD severity, and comorbidities. Medication treatment by drug class was described.

RESULTS

Of CSHCN with current ADHD, 74.0% had received medication treatment in the past week, 44.0% had received behavioral therapy in the past year, and 10.2% used dietary supplements for ADHD in the past year. Overall, 87.3% had received past week medication treatment or past year behavioral therapy (both, 30.7%; neither, 12.7%). Among preschool-aged CSHCN with ADHD, 25.4% received medication treatment alone, 31.9% received behavioral therapy alone, 21.2% received both treatments, and 21.4% received neither treatment. Central nervous system stimulants were the most common medication class (84.8%) among CSHCN with ADHD, followed by the selective norepinephrine reuptake inhibitor atomoxetine (8.4%).

CONCLUSION

These estimates provide a benchmark of clinical practice for the period directly preceding issuance of the American Academy of Pediatrics' 2011 ADHD guidelines. Most children with ADHD received medication treatment or behavioral therapy; just under one-third received both. Multimodal treatment was most common for CSHCN with severe ADHD and those with comorbidities. Approximately one-half of preschoolers received behavioral therapy, the recommended first-line treatment for this age group.

Behavioral interventions in attention-deficit/hyperactivity disorder: a meta-analysis of randomized controlled trials across multiple outcome domains

OBJECTIVE

Behavioral interventions are recommended as attention-deficit/hyperactivity disorder (ADHD) treatments. However, a recent meta-analysis found no effects on core ADHD symptoms when raters were probably blind to treatment allocation. The present analysis is extended to a broader range of child and parent outcomes.

METHOD

A systematic search in PubMed, Ovid, Web of Knowledge, ERIC, and CINAHAL databases (up to February 5, 2013) identified published randomized controlled trials measuring a range of patient and parent outcomes for children and adolescents diagnosed with ADHD (or who met validated cutoffs on rating scales).

RESULTS

Thirty-two of 2,057 nonduplicate screened records were analyzed. For assessments made by individuals closest to the treatment setting (usually unblinded), there were significant improvements in parenting quality (standardized mean difference [SMD] for positive parenting 0.68; SMD for negative parenting 0.57), parenting self-concept (SMD 0.37), and child ADHD (SMD 0.35), conduct problems (SMD 0.26), social skills (SMD 0.47), and academic performance (SMD 0.28). With probably blinded assessments, significant effects persisted for parenting (SMD for positive parenting 0.63; SMD for negative parenting 0.43) and conduct problems (SMD 0.31).

CONCLUSION

In contrast to the lack of blinded evidence of ADHD symptom decrease, behavioral interventions have positive effects on a range of other outcomes when used with patients with ADHD. There is blinded evidence that they improve parenting and decrease childhood conduct problems. These effects also may feed through into a more positive parenting self-concept but not improved parent mental well-being.

Nova Scotia Teachers’ ADHD Knowledge, Beliefs, and Classroom Management Practices

Attention-deficit/hyperactivity disorder (ADHD) has a significant impact on children’s social, emotional, and academic performance in school, and as such, teachers are in a good position to provide evidence-based interventions to help ensure optimal adjustment of their students. The current study examined teachers’ knowledge and beliefs about ADHD, their self-reported use of evidence-based instructional and behaviour management strategies in the classroom, and the relationships between knowledge, beliefs, and classroom practices. It was expected that teachers would have a moderate amount of knowledge about ADHD, mixed positive and negative beliefs about ADHD, that they would regularly use less intensive evidence-based behaviour management strategies, and that more knowledge and positive beliefs about ADHD would be correlated with higher use of effective classroom practices. Web-based questionnaires were completed by 113 teachers from six school boards across Nova Scotia. Results indicated that the mean teacher knowledge score was ~68% and that they had more knowledge about symptoms/diagnosis of ADHD and less knowledge about general ADHD facts and about evidence-based treatments. Teachers had slightly more positive than negative beliefs about ADHD and reported occasional use of evidence-based instructional and behaviour management practices in their classrooms. There was a significant correlation between teachers’ beliefs about ADHD and their use of evidence-based behaviour management practices, but there was no significant correlation between specific ADHD knowledge and classroom practices. Information gained from this study has implications for the content of ADHD teacher training and professional development programs as well as for school psychologists and those in teacher consultation roles.

ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children; the American Academy of Pediatrics first published clinical recommendations for the diagnosis and evaluation of ADHD in children in 2000; recommendations for treatment followed in 2001.

Executive impairment determines ADHD medication response: implications for academic achievement

Methylphenidate (MPH) often ameliorates attention-deficit/hyperactivity disorder (ADHD) behavioral dysfunction according to indirect informant reports and rating scales. The standard of care behavioral MPH titration approach seldom includes direct neuropsychological or academic assessment data to determine treatment efficacy. Documenting "cool" executive-working memory (EWM) and "hot" self-regulation (SR) neuropsychological impairments could aid in differential diagnosis of ADHD subtypes and determining cognitive and academic MPH response. In this study, children aged 6 to 16 with ADHD inattentive type (IT; n = 19) and combined type (n = 33)/hyperactive-impulsive type (n = 4) (CT) participated in double-blind placebo-controlled MPH trials with baseline and randomized placebo, low MPH dose, and high MPH dose conditions. EWM/ SR measures and behavior ratings/classroom observations were rank ordered separately across conditions, with nonparametric randomization tests conducted to determine individual MPH response. Participants were subsequently grouped according to their level of cool EWM and hot SR circuit dysfunction. Robust cognitive and behavioral MPH response was achieved for children with significant baseline EWM/SR impairment, yet response was poor for those with adequate EWM/ SR baseline performance. Even for strong MPH responders, the best dose for neuropsychological functioning was typically lower than the best dose for behavior. Findings offer one possible explanation for why long-term academic MPH treatment gains in ADHD have not been realized. Implications for academic achievement and medication titration practices for children with behaviorally diagnosed ADHD will be discussed.

Kognitive Kontrolle und Selbstregulation bei Kindern mit ADHS

Kinder mit ADHS sind unaufmerksam, impulsiv und hyperaktiv, was zu Lern- und Leistungsstörungen sowie zu Schwierigkeiten im Umgang mit Eltern, Lehrern und Gleichaltrigen führt. Aktuell wird ADHS im Zusammenhang mit Selbstregulationsdefiziten diskutiert. Demzufolge gehen die Probleme der von ADHS Betroffenen auf mangelnde Selbstregulationsfähigkeiten sowie defizitäre exekutive Funktionen und dabei vor allem auf mangelnde kognitive Kontrolle zurück. Folglich erscheinen Interventionen, die auf die Förderung der Selbstregulation abzielen (z. B. Wenn-Dann-Pläne) als vielversprechend für die Besserung einer ADHS-Symptomatik.

Ability of college students to simulate ADHD on objective measures of attention

OBJECTIVE

The authors examined the ability of college students to simulate ADHD symptoms on objective and self-report measures and the relationship between knowledge of ADHD and ability to simulate ADHD.

METHOD

Undergraduate students were assigned to a control or a simulated ADHD malingering condition and compared with a clinical AD/HD group. The authors used several clinical attentional measures and symptom validity tests to differentiate experimental groups via a series of multivariate procedures.

RESULTS

Simulators successfully feigned ADHD symptoms on a retrospective self-report measure. Moreover, knowledge of ADHD was unrelated to objective attentional measure performance. Overall, participants who simulated ADHD on some objective measures (i.e., specific Wechsler Adult Intelligence Scale-III [WAIS-III] subtests) showed similar performance to the clinical ADHD comparison sample.

CONCLUSION

The implications of these findings highlight the importance of relying on multiple vectors of information, be it objective, observational, self-report, or reports by others, when diagnosing ADHD and assessing factors related to potential secondary gain.

Maternal attributions, affect, and parenting in attention deficit hyperactivity disorder and comparison families

The goal of this study was to simultaneously examine maternal attributions, affect, and parenting in mothers of children with and without attention deficit hyperactivity disorder (ADHD) using a multimethod approach (vignettes, confederate child video clips, and video clips of mother's own child). Of the participants, 23 were 7- to 12-year-old children (19 boys, 4 girls) with ADHD and their mothers, and 29 were 7- to 12-year-old comparison children (21 boys, 8 girls) and their mothers. Results indicated that mothers of children with ADHD attributed inattentive-impulsive behavior to less controllable and intentional factors and reported more negative affect and power assertive parenting in response to it than comparison mothers. They also attributed this behavior to more internal factors than comparison mothers but only when viewing their own children and to more global/stable factors but only when viewing their own children or a confederate child. Interestingly, mothers of children with ADHD reported more positive parenting in response to prosocial behavior while attributing this behavior to less controllable and global/stable factors than comparison mothers; compliance also was seen as less controllable, global/stable, and intentional by mothers of children with ADHD.

Changes in social competence in young children treated because of conduct problems as viewed by multiple informants

In the present study changes in social competence were examined in a clinic sample of 127 children aged 4-8. The children were recruited to a controlled treatment study because of conduct problems at home and were randomised to the Incredible Years parent training (PT), combined PT and child therapy (CT) or a waiting-list control-group. Assessments were conducted pre- and post-treatment and at a one-year follow-up by multiple informants (mother, father, teacher and child). Parent training combined with child treatment showed most improvement in child social competence based on mother, father and child reports, however, father reports showed positive results for children treated with PT only. Treated mothers and fathers showed a decrease in correlations in their reports of social competence in the child after treatment as compared to parents in the waiting-list condition. No generalisation effects to peer-relationships in day-care/school were found, neither on teacher or child reports. A broad perspective using multiple informants from different settings is needed when effects of treatment of young children with conduct problems are evaluated and should include various aspects of social competence.

Maternal Depressive Symptomatology and Parenting Behavior: Exploration of Possible Mediators

Possible mediators of the relation between maternal depressive symptomatology and parenting behavior were examined for 96 children with ADHD and their mothers drawn from the Multimodal Treatment Study of Children with ADHD (MTA) as part of an add-on investigation conducted by two of the six MTA sites. General cognitions (i.e., maternal locus of control and self-esteem) and parenting-specific factors (i.e., maternal parenting efficacy and parenting stress) were examined as possible mediators. Findings provide initial support that maternal parenting stress, as well as maternal locus of control and self-esteem mediate the relation between maternal depressive symptomatology and parenting behavior. This provides support for the argument that some families of children with ADHD may benefit from an expanded version of parent management training that includes sessions directly targeting affective and cognitive factors in parents, similar to treatment programs used to treat childhood conduct problems.

Child and parent predictors of perceptions of parent--child relationship quality

OBJECTIVE/METHOD

Predictors of perceptions of parent-child relationship quality were examined for 175 children with ADHD, 119 comparison children, and parents of these children, drawn from the follow-up phase of the Multimodal Treatment Study of Children with ADHD.

RESULTS/CONCLUSION

Children with ADHD perceived their mothers and fathers as more power assertive than comparison children. Children higher on depressive symptomatology also perceived their mothers and fathers as less warm and more power assertive. Mothers perceived themselves as more power assertive and fathers perceived themselves as less warm if they were higher on depressive symptomatology themselves or had children with ADHD or higher levels of depressive symptomatology. Several interactions indicated that the association between child factors and parental perceptions of warmth and power assertion often depended on parental depressive symptomatology. The findings resolve a previous contradiction in the literature regarding the relationship between child depressive symptoms and parental perceptions of parent-child relationship quality.

A meta-analysis of combined treatments for children diagnosed with ADHD

OBJECTIVE

Meta-analytic procedures are used to review the literature of combined treatments of psychosocial and pharmacological treatments for children diagnosed with ADHD.

METHOD

Eight combined treatment studies meet specific inclusion and exclusion criteria regarding the core and peripheral features of the disorder.

RESULTS

The results of this study highlight the individual and average effect sizes within the categories of inattention, hyperactivity, impulsivity, social skills, and academics. These findings are compared with the effect sizes of meta-analytic findings previously reported in the pharmacological literature.

CONCLUSION

The results reveal large effect sizes for the core features of the disorder and the peripheral feature of social skills. A small effect size is found for the peripheral feature of academics. Findings are discussed in light of the paucity of included studies focused on combined treatments for ADHD.

Effectiveness of a school-based multicomponent program for the treatment of children with ADHD

The objective of this study was to evaluate the efficacy of a multicomponent program for treating attention-deficit/hyperactivity disorder (ADHD) carried out by teachers in a classroom context. Dependent measures included neuropsychological tasks, behavioral rating scales for parents and teachers, direct observation of behavior in the classroom, and academic records of children with ADHD. Fifty children with ADHD participated in the study. The teachers of 29 of the 50 students were trained in the use of behavior modification techniques, cognitive behavior strategies, and instructional management strategies. The other 21 students formed the control group. Parents' and teachers'ratings detected improvements in primary symptoms (inattention-disorganization, hyperactivity-impulsivity) and in behavioral difficulties usually associated with ADHD (e.g., antisocial behavior, psychopathological disorders, anxiety). Furthermore, the results showed increased academic scores, enhanced classroom behavioral observations, and improved teachers' knowledge about the strategies directed toward responding to the children's educational needs.

Once-a-day Concerta methylphenidate versus three-times-daily methylphenidate in laboratory and natural settings

OBJECTIVE

Methylphenidate (MPH), the most commonly prescribed drug for attention-deficit/hyperactivity disorder (ADHD), has a short half-life, which necessitates multiple daily doses. The need for multiple doses produces problems with medication administration during school and after-school hours, and therefore with compliance. Previous long-acting stimulants and preparations have shown effects equivalent to twice-daily dosing of MPH. This study tests the efficacy and duration of action, in natural and laboratory settings, of an extended-release MPH preparation designed to last 12 hours and therefore be equivalent to 3-times-daily dosing.

METHODS

Sixty-eight children with ADHD, 6 to 12 years old, participated in a within-subject, double-blind comparison of placebo, immediate-release (IR) MPH 3 times a day (tid), and Concerta, a once-daily MPH formulation. Three dosing levels of medication were used: 5 mg IR MPH tid/18 mg Concerta once a day (qd); 10 mg IR MPH tid/36 mg Concerta qd; and 15 mg IR MPH tid/54 mg Concerta qd. All children were currently medicated with MPH at enrollment, and each child's dose level was based on that child's MPH dosing before the study. The doses of Concerta were selected to be comparable to the daily doses of MPH that each child received. To achieve the ascending rate of MPH delivery determined by initial investigations to provide the necessary continuous coverage, Concerta doses were 20% higher on a daily basis than a comparable tid regimen of IR MPH. Children received each medication condition for 7 days. The investigation was conducted in the context of a background clinical behavioral intervention in both the natural environment and the laboratory setting. Parents received behavioral parent training and teachers were taught to establish a school-home daily report card (DRC). A DRC is a list of individual target behaviors that represent a child's most salient areas of impairment. Teachers set daily goals for each child's impairment targets, and parents provided rewards at home for goal attainment. Each weekday, teachers completed the DRC, and it was used as a dependent measure of individualized medication response. Teachers and parents also completed weekly standardized ratings of behavior and treatment effectiveness. To evaluate the time course of medication effects, children spent 12 hours in a laboratory setting on Saturdays and medication effects were measured using procedures and methods adapted from our summer treatment program. Measures of classroom behavior and academic productivity/accuracy were taken in a laboratory classroom setting during which children completed independent math and reading worksheets. Measures of social behavior were taken in structured, small-group board game settings and unstructured recess settings. Measures included behavior frequency counts, academic problems completed and accuracy, independent observations, teacher and counselor ratings, and individualized behavioral target goals. Reports of adverse events, sleep quality, and appetite were collected.

RESULTS

On virtually all measures in all settings, both drug conditions were significantly different from placebo, and the 2 drugs were not different from each other. In children's regular school settings, both medications improved behavior as measured by teacher ratings and individualized target behaviors (the DRC); these effects were seen into the evening as measured by parent ratings. In the laboratory setting, effects of Concerta were equivalent to tid MPH and lasted at least through 12 hours after dosing. Concerta was significantly superior to tid MPH on 2 parent rating scores, and when asked, more parents preferred Concerta than preferred tid IR MPH or placebo. Side effects on children's sleep and appetite were similar for the 2 preparations. In the lab setting, both medications improved productivity and accuracy on arithmetic seatwork assignments, disruptive and on-task behavior, and classroom rule following. Both medications improved children's rule following and negative behavior in small group board games, as well as in unstructured recess settings. Individual target behaviors also showed significant improvement with medication across domains in the laboratory setting. Children's behavior across settings deteriorated across the laboratory day, and the primary effect of medication was to prevent this deterioration as the day wore on. Results support the use of background behavioral treatment in clinical trials of stimulant medication, and illustrate the utility of a measure of individualized daily target goals (ie, the DRC) as an objective measure of medication response in both the laboratory and natural school settings.

CONCLUSION

This investigation clearly supports the efficacy of the Concerta long-acting formulation of MPH for parents who desire to have medication benefits for their child throughout the day and early evening. (ABSTRACT TRUNCATED)