The management of ADHD in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG)

Establishing the Research Priorities of ADHD Professionals: An International Delphi Study

OBJECTIVES

To determine ADHD research priorities from the perspective of ADHD professionals internationally.

METHOD

A two-stage modified Delphi design was used. In Stage 1 (qualitative), participants listed research questions relating to ADHD that they perceived to be most important (N = 132). In Stage 2 (quantitative), participants were then asked to rate each research question that was deemed appropriate (able to be researched and not already addressed by research) in terms of perceived importance (N = 180).

RESULTS

Stage 1 generated 382 research questions with 10 broad areas identified for example, co-occurring conditions and treatment, etc. The top 20 most important questions related to ADHD in women/girls, long-term medication use, non-pharmacological interventions, ADHD measurement/rating scales, and efficacy of emotional regulation interventions.

CONCLUSION

These results can inform an ADHD research agenda which represents the views of the individuals from major ADHD professional groups internationally. Parallel work is needed focusing on research priorities from the perspective of ADHD consumers.

Commentary: Using QbTest for monitoring pharmacological treatment response in ADHD - are we there yet?

Individuals with attention-deficit/hyperactivity disorder (ADHD) exhibit varied responses to pharmacological treatments (e.g. stimulants and non-stimulants). Accurately and promptly detecting treatment-related improvements, response failure, or deterioration poses significant challenges, as current monitoring primarily relies on subjective ratings. In this commentary, we critically evaluate the evidence supporting the use of QbTest for objectively monitoring ADHD treatment response in clinical practice. We also offer recommendations for future research, advocating for rigorous clinical trials and longitudinal studies to further explore the potential utilisation of QbTest and other tools for monitoring treatment responses in individuals with ADHD.

In silico molecular docking and in vitro analysis of atomoxetine

Although atomoxetine, a selective norepinephrine reuptake inhibitor, is widely used in the treatment of attention-deficit/hyperactivity disorder (ADHD), there is limited data on its cytogenetic effects. This study aimed to investigate the cytotoxicity and genotoxicity of atomoxetine in vivo and silico. Chromosome aberration and micronucleus assays were used to analyze the genotoxic effect of atomoxetine in human peripheral blood lymphocytes under culture conditions. The mitotic index was assessed for cytotoxic potential. For the docking analysis, DNA receptor (1BNA) was prepared with ChimeraX, and the Atomoxetine molecule was optimized by Avogadro2.0 software. In silico molecular docking analysis was carried out utilizing SwissDock online platform. The results obtained were visualized using ChimeraX and Pymol software. Atomoxetine doses of 9.6 µg/mL (equal to about 1.2 mg/kg as a maintenance dose), 14.4 µg/mL (equal about to 1.8 mg/kg as the highest dose systematically tested), 48.0 µg/mL (equal about to 6 mg/kg as five times the maintenance dose) and 96.0 µg/mL (equal about to 12 mg/kg as ten times the maintenance dose) were analyzed. The findings clearly indicate that atomoxetine has no genotoxic effect at the therapeutic dose. However, we observed genotoxic effects at 48.0 and 96.0 µg/mL doses. No strong binding affinity occurs in silico analyses. As one of the initial inquiries into the in silico and in vivo appraisal of atomoxetine's genotoxic impacts, the research has established that atomoxetine does not significantly affect the frequency of chromosomal damage or micronucleus formation. Genotoxic effects should be kept in mind at doses above clinical practice.

Research Review: Pharmacological and non-pharmacological treatments for adolescents with attention deficit/hyperactivity disorder - a systematic review of the literature

BACKGROUND

Attention Deficit/Hyperactivity Disorder (ADHD) demonstrates unique developmental manifestations in adolescence with implications for optimized, age-appropriate treatment. This 10-year update is the third in a series of systematic reviews examining the efficacy and safety of adolescent ADHD treatments. We broadly examined efficacy on ADHD symptoms, impairments, and other reported outcomes. Acute and long-term efficacy, and treatment moderators, were considered.

METHOD

We performed PubMed, EMBASE, and PsycINFO searches for articles published or in press from 2013 to 2024, integrated with hand search and randomized controlled trials (RCTs) identified in this series' earlier reviews. RCTs examining the safety or efficacy of interventions delivered to adolescents (ages 10.0-19.9) with a diagnosis of ADHD were included. Study characteristics were extracted and reviewed, quality of evidence was assessed using GRADE, and effect sizes were calculated for individual studies and illustrated using forest plots.

RESULTS

Sixty-three RCTs were identified. Quality of evidence ranged from high (medication; k = 29) to very low (nutrient supplementation, neurofeedback, occupational therapy; k = 1 each). Medications demonstrated consistent strong impact on ADHD symptoms and inconsistent impact on impairment. Diverse cognitive/behavioral treatments (C/BTs) demonstrated inconsistent impact on ADHD symptoms but strong and consistent impact on impairment and executive function skills, plus moderate benefits on internalizing symptoms. No interventions demonstrated significant safety concerns. Long-term maintenance (up to 3 years post-treatment) was demonstrated for C/BTs, though moderate quality of evidence was noted because participants cannot be fully blinded to receipt of treatment.

CONCLUSIONS

The effects of C/BTs and medication appear complementary, not duplicative. Combining medication and C/BT is advised at treatment outset to maximize engagement, maintenance, and response breadth (i.e. improving both ADHD symptoms/cognitive performance and coping skills/functional impairments). Engagement strategies (e.g. motivational interviewing) may facilitate uptake. Novel treatments do not yet demonstrate effects on ADHD symptoms or impairments in adolescents but remain a promising area for research.

The ADHD Assessment Quality Assurance Standard for Children and Teenagers (CAAQAS)

Around 5% of the children and teenagers worldwide are affected by Attention-Deficit/Hyperactivity Disorder [ADHD], making it a major public health concern. Recently, demand for assessments has substantially increased, putting strain on healthcare and waiting lists. There is concern that pressure to clear service bottlenecks is leading to variable quality and reliability of ADHD assessments in this population. The ADHD Assessment Quality Assurance Standard for Children and Teenagers [CAAQAS] aims to address this by proposing a quality framework for ADHD assessments in this population. CAAQAS is intended to complement formal training, provide support to clinicians, inform commissioners, and empower children, teenagers, and caregivers on what to expect from an assessment and assessment report. Our goal is to promote evidence-based high-quality assessments, improve diagnostic accuracy, and reduce the risks of overdiagnosis, misdiagnosis, and underdiagnosis. Seven key topics were identified by authors which guided the development of this expert consensus statement. It was agreed that a high-quality diagnostic assessment of ADHD in this population commences with advance preparation to facilitate engagement of the child or teenager and caregivers. The consensus agreed that the minimum/essential standards for assessing and diagnosing ADHD adopt a systematic approach from pre-assessment through assessment to post-diagnostic stage, enabling ADHD to be disentangled from differential diagnoses. The process applies multi-source information to inform an assessment of development history and early risk factors, history of physical, mental health and other neurodevelopmental conditions, family, educational, and social histories. Assessment of core ADHD symptoms should include specific developmentally appropriate examples of associated difficulties and impairments. Neuropsychiatric and physical comorbidities should be assessed and identified. Recommendations for report writing are intended to facilitate effective communication between ADHD specialists and other services, and we highlight the importance of linking the diagnosis to an appropriate post-diagnostic discussion. Further, we discuss core competencies required to conduct a diagnostic assessment of ADHD in children and teenagers.

Mental imagery for addressing mechanisms underlying motor impairments in children with attention deficit hyperactivity disorder (ADHD)

Children with attention deficit hyperactivity disorder (ADHD) exhibit various degrees of motor and cognitive impairments in fine and gross motor skills. These impairments impact social functioning, while also hindering academic achievement, self-esteem, and participation. Specifically, motor impairments are not fully addressed by current therapies. For example, approximately 50% of children with ADHD exhibit significant motor impairments, as per clinical measures, while the other 50% experience more impairments in motor planning, execution and control than do typically developed (TD) children. Such findings indicate that ADHD-specific mechanisms may be underpinning motor impairments. In this paper, we outline ADHD impairments in motor planning, execution, and control, and the potential role of two such mechanisms: internal motor representation and timing perception. Next, we suggest mental imagery as an approach for treating ADHD motor impairments, potentially through addressing internal motor representation and timing perception.

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of Well Parent Japan in routine care in Japan: The training and nurturing support for mothers (TRANSFORM) study

BACKGROUND

Well Parent Japan (WPJ) is a new hybrid group parent training programme combining sessions to improve mothers' psychological well-being with a culturally adapted version of the New Forest Parenting Programme (NFPP). This study investigates the effectiveness and cost-effectiveness of WPJ against treatment as usual (TAU) within Japanese child mental health services.

METHODS

TRANSFORM was a pragmatic multi-site randomised controlled trial (RCT) with two parallel arms. Altogether 124 mothers of 6-12-year-old children with DSM-5 ADHD were randomised to WPJ (n = 65) or TAU (n = 59). Participants were assessed at baseline, post-treatment and three-month follow-up. The primary outcome was parent-domain stress following intervention. Secondary outcomes included maternal reports of child-domain stress, parenting practices, parenting efficacy, mood, family strain, child behaviour and impairment. Objective measures of the parent-child relationship were collected at baseline and post-treatment. Data analysis was intention to treat (ITT) with treatment effects quantified through analysis of covariance (ANCOVA) via multilevel modelling. An incremental cost-effectiveness ratio (ICER) assessed WPJ's cost-effectiveness.

RESULTS

WPJ was superior to TAU in reducing parent-domain stress post-treatment (adjusted mean difference = 5.05, 95% CI 0.33 to 9.81, p = .036) and at follow-up (adjusted mean difference 4.82, 95% CI 0.09 to 9.55, p = .046). Significant WPJ intervention effects were also observed for parenting practices, parenting efficacy and family strain. WPJ and TAU were not significantly different post-intervention or at follow-up for the other secondary outcomes. The incremental cost of WPJ was 34,202 JPY (315.81 USD). The probability that WPJ is cost-effective is 74% at 10,000 JPY (USD 108.30) per one-point improvement in parenting stress, 92% at 20,000 JPY (216.60 USD). The programme was delivered with high fidelity and excellent retention.

CONCLUSIONS

WPJ can be delivered in routine clinical care at modest cost with positive effects on self-reported well-being of the mothers, parenting practices and family coping. WPJ is a promising addition to psychosocial interventions for ADHD in Japan.

The use of telehealth in attention-deficit/hyperactivity disorder: a survey of parents and caregivers

The use of telehealth became widespread during the COVID-19 pandemic, including in child and adolescent attention-deficit/hyperactivity disorder (ADHD) services. Telehealth is defined as live, synchronous phone and video appointments between a healthcare provider and a parent and/or child with ADHD. There is a dearth of research on the use of telehealth within this population. The aim of this study was to examine parents' and caregivers' perceptions of telehealth for children and adolescents with ADHD. A cross-sectional survey design was employed. Recruitment of parents and caregivers of children and adolescents with ADHD was conducted online. The survey asked participants about their views of telehealth, previous experience, and willingness to use telehealth. Quantitative data were analysed using STATA. Qualitative data were analysed using content analysis. One hundred and twelve respondents participated in the survey. Participants were mostly female (n = 97, 86.6%) and aged between 45 and 54 (n = 64, 57.1%). Of the 61 (54.5%) participants with experience of telehealth, the majority reported that that they were at least satisfied with telehealth visits (n = 36, 59%), whilst approximately half rated their quality more poorly than in-person visits (n = 31, 50.8%). The majority of respondents (n = 91, 81.3%) reported that they would be willing to use telehealth for their child's future appointments. Most common reasons selected for wanting to use telehealth included saving time, improvements to the family routine, and reducing costs. Reasons selected for not wanting to use telehealth included not being able to receive hands-on care, belief that the quality of care is poorer than in-person consultations, and distraction of the child during telehealth visits. The study demonstrates that parents recognise deficits and benefits of telehealth, suggesting a need to build their trust and confidence in remote ADHD care.

Drug Holidays May Attenuate Beneficial Effects of Treatment on Emotion Regulation and Recognition Among Children with ADHD: A Single-Center, Prospective Study

Background

In this study, we aimed to evaluate the effects of drug holidays during summer vacations on children with attention deficit/hyperactivity disorder (ADHD) treated with methylphenidate in terms of ADHD symptoms and emotion regulation (ER).

Methods

This single-center, naturalistic, prospective cohort study included pre-, post-, and post-drug holiday evaluations. All patients diagnosed with ADHD and included in our study were administered the Clinical Global Impression Scale, Affective Reactivity Index-parent and child, reading the mind in the eyes test (RMET), Faces test and Cognitive Emotion Regulation Questionnaire for Children 3 times. Fifty-six patients met the inclusion criteria and ten were lost to follow-up. Thirty-nine participants had complete evaluations at all time points.

Results

Both parent and self-report ratings of child irritability were significantly reduced after methylphenidate (MPH) treatment (P=.003 and .002, respectively), although they returned to baseline after drug holidays (P=.618 and .974, respectively). The use of self-blame as a cognitive emotion regulation strategy increased significantly after treatment and remained significantly elevated even after drug holidays (P=.024 and .022, respectively). Children used planning as a cognitive strategy significantly more frequently during MPH treatment (P=.034), although this elevation was temporary and returned to baseline levels after the drug holidays (P=.890). Reading the mind in the eyes test performance was significantly improved after MPH treatment and did not change after drug holidays (P=.009 and .006, respectively), while there was a tendency for facial emotion recognition abilities to improve at the last visit (P=.051).

Conclusion

Our results suggest that MPH treatment improves child- and parent-reported irritability, clinician-rated disorder severity, RMET performance, and the use of planning as a cognitive ER strategy, although only improvement in RMET performance continued after drug holidays. Our results may support the importance of continuing treatment over the holidays for most children with ADHD unless necessitated by adverse events, growth problems, or development of tolerance.

Experience of neurofeedback and methylphenidate in children with ADHD

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity. ADHD is commonly treated with medication, such as methylphenidate, but some families and practitioners prefer psychosocial interventions as first line treatments. Many studies have investigated neurofeedback as a potential non-pharmacological treatment for ADHD yielding contradictory findings regarding its efficiency. Qualitative research on neurofeedback in ADHD is limited and can add valuable information on the acceptability and perceived efficacy among service users. This study aimed to explore the perceptions and experiences of children and adolescents with ADHD regarding the use of neurofeedback and methylphenidate. Eleven interviews with children and their parents explored their subjective experiences and perceived changes. Overall, neurofeedback was negatively experienced by those families: the intervention did not meet their expectations, and they reported minimal observed changes. The treatment with methylphenidate, however, was more manageable for families and was perceived to be more efficient despite its side effects.

Lifestyle-specific association between adversity dimensions with group-based mental health trajectories

BACKGROUND

Childhood adversity (CA) has a substantial correlation with mental health problems. Keeping a healthy lifestyle is essential for mental health interventions; it is unclear, however, how healthy lifestyle affect the relationship between CA and persistent mental health problems.

METHODS

This longitudinal study (n = 1112, 54.5 % male) collected the data on CA (measured through three dimensions: threat, deprivation and unpredictability), mental health problems, and lifestyle factors. Group-based multi-trajectory modeling (GBMTM) was utilized to estimate trajectories for three mental health problems (i.e., depression, ADHD and overanxiety). Close friendships, regular physical activity, appropriate sleep duration, shorter screen time, and healthy eating were combined to establish a healthy lifestyle score (which ranges from 0 to 5). Higher scores indicated a healthier lifestyle.

RESULTS

Three trajectories of mental health problems were identified: persistently low risk (24.9 %), persistently medium-high risk (50.0 %), and persistently high risk (25.1 %). Multinomial logistic regression showed that high adversity (high-threat: β = 2.01, P < 0.001; high-deprivation: β = 1.03, P < 0.001; high-unpredictability: β = 0.83, P = 0.001; high-overall adversity: β = 1.64, P < 0.001) resulted in a persistently high risk of mental health problems; these outcomes were maintained after robust control for covariates. Further lifestyle stratification, null associations were observed among children with a healthy lifestyle, irrespective of their gender; however, after controlling for covariates, the above associations remained relatively stable only among boys.

LIMITATIONS

The generalizability of our findings is restricted by 1) limited racial diversity and 2) missing data.

CONCLUSIONS

This finding underscores the benefits of promoting a healthy lifestyle in children to prevent persistent mental health problems caused by CA.

Review of Clinical Considerations in the Management of Adolescents with ADHD During Ramadan

Background:

Fasting in Ramadan, a holy month in Islam, is considered a religious obligation to Muslims after puberty. Fasting during Ramadan entails abstinence from consuming food and liquids, as well as abstaining from other activities, including smoking and sexual activity, from dawn until sunset. Literature exists regarding the management of multiple medical conditions impacted by the month of fasting; however, limited literature exists to guide the management of Attention-Deficit/Hyperactivity Disorder (ADHD) during Ramadan.

Methods:

This systematic review employed a PUBMED search which was conducted using keywords ((ADHD) AND (Muslims)) OR ((ADHD) AND (FASTING)) OR ((ADHD) AND (RAMADAN)) OR ((RAMADAN) AND (MANAGEMENT)) and search strategies to find existing literature on ADHD management during Ramadan or while fasting.

Results:

Eight hundred and sixty-one results were obtained. Of these, full texts of clinical trials, systematic reviews, reviews, randomized control trials, and metaanalyses resulted in 303 results that were screened by title or abstract for relevance to the topic. The duplicate articles were removed. Eighty-nine results were incorporated into this paper, including full articles, book excerpts, and online articles.

Discussion:

Muslim adolescents may face challenges with academic and social functioning as they navigate psychosocial changes in the context of Ramadan. ADHD management options should be discussed with individuals who are planning to fast. Pharmacologic management options include continuing on the current regimen, dose adjustment to mitigate side effect exacerbation, a change in medication class, or a change in medication formulation. For severe cases or cases with comorbid conditions, continued fasting may not be recommended. In these cases, the patient should attempt to seek counsel with their community’s religious scholar in collaboration with their medication provider. Ultimately, there are limitations in the available data, and there is a need for further investigation into the impacts of fasting during Ramadan on individuals with ADHD and the effectiveness of interventions to promote treatment adherence.

Pharmacological Interventions for Attention-Deficit/Hyperactivity Disorder in Children and Adolescents with Tourette Disorder: A Systematic Review and Network Meta-Analysis

Objective: To evaluate the comparative efficacy of pharmacological interventions for children and adolescents with a dual diagnosis of persistent tic disorders or Tourette disorder and attention-deficit/hyperactivity disorder (TD + ADHD). Methods: We searched CENTRAL, Embase, PubMed, PsycInfo, Web of Sciences, ClinicalTrials.gov, and WHO ICTRP up to September 2023 to identify double-blinded randomized controlled trials (RCTs) assessing pharmacological interventions for children and adolescents with TD + ADHD. Outcomes were change in ADHD symptoms (primary) and tics (secondary) severity. Standardized mean difference (SMD) was calculated and pooled in random-effects network meta-analysis. The Confidence in Network Meta-Analysis framework was adopted to determine certainty of evidence. Results: We included 8 RCTs involving 575 participants. Network meta-analyses demonstrated that α2 agonists (SMD, 95% confidence interval [CI] ADHD: -0.72 [-1.13 to -0.31]; TD: -0.70 [-0.96 to -0.45]) and stimulants + α2 agonists (ADHD: -0.84 [-1.54 to -0.13]; TD: -0.60 [-1.04 to -0.17]) were more efficacious than placebo for ADHD symptoms and tics severity. Stimulants alone were more efficacious than placebo for ADHD symptoms severity only, but they did not worsen tics (ADHD: -0.54 [-1.05 to -0.03]; TD: -0.22 [-0.49 to 0.05]). There were no significant differences between any pairs of medications that were found efficacious against placebo for ADHD symptoms or tics severity. Certainty in the evidence varied from low to very low. Conclusions: Stimulants are efficacious for ADHD symptoms severity and do not increase tics severity in TD + ADHD. α2 agonists are efficacious for both ADHD symptoms and tics severity in TD + ADHD. These findings should inform guidelines and help guide shared decision-making to choose a medication for children with TD + ADHD.

[Formula: see text] PENDAH program for parents with children with attention deficit hyperactivity disorder. French adaptation of a behavioral parent training group: pilot study

Behavioral parent training (BPT) is recognized as an effective part of the care offered to children with attention deficit hyperactivity disorder (ADHD). The aim of this pilot study was to objectively examine the effect that this intervention may have on motor activity, in addition to the measures classically found in this type of study. Parents of 24 school-aged children (6-12 year) with ADHD who met eligibility criteria were enrolled in the study. Before, after and five months after the intervention, we used three-dimensional accelerometers over one-week periods to measure the children's motor activity, and questionnaires for parental stress, quality of life, ADHD symptoms, anxiety and sensory disorders. To measure motor activity, a control group of normotypic children matched for age, sex and socio-professional category was set up. The experimental group showed slight decreases in motor activity compared with the control group, particularly in the classroom. The intervention showed improvements for parents in average stress and quality of life, and for children in average intensity global ADHD symptom, inattention, opposition and aggression, in line with previous studies on the effectiveness of BPT. The trial is the first clinical study to assess the effects of BPT on motor activity in children with ADHD.

Precision pharmacotherapy of atomoxetine in children with ADHD: how to ensure the right dose for the right person?

Non-stimulant atomoxetine is recognized in various current clinical guidelines as an important alternative to stimulants for the pharmacological treatment of attention deficit/hyperactivity disorder (ADHD) in children. While its efficacy and tolerability for core symptoms are established, there is considerable inter-individual variability in response and exposure, highlighting the need for personalized dosing. In this review, we evaluated existing studies and summarized comprehensive evidence supporting the clinical implementation of therapeutic drug monitoring (TDM) and personalized dosing of atomoxetine, organized around a series of logically structured questions. Although there are notable gaps in achieving personalized dosing across multiple critical elements, the available evidence is helpful to endorse personalized dose adjustments based on TDM and CYP2D6 genotyping "whenever possible." We advocate for ongoing improvement and enhancement in clinical practice. Future advancements will rely on a deeper understanding of ADHD, facilitating more precise diagnoses and personalized treatment strategies.

Enhancing spatial memory and pattern separation: Long-term effects of stimulant treatment in individuals with ADHD

This study explores the under-researched domain of long-term stimulant treatment in children and adolescents diagnosed with attention deficit hyperactivity disorder (ADHD). The necessity for extended treatment duration, often accompanied by safety concerns and side effects leading to treatment discontinuation, underscores the significance of this investigation. Concurrently, comparative studies have revealed adverse impacts on vulnerable regions within the hippocampal formation, accompanied by behavioral perturbations. We employed computerized tests and virtual reality to assess spatial memory, pattern separation, and object recognition memory in a cohort of children diagnosed with ADHD receiving stimulant treatment. We compared their performance to a group of neurotypical peers. Our findings indicate that the ADHD group exhibited a lower performance in spatial memory, pattern separation, and object recognition memory than ND group. Intriguingly, a positive relationship emerged between the duration of stimulant treatment and performance in these variables. Notably, this improvement was not immediate to MPH treatment but becomes significant after 24 months of treatment. In contrast to previous comparative investigations, our study did not reveal a detrimental impact on spatial navigation, object recognition memory, or pattern separation, despite the known interplay of these cognitive processes with the hippocampal formation. These results shed new light on the nuanced effects of stimulant treatment in ADHD, underscoring the need for a more comprehensive understanding of long-term treatment outcomes.

Hyped-up or meditate: A scoping review of mindfulness-based group interventions for adolescents with attention deficit hyperactivity disorder

The objective of this scoping review is to evaluate the effectiveness of mindfulness training in improving functioning in adolescents (aged 12-19 years) diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). Previous research has demonstrated that psychological interventions improve functioning in a myriad of domains for individuals diagnosed with ADHD, such as attention training, interpersonal relationships, and social skills. Mindfulness-based interventions (MBI) are indicated as an intervention in attention training. It maybe argued that group based MBI programmes should begin early, for children and adolescents at a time that is critical in their development. Methods and reporting are in line with the PRISMA extension for scoping reviews, the protocol is preregistered in the (Open Science Framework register). The study outcomes included attention, impulsivity, and relationships of adolescents with ADHD. Findings demonstrated preliminary evidence for the use of group-based mindfulness interventions with adolescents continues to be nascent. Although studies reported positive results, the evidence of its effectiveness for adolescents with ADHD is inconclusive, due to limited studies available and the limitations of the study design. This scoping review provides a panorama of MBI for ADHD adolescents.

Cardiovascular Management of Aortopathy in Children: A Scientific Statement From the American Heart Association

Aortopathy encompasses a spectrum of conditions predisposing to dilation, aneurysm, dissection, or rupture of the aorta and other blood vessels. Aortopathy is diagnosed commonly in children, from infancy through adolescence, primarily affecting the thoracic aorta, with variable involvement of the peripheral vasculature. Pathogeneses include connective tissue disorders, smooth muscle contraction disorders, and congenital heart disease, including bicuspid aortic valve, among others. The American Heart Association has published guidelines for diagnosis and management of thoracic aortic disease. However, these guidelines are predominantly focused on adults and cannot be applied adeptly to growing children with emerging features, growth and developmental changes, including puberty, and different risk profiles compared with adults. Management to reduce risk of progressive aortic dilation and dissection or rupture in children is complex and involves genetic testing, cardiovascular imaging, medical therapy, lifestyle modifications, and surgical guidance that differ in many ways from adult management. Pediatric practice varies widely, likely because aortopathy is pathogenically heterogeneous, including genetic and nongenetic conditions, and there is limited published evidence to guide care in children. To optimize care and reduce variation in management, experts in pediatric aortopathy convened to generate this scientific statement regarding the cardiovascular care of children with aortopathy. Available evidence and expert consensus were combined to create this scientific statement. The most common causes of pediatric aortopathy are reviewed. This document provides a general framework for cardiovascular management of aortopathy in children, while allowing for modification based on the personal and familial characteristics of each child and family.

Treatments in the pipeline for attention-deficit/hyperactivity disorder (ADHD) in adults

To provide an overview of treatments in the pipeline for adults with attention-deficit/hyperactivity disorder (ADHD), we searched https://clinicaltrials.gov/and and https://www.clinicaltrialsregister.eu/ from 01/01/2010-10/18/2023 for ongoing or completed phase 2 or 3 randomised controlled trials (RCTs), assessing pharmacological or non-pharmacological interventions for adults with ADHD with no current regulatory approval. We found 90 eligible RCTs. Of these, 24 (27 %) reported results with statistical analysis for primary efficacy endpoints. While several pharmacological and non-pharmacological interventions had evidence of superiority compared to the control condition from a single RCT, centanafadine (norepinephrine, dopamine, and serotonin re-uptake inhibitor) was the only treatment with evidence of efficacy on ADHD core symptoms (small effect size=0.28-0.40) replicated in at least one additional RCT, alongside reasonable tolerability. Overall, the body of ongoing RCTs in adults with ADHD is insufficient, without any intervention on the horizon to match the efficacy of stimulant treatment or atomoxetine and with better tolerability profile. Additional effective and well tolerated treatments for adults with ADHD require development and testing.

Improving the efficacy and effectiveness of evidence-based psychosocial interventions for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and impairing mental health disorder of childhood. Decades of empirical research has established a strong evidence-based intervention armamentarium for ADHD; however, limitations exist in regards to efficacy and effectiveness of these interventions. We provide an overview of select evidence-based interventions for children and adolescents, highlighting potential approaches to further improving the efficacy and effectiveness of these interventions. We conclude with broader recommendations for interventions, including considerations to moderators and under-explored intervention target areas as well as avenues to improve access and availability of evidence-based interventions through leveraging underutilized workforces and leveraging technology.

Early and repeated screening detects children with persistent attention-deficit/hyperactivity disorder

Preschool screening of attention-deficit/hyperactivity disorder (ADHD) has been found too inaccurate to be clinically useful. This may be due to the known instability of ADHD symptoms from preschool onwards, and the use of a single screening only. We hypothesized that by identifying a group of children with persistent ADHD from preschool to school age and repeating the screening, the clinical usefulness of screening would increase. This study is part of the prospective longitudinal, population-based Norwegian Mother, Father and Child Cohort Study, with a diagnostic parent interview at 3.5 years and follow-up with parent questionnaires at ages 5 and 8 years (n = 707). We identified a group classified with ADHD at all three time points (persistent ADHD). We then used the Child Behavior Checklist ADHD DSM-oriented scale at ages 3.5 and 5 years to investigate the accuracies of single- and two-stage screening at different thresholds to identify children with persistent ADHD. About 30% of the children were classified with ADHD at least once across time (at ages 3.5, 5, and/or 8 years), but only 4% (n = 30) had persistent ADHD. At all thresholds, the two-stage screening identified children with persistent ADHD more accurately than single screening, mainly due to a substantial reduction in false positives. Only a small group of children were classified with persistent ADHD from preschool to school age, underlining that future screening studies should distinguish this group from those with fluctuating symptoms when estimating screening accuracies. We recommend a two-stage screening process to reduce false positives.

Primary care provision for young people with ADHD: a multi-perspective qualitative study

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder. UK guidance states that primary care has a vital role in effective ADHD management, including referral, medication prescribing and monitoring, and providing broader mental health and wellbeing support. However, many GPs feel unsupported to provide health care for young people with ADHD. Inadequate health care is associated with rising costs for patients and society.

AIM

To investigate the experiences of young people with ADHD accessing primary care in England, from the perspectives of people with lived experience of ADHD and healthcare professionals (HCPs).

DESIGN AND SETTING

A qualitative study. Interviews were conducted with HCPs (GPs, practice managers, and a wellbeing worker) and people with lived experience of ADHD (young people aged 16-25 years and their supporters) located in integrated care systems across England.

METHOD

Semi-structured interviews were conducted with participants at five purposively selected general practices (varying by deprivation, ethnicity, and setting). Questions focused on experiences of accessing/providing health care for ADHD. Reflexive thematic analysis was undertaken within a critical realist framework to understand how provision works in practice and to explore potential improvements.

RESULTS

In total, 20 interviews were completed with 11 HCPs and nine people with lived experience. Three themes were generated: a system under stress, incompatibility between ADHD and the healthcare system, and strategies for change in ADHD primary care provision.

CONCLUSION

Standardisation of ADHD management in primary care, providing better information and support for HCPs, and advising on reasonable adjustments for people with lived experience could help improve access to effective treatments for young people living with ADHD.

Retrospective Study on the Therapeutic Effect of Repetitive Transcranial Magnetic Stimulation Combined with Tiapride Hydrochloride Tablets in Children with Attention Deficit Hyperactivity Disorder

Objective

This study aimed to explore the application effect of repetitive transcranial magnetic stimulation (rTMS) combined with tiapride hydrochloride tablets in children with attention deficit hyperactivity disorder (ADHD).

Methods

The medical records of 197 children with ADHD in our hospital from January 2022 to January 2023 were retrospectively analysed. Seven children who did not meet the inclusion criteria were excluded, and 190 children were finally included in this retrospective study. Based on the different clinical therapeutic methods, these children were divided into tiapride (n = 64), rTMS (n = 64), and combination (n = 62) groups. The clinical effects of different therapeutic schemes were compared. The clinical effectiveness and the scores of Swanson, Nolan, and Pelham Rating Scale Version IV (SNAP-IV), Conners Parent Symptom Questionnaire (PSQ), and Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) were compared among the 3 groups.

Results

There was no significant difference in gender, age, course of disease, weight, and WISC-IV score among the combination, tiapride, and rTMS groups (all P > .05). The effective rate of treatment in the combination group (93.55%) was significantly higher than that in the tiapride group (78.13%) and the rTMS group (81.25%). There was a significant difference in the comparison of the combination group with the tiapride group (P = .013) and the rTMS group (P = .038). Before treatment, no significant difference existed in the scores of attention deficit symptoms and hyperactivity disorder symptoms among the 3 groups (all P > .05). After 3 months of treatment, the difference score of the combination group before and after treatment was significantly higher than that of other 2 groups (all P < .001). Before treatment, no significant difference was found in the scores of conduct problems, learning problems, psychosomatic disorders, impulsive hyperactivity, anxiety and hyperactivity index among the 3 groups (all P > .05). After treatment, the combination group had significantly higher difference score before and after treatment than other 2 groups (all P < .001). There was no significant difference in WFIRS-P scores among the 3 groups before treatment (all P > .05). After treatment, the difference score in the combination group before and after treatment was significantly higher compared with other 2 groups (all P < .001).

Conclusion

Transcranial magnetic stimulation combined with tiapride hydrochloride tablets had a positive effect on improving the condition of children with ADHD, with certain clinical promotion value.

Practitioner Review: Clinical utility of the QbTest for the assessment and diagnosis of attention-deficit/hyperactivity disorder - a systematic review and meta-analysis

BACKGROUND

Several computerised cognitive tests (e.g. continuous performance test) have been developed to support the clinical assessment of attention-deficit/hyperactivity disorder (ADHD). Here, we appraised the evidence-base underpinning the use of one of these tests - the QbTest - in clinical practice, by conducting a systematic review and meta-analysis investigating its accuracy and clinical utility.

METHODS

Based on a preregistered protocol (CRD42022377671), we searched PubMed, Medline, Ovid Embase, APA PsycINFO and Web of Science on 15th August 2022, with no language/type of document restrictions. We included studies reporting accuracy measures (e.g. sensitivity, specificity, or Area under the Receiver Operating Characteristics Curve, AUC) for QbTest in discriminating between people with and without DSM/ICD ADHD diagnosis. Risk of bias was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2). A generic inverse variance meta-analysis was conducted on AUC scores. Pooled sensitivity and specificity were calculated using a random-effects bivariate model in R.

RESULTS

We included 15 studies (2,058 participants; 48.6% with ADHD). QbTest Total scores showed acceptable, rather than good, sensitivity (0.78 [95% confidence interval: 0.69; 0.85]) and specificity (0.70 [0.57; 0.81]), while subscales showed low-to-moderate sensitivity (ranging from 0.48 [0.35; 0.61] to 0.65 [0.52; 0.75]) and moderate-to-good specificity (from 0.65 [0.48; 0.78] to 0.83 [0.60; 0.94]). Pooled AUC scores suggested moderate-to-acceptable discriminative ability (Q-Total: 0.72 [0.57; 0.87]; Q-Activity: 0.67 [0.58; 0.77); Q-Inattention: 0.66 [0.59; 0.72]; Q-Impulsivity: 0.59 [0.53; 0.64]).

CONCLUSIONS

When used on their own, QbTest scores available to clinicians are not sufficiently accurate in discriminating between ADHD and non-ADHD clinical cases. Therefore, the QbTest should not be used as stand-alone screening or diagnostic tool, or as a triage system for accepting individuals on the waiting-list for clinical services. However, when used as an adjunct to support a full clinical assessment, QbTest can produce efficiencies in the assessment pathway and reduce the time to diagnosis.

Association of Prenatal Dietary Toxicants and Inorganic Arsenic Exposure with Children's Emotional and Behavioral Problems: ECLIPSES Study

Prenatal exposure to dietary toxicants is linked to neurocognitive issues, but its effect on early emotional and behavioral development in children is less clear. To explore the relationship between prenatal intake of As, iAs, Cd, MeHg, Pb, PCDD/Fs, DL-PCBs, and NDL-PCBs and emotional and behavioral issues in four-year-old children. This study included 192 mother-child pairs from the ECLIPSES study, assessing prenatal dietary toxicant exposure through a food-frequency questionnaire and Catalan Food Safety Agency data. Children's emotional and behavioral scores were evaluated using the Child Behavior Checklist for ages 1.5-5 years. Multivariable regression and logistic models were used, focusing on iAs after finding significant preliminary associations. Increased prenatal dietary intake of iAs was associated with internalizing, externalizing, and attention-deficit/hyperactivity problems. Higher iAs levels (>4.16 μg/day) significantly increased the risk of total problems (OR = 2.94) and specific issues like anxious/depressed (OR = 4.88), anxiety (OR = 3.27), and oppositional defiant problems (OR = 4.30). High iAs consumption correlated with the intake of meat, eggs, cereals, tubers, fruits, and pulses Prenatal dietary iAs exposure is associated with various emotional and behavioral problems in children. Monitoring and reducing iAs levels in food are crucial for public health.

Pupils' inclusion as a process of narrative interactions: tackling ADHD typification through MADIT methodology

BACKGROUND

ADHD is the most common childhood neurodevelopmental disorder. The symptomatology makes the management of ADHD particularly demanding in school, so teachers' training programs have been widely implemented. Nevertheless, these interventions could lead teachers to concentrate on the dysfunctional elements of these students, exposing them to the risk of stigmatisation. Conceptualising stigma and inclusion as narrative processes, the present study observed how teacher ADHD training texts, endorsed by the Italian government, impact on the inclusion process of students.

METHODS

The research analysed a corpus of N = 31,261 text occurrences and focused on three areas: (1) ADHD as a clinical condition; (2) the impact of ADHD characteristics in the scholastic setting; (3) interventions to manage ADHD criticalities in school settings. To observe the interactive processes fostered by the narratives under scrutiny, we used Dialogic Science and MADIT methodology, since they allow us to measure the language use modalities through an index: the Dialogical Weight (dW). The value of dW ranges between 0.1 (min) and 0.9 (max) and is linked to the potential outcomes of inclusion for students with ADHD. A low dW accounts for narratives entrenched in personal beliefs presented as absolute truths, undermining inclusion of students with ADHD. In contrast, high dW signals language interaction relying on sharable elements, able to foster social unity and diminish stigma.

RESULTS

The results yielded a critical discursive configuration, both in general and for the three distinct areas. We measured an overall Dialogical Weight of 0.4dW and, for the three areas (1) = 0.3dW; (2) = 0.3dW; (3) = 0.4dW. The analysed text does not maximise the triggering of inclusive interactions, as they rely on individual references and present one's narrative as the sole plausible perspective: reinforcing already existing positions and exposing to the risk of stereotyping of the pupils.

CONCLUSIONS

The study highlighted how the ADHD training materials analysed, focusing on a purely informational and clinical approach, lose in effectiveness with respect to generating inclusive school settings. Finally, to promote the inclusion of these pupils, elements are offered for outlining an approach based on fostering active participation by all roles involved.

Barriers and facilitators to implementing a Canadian shared-care ADHD program in pediatric settings in Shanghai: a consolidated framework for implementation research approach

OBJECTIVES

The vast majority of children with Attention-Deficit Hyperactivity Disorder (ADHD) do not have access to proper diagnosis and treatment in China. The goal of this project is to identify the challenges and facilitators in implementing a Canadian ADHD Shared Care Pathways program in pediatric settings in Shanghai region.

METHODS

Purposive semi-structured focus groups were conducted on a total of 13 healthcare practitioners from the Shanghai Xinuha, Ninghai and Chongming hospitals. Two independent researchers conducted a thematic analysis of the data with themes emerging based on the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Notable barriers identified by participants included: (1) lack of knowledge in the management of ADHD, primarily among general practitioners; (2) lack of resources such as lack of staff, time, and medication for ADHD; (3) challenges in implementing an international multicentre intervention (such as communication difficulties between teams and integration of resources available in different hospitals); and (4) mental health stigma, difficulties in identifying ADHD patients, and logistical problems related to medication procurement rules put in place by provincial governments. Notable facilitators included: (1) the strong motivation of stakeholders and their confidence in their ability to learn and subsequently execute action plans to achieve the implementation goal; (2) the compatibility between the values and goals of the stakeholders and those of the program despite some cultural tension, a positive learning climate, strong tensions for change, and the high interest of organization leaders in engaging in the program (3) the perceived benefits of the program, such as standardization of the diagnostic and treatment process, and engaging primary care providers in ADHD management; and (4) the strong relationship between participating institutions and schools as well as provincial health initiatives available to support collaborative models of care. Mixed factors to implementation were also explored.

CONCLUSIONS

Appropriate training of health care providers, cultural adaptation of the program, increase public awareness about ADHD to decrease stigma, as well as strong project management and guidelines that clearly describe the role and expectations of each team member appeared essential to successful implementation.

ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment

OBJECTIVE

To provide updated national prevalence estimates of diagnosed attention-deficit/hyperactivity disorder (ADHD), ADHD severity, co-occurring disorders, and receipt of ADHD medication and behavioral treatment among U.S. children and adolescents by demographic and clinical subgroups using data from the 2022 National Survey of Children's Health (NSCH).

METHOD

This study used 2022 NSCH data to estimate the prevalence of ever diagnosed and current ADHD among U.S. children aged 3-17 years. Among children with current ADHD, ADHD severity, presence of current co-occurring disorders, and receipt of medication and behavioral treatment were estimated. Weighted estimates were calculated overall and for demographic and clinical subgroups (n = 45,169).

RESULTS

Approximately 1 in 9 U.S. children have ever received an ADHD diagnosis (11.4%, 7.1 million children) and 10.5% (6.5 million) had current ADHD. Among children with current ADHD, 58.1% had moderate or severe ADHD, 77.9% had at least one co-occurring disorder, approximately half of children with current ADHD (53.6%) received ADHD medication, and 44.4% had received behavioral treatment for ADHD in the past year; nearly one third (30.1%) did not receive any ADHD-specific treatment.

CONCLUSIONS

Pediatric ADHD remains an ongoing and expanding public health concern, as approximately 1 million more children had ever received an ADHD diagnosis in 2022 than in 2016. Estimates from the 2022 NSCH provide information on pediatric ADHD during the last full year of the COVID-19 pandemic and can be used by policymakers, government agencies, health care systems, public health practitioners, and other partners to plan for needs of children with ADHD.

One year follow-up of participants in a randomised controlled trial of a CBT-based group therapy programme for adolescents diagnosed with ADHD

BACKGROUND

Adolescents with ADHD often struggle on many areas of their lives and have a high risk of adverse outcomes and negative life trajectories. Multimodal treatment including psychosocial interventions is recommended but evidence regarding effect of such interventions is still limited.

MATERIALS AND METHODS

This study was a follow-up study of adolescents participating in a randomised controlled trial (RCT) of a group intervention based on cognitive behavioural therapy (CBT). Participants were adolescents diagnosed with ADHD and still impaired by their symptoms after standard treatment including psychoeducation and medication. All participants were interviewed by telephone one year after inclusion, and outcome measures included both quantitative and qualitative measures.

RESULTS

There were 100 adolescents included in the study. We found no significant differences between treatment and control group on measures of ADHD-symptoms, self-efficacy, overall problems, global psychosocial functioning, or symptom severity at one-year follow-up. Still, participants in the intervention group reported on positive gains and that they learned a lot about ADHD and themselves.

CONCLUSIONS

The intervention delivered in this trial failed to show a treatment effect on symptom level when added to standard care. Participants did however report on positive gains and felt they learned a lot. More research is needed to explore how the programme and delivery of treatment might be improved, and which patients might benefit the most from this type of interventions.

Methylphenidate and Sleep Difficulties in Children and Adolescents With ADHD: Results From the 2-Year Naturalistic Pharmacovigilance ADDUCE Study

OBJECTIVE

Short-term RCTs have demonstrated that MPH-treatment significantly reduces ADHD-symptoms, but is also associated with adverse events, including sleep problems. However, data on long-term effects of MPH on sleep remain limited.

METHODS

We performed a 2-year naturalistic prospective pharmacovigilance multicentre study. Participants were recruited into three groups: ADHD patients intending to start MPH-treatment (MPH-group), those not intending to use ADHD-medication (no-MPH-group), and a non-ADHD control-group. Sleep problems were assessed with the Children's-Sleep-Habits-Questionnaire (CSHQ).

RESULTS

1,410 participants were enrolled. Baseline mean CSHQ-total-sleep-scores could be considered clinically significant for the MPH-group and the no-MPH-group, but not for controls. The only group to show a significant increase in any aspect of sleep from baseline to 24-months was the control-group. Comparing the MPH- to the no-MPH-group no differences in total-sleep-score changes were found.

CONCLUSION

Our findings support that sleep-problems are common in ADHD, but don't suggest significant negative long-term effects of MPH on sleep.

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD; also known as hyperkinetic disorder) is a common neurodevelopmental condition that affects children and adults worldwide. ADHD has a predominantly genetic aetiology that involves common and rare genetic variants. Some environmental correlates of the disorder have been discovered but causation has been difficult to establish. The heterogeneity of the condition is evident in the diverse presentation of symptoms and levels of impairment, the numerous co-occurring mental and physical conditions, the various domains of neurocognitive impairment, and extensive minor structural and functional brain differences. The diagnosis of ADHD is reliable and valid when evaluated with standard diagnostic criteria. Curative treatments for ADHD do not exist but evidence-based treatments substantially reduce symptoms and/or functional impairment. Medications are effective for core symptoms and are usually well tolerated. Some non-pharmacological treatments are valuable, especially for improving adaptive functioning. Clinical and neurobiological research is ongoing and could lead to the creation of personalized diagnostic and therapeutic approaches for this disorder.

Cardiovascular Safety of Atomoxetine and Methylphenidate in Patients With Attention-Deficit/Hyperactivity Disorder in Japan: A Self-Controlled Case Series Study

OBJECTIVE

To investigate the association between atomoxetine or methylphenidate use and arrhythmia, heart failure (HF), stroke, and myocardial infarction (MI) in attention-deficit/hyperactivity disorder (ADHD) patients mainly focused on the people of working age.

METHODS

In a self-controlled case series study using a Japanese claims database, we identified events of arrhythmia, HF, stroke, and MI among 15,472 atomoxetine new users and 12,059 methylphenidate new users. Adjusted incidence rate ratios (aIRRs) of outcome events were estimated using multivariable conditional Poisson regression.

RESULTS

An increased risk of arrhythmia was observed during the first 7 days after the initial atomoxetine exposure (aIRR 6.22, 95% CI [1.90, 20.35]) and in the subsequent exposure (3.23, [1.58, 6.64]). No association was found between methylphenidate exposure and arrhythmia, nor between atomoxetine or methylphenidate exposure and HF. The limited number of stroke and MI cases prevented thorough analysis.

CONCLUSIONS

Clinicians should consider monitoring for arrhythmia after patients initiating or re-initiating atomoxetine.

Economic Burden and Service Utilization of Children With Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis

OBJECTIVES

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children. This study aims to systematically synthesize the literature on service utilization and costs for children with ADHD.

METHODS

The search included 9 databases for peer-reviewed primary studies in English from 2007 to 2023. Two independent reviewers conducted title/abstract and full-text screenings and quality assessment. Meta-analysis was conducted on direct medical costs.

RESULTS

Thirty-two studies were included. Children with ADHD have used more pharmaceuticals, mental health, and special education services than children without ADHD (counterparts). Nevertheless, one study found that children with ADHD were twice as likely to have unmet health needs than their counterparts. Annual health system costs per patient were highly varied and higher in children with ADHD ($722-$11 555) than their counterparts ($179-$3646). From a societal perspective, children with ADHD were associated with higher costs ($162-$18 340) than their counterparts ($0-2540). The overall weighted mean direct medical cost was $5319 for children with ADHD compared with $1152 for their counterparts when all studies with different sample sizes were considered together, with the difference being $4167. Limited literature on productivity losses associated with ADHD reported them as a substantial cost. ADHD in children had a "large" effect on the increment of direct medical costs.

CONCLUSIONS

ADHD was associated with increased service utilization and costs. However, unmet health needs or underuse among children with ADHD was also evident. Governments should endeavor to improve access to effective services for children with ADHD to mitigate the impact of ADHD.

Behavioral Parent Training for School-Aged Children With ADHD: A Systematic Review of Randomized Control Trials

BACKGROUND

All guidelines for the treatment of ADHD in children include behavioral parent training in combination with other strategies. In the past, several systematic reviews have been carried out that were either outdated or not sufficiently specific to ADHD. We wanted to conduct a new review focusing on a specific ADHD population of school age (4-12 years) and on behavioral and cognitive programs. We aimed to test our hypothesis that behavioral parent training would improve parents' difficulties, children's symptomatology, and the quality of life of families with ADHD.

METHODS

PUBMED, PsychInfo, Web of Science, ERIC, and Cochrane databases were searched for original articles on randomized control trials on behavioral parent training group for children with ADHD aged from 4 to 12 years until July 2023.

RESULTS

A total of 20 studies were included in the systematic review. The results were divided into four categories: parent data, child data collected by parents, teachers, or researchers. A qualitative analysis revealed for parents, effects on parental stress, feelings of parental efficacy, and negative parental educational behavior. As regard children, only effects are noted for parental assessment, on ADHD symptomatology, externalized disorders, and social skills.

CONCLUSION

Despite the heterogeneity or small number of studies in some categories, BPTs have positive effects on both parents and children. There are no convincing results to support the generalization of progress. This would seem to indicate that it remains essential to consider actions specific to each problematic environment for the child.

Barriers and Enablers of Service Access and Utilization for Children and Adolescents With Attention Deficit Hyperactivity Disorder: A Systematic Review

OBJECTIVE

To update a systematic review of the literature on the barriers and enablers of service access and utilization for children and adolescents with a diagnosis, or symptoms of attention deficit/hyperactivity disorder (ADHD), from the perspective of caregivers, clinicians, and teachers.

METHODS

Five databases were searched for peer-reviewed literature published from May 2012 to March 2023. Two independent reviewers completed a two-stage screening process and quality assessment.

RESULTS

Of 4,523 search results, 30 studies were included. Five main themes were generated: 1) Awareness of ADHD, 2) Stigma, 3) Parental choice and partnerships, 4) Education services as an integral component, 5) Referrals, waiting times, and logistics. More than half of the studies reported poor acknowledgement, expertise of ADHD, and stigma.

CONCLUSION

Findings highlight the need for ongoing ADHD education for all involved and policy changes to service delivery systems to increase the availability of health providers with specialist ADHD expertise.

Translating Decades of Neuroscience Research into Diagnostic and Treatment Biomarkers for ADHD

In this chapter, we review scientific findings that form the basis for neuroimaging and neurophysiological biomarkers for ADHD diagnosis and treatment. We then highlight the different challenges in translating mechanistic findings into biomarkers for ADHD diagnosis and treatment. Population heterogeneity is a primary barrier for identifying biomarkers of ADHD diagnosis, which requires shifts toward dimensional approaches that identify clinically useful subgroups or prospective biomarkers that can identify trajectories of illness, function, or treatment response. Methodological limitations, including emphasis on group level analyses of treatment effects in small sample sizes, are the primary barriers to biomarker discovery in ADHD treatment. Modifications to clinical trials, including shifting towards testing biomarkers of a priori prediction of functionally related brain targets, treatment response, and side effects, are suggested. Finally, future directions for biomarker work are discussed.

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.

Lisdexamphetamine versus methylphenidate for paediatric patients with attention-deficit hyperactivity disorder and type 1 diabetes (LAMAinDiab): protocol for a multicentre, randomised cross-over clinical trial in an outpatient telemedicine-supported setting

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) affects 5%-10% of paediatric population and is reportedly more common in children with type 1 diabetes (T1D), exacerbating its clinical course. Proper treatment of ADHD in such patients may thus provide neurological and metabolic benefits. To test this, we designed a non-commercial second phase clinical trial comparing the impact of different pharmacological interventions for ADHD in children with T1D.

METHODS AND ANALYSIS

This is a multicentre, randomised, open-label, cross-over clinical trial in children and adolescents with ADHD and T1D. The trial will be conducted in four reference paediatric diabetes centres in Poland. Over 36 months, eligible patients with both T1D and ADHD (aged 8-16.5 years, T1D duration >1 year) will be offered participation. Patients' guardians will undergo online once-weekly training sessions behaviour management for 10 weeks. Afterward, children will be randomised to methylphenidate (long-release capsule, doses 18-36-54 mg) versus lisdexamphetamine (LDX, 30-50-70 mg). Pharmacotherapy will continue for 6 months before switching to alternative medication. Throughout the trial, the participants will be evaluated every 3 months by their diabetologist and online psychological assessments. The primary endpoint (ADHD symptom severity, Conners 3.0 questionnaire) will be assessed by a blinded investigator. Secondary endpoints will include HbA1c, continuous glucose monitoring indices and quality-of-life (PedsQL).

ETHICS AND DISSEMINATION

The trial is approved by Bioethical Committee at Medical University of Lodz and Polish regulatory agency (RNN/142/22/KE, UR/DBL/D/263/2022). The results will be communicated to the research and clinical community, and Polish agencies responsible for healthcare policy. Patient organisations focused on paediatric T1D will be notified by a consortium member. We hope to use the trial's results to promote collaboration between mental health professionals and diabetes teams, evaluate the economic feasibility of using LDX in patients with both diseases and the long run improve ADHD treatment in children with T1D.

TRIAL REGISTRATION NUMBERS

EU Clinical Trials Register (EU-CTR, 2022-001906-24) and NCT05957055.

Cost-effectiveness and budget impact analysis of lisdexamfetamine versus methylphenidate for patients under 18 with attention-deficit/hyperactivity disorder in Iran

BACKGROUND

Lisdexamfetamine (LDX) and Methylphenidate (MPH) are stimulant agents that have been shown to provide significant benefits in the management of attention-deficit/hyperactivity disorder (ADHD) in patients.

AIM

This study aimed to assess the cost-effectiveness and the budget impact of LDX compared to MPH as the first-line treatment for ADHD.

METHODS

A one-year cost-effectiveness analysis (CEA) was conducted to compare the effects of LDX and MPH in reducing disease symptoms and patient costs and improving quality of life (QoL) from a social perspective. Clinical data were obtained using the EQ-5D questionnaire. In contrast, economic data were sourced from the official website of the Iranian Food and Drug Association (FDA), the national book of tariffs, and specific questionnaires designed to evaluate patients' direct and indirect costs. 197 patients were included in the study, including individuals who sought psychiatric evaluation at a hospital in Mashhad and those who obtained ADHD medications from governmental pharmacies. The cost-effectiveness of the study medicine was assessed using the decision tree method, and the results were presented as the Incremental Cost-Effectiveness Ratio (ICER). Deterministic Sensitivity Analysis (DSA) and Probabilistic Sensitivity Analysis (PSA) were performed to assess the robustness of the findings. Additionally, a Budget Impact Analysis (BIA) was conducted over five years, considering three different scenarios, to evaluate the financial implications of incorporating LDX into the national pharmaceutical system.

RESULTS

The ICER for LDX therapy compared to MPH was estimated at USD 264.28 (with an incremental cost of USD 54.9, incremental effectiveness of 0.208, and Quality-Adjusted Life Years (QALYs) gained of 0.765). The PSA indicated a 0.994% probability of LDX being cost-effective, considering a threshold of USD 2450 per QALY. Furthermore, the DSA revealed that the acquisition cost of LDX influenced the model's sensitivity. The BIA demonstrated that incorporating LDX into Iran's healthcare system would result in a financial burden of approximately $368,566 in the first year, representing an additional cost of $11,154 compared to the non-availability of this medicine and the use of previous medications. It is projected that by 2027, the financial burden of treating ADHD with LDX will reach approximately USD 443,879 over five years, amounting to an increase of $71,154 compared to the absence of this medicine.

CONCLUSION

From a social perspective, the inclusion of LDX in the treatment regimen for ADHD is associated with higher costs and an increased financial burden. However, based on our analysis, LDX appears to be a cost-effective choice for managing ADHD in Iran when compared to MPH.

Potential effectiveness of digital therapeutics specialized in executive functions as adjunctive treatment for clinical symptoms of attention-deficit/hyperactivity disorder: a feasibility study

Introduction

The role of digital therapeutics (DTx) in the effective management of attention deficit/hyperactivity disorder (ADHD) is beginning to gain clinical attention. Therefore, it is essential to verify their potential efficacy.

Method

We aimed to investigate the improvement in the clinical symptoms of ADHD by using DTx AimDT01 (NUROW) (AIMMED Co., Ltd., Seoul, Korea) specialized in executive functions. NUROW, which consists of Go/No-go Task- and N-Back/Updating-based training modules and a personalized adaptive algorithm system that adjusts the difficulty level according to the user's performance, was implemented on 30 Korean children with ADHD aged 6 to 12 years. The children were instructed to use the DTx for 15 min daily for 4 weeks. The Comprehensive attention test (CAT) and Childhood Behavior Checklist (CBCL) were used to assess the children at baseline and endpoint. In contrast, the ADHD-Rating Scale (ARS) and PsyToolkit were used weekly and followed up at 1 month, for any sustained effect. Repeated measures ANOVA was used to identify differences between the participants during visits, while t-tests and Wilcoxon signed-rank tests were used to identify changes before and after the DTx.

Results

We included 27 participants with ADHD in this analysis. The ARS inattention (F = 4.080, p = 0.010), hyperactivity (F = 5.998. p < 0.001), and sum (F = 5.902, p < 0.001) significantly improved. After applying NUROW, internalized (t = -3.557, p = 0.001, 95% CI = -3.682--0.985), other (Z = -3.434, p = 0.001, effect size = -0.661), and sum scores (t = -3.081, p = 0.005, 95% CI = -10.126--2.022) were significantly changed in the CBCL. The overall effect was confirmed in the ARS sustained effect analysis even after 1 month of discontinuing the DTx intervention.

Discussion

According to caregivers, the findings indicate that DTx holds potential effect as an adjunctive treatment in children with ADHD, especially in subjective clinical symptoms. Future studies will require detailed development and application targeting specific clinical domains using DTx with sufficient sample sizes.Clinical trial registration: KCT0007579.

Do Children With Attention-Deficit/Hyperactivity Disorder Symptoms Become Socially Isolated? Longitudinal Within-Person Associations in a Nationally Representative Cohort

Objective

This study examined longitudinal associations between attention-deficit/hyperactivity disorder (ADHD) symptoms and social isolation across childhood. The study tested the direction of this association across time, while accounting for preexisting characteristics, and assessed whether this association varied by ADHD presentation, informant, sex, and socioeconomic status.

Method

Participants included 2,232 children from the Environmental Risk (E-Risk) Longitudinal Twin Study. ADHD symptoms and social isolation were measured at ages 5, 7, 10, and 12. Random-intercept cross-lagged panel models were used to assess the directionality of the association across childhood.

Results

Children with increased ADHD symptoms were consistently at increased risk of becoming socially isolated later in childhood, over and above stable characteristics (β = .05-.08). These longitudinal associations were not bidirectional; isolated children were not at risk of worsening ADHD symptoms later on. Children with hyperactive ADHD presentation were more likely to become isolated, compared with inattentive presentation. This was evident in the school setting, as observed by teachers, but not by mothers at home.

Conclusion

The study findings highlight the importance of enhancing peer social support and inclusion for children with ADHD, particularly in school settings. This study adds explanatory value beyond traditional longitudinal methods, as the results represent how individual children change over time, relative to their own preexisting characteristics.

Diversity & Inclusion Statement

We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Behavioural and nondirective parent training for children with externalising disorders: First steps towards personalised treatment recommendations

For children with externalising disorders, parent training programmes with different theoretical foundations are available. Currently, there is little knowledge concerning which programme should be recommended to a family based on their individual needs (e.g., single parenthood). The personalised advantage index (PAI) indicates the predicted treatment advantage of one treatment over another. The aim of the present study was to examine the usefulness of this score in providing individualised treatment recommendations. The analysis considered 110 parents (per-protocol sample) of children (4-11 years) with attention-deficit/hyperactivity (ADHD) or oppositional defiant disorder (ODD), randomised to either a behavioural or a nondirective telephone-assisted self-help parent training. In multiple moderator analyses with four different regression algorithms (linear, ridge, k-nearest neighbors, and tree), the linear model was preferred for computing the PAI. For ODD, families randomised to their PAI-predicted optimal intervention showed a treatment advantage of d = 0.54, 95% CI [0.17, 0.97]; for ADHD, the advantage was negligible at d = 0.35, 95% CI [-0.01, 0.78]. For children with conduct problems, it may be helpful if the PAI includes the treatment moderators single parent status and ODD baseline symptoms when providing personalised treatment recommendations for the selection of behavioural versus nondirective parent training. TRIAL REGISTRATION: The study was registered prospectively with ClinicalTrials.gov (Identifier NCT01350986).

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015.

OBJECTIVES

To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate.

SELECTION CRITERIA

We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non-serious, general behaviour, and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel-group trials and first-period data from cross-over trials formed the basis of our primary analyses. We undertook separate analyses using end-of-last period data from cross-over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach.

MAIN RESULTS

We included 212 trials (16,302 participants randomised); 55 parallel-group trials (8104 participants randomised), and 156 cross-over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross-over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male-female ratio was 3:1. Most trials were carried out in high-income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias.

PRIMARY OUTCOMES

methylphenidate versus placebo or no intervention may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -0.88 to -0.61; I² = 38%; 21 trials; 1728 participants; very low-certainty evidence). This corresponds to a mean difference (MD) of -10.58 (95% CI -12.58 to -8.72) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD-RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68).

SECONDARY OUTCOMES

methylphenidate may cause more adverse events considered non-serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher-rated general behaviour versus placebo (SMD -0.62, 95% CI -0.91 to -0.33; I² = 68%; 7 trials 792 participants; very low-certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI -0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The majority of our conclusions from the 2015 version of this review still apply. Our updated meta-analyses suggest that methylphenidate versus placebo or no-intervention may improve teacher-rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non-serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non-serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes.

Long-term safety of methylphenidate in children and adolescents with ADHD: 2-year outcomes of the Attention Deficit Hyperactivity Disorder Drugs Use Chronic Effects (ADDUCE) study

BACKGROUND

Methylphenidate is the most frequently prescribed medication for the treatment of ADHD in children and adolescents in many countries. Although many randomised controlled trials support short-term efficacy, tolerability, and safety, data on long-term safety and tolerability are scarce. The aim of this study was to investigate the safety of methylphenidate over a 2-year period in relation to growth and development, psychiatric health, neurological health, and cardiovascular function in children and adolescents.

METHODS

We conducted a naturalistic, longitudinal, controlled study as part of the ADDUCE research programme in 27 European child and adolescent mental health centres in the UK, Germany, Switzerland, Italy, and Hungary. Participants aged 6-17 years were recruited into three cohorts: medication-naive ADHD patients who intended to start methylphenidate treatment (methylphenidate group), medication-naive ADHD patients who did not intend to start any ADHD medication (no-methylphenidate group), and a control group without ADHD. Children with ADHD diagnosed by a qualified clinician according to the DSM-IV criteria and, in the control group, children who scored less than 1·5 on average on the Swanson, Nolan, and Pelham IV rating scale for ADHD items, and whose hyperactivity score on the parent-rated Strengths and Difficulties Questionnaire was within the normal range (<6) were eligible for inclusion. Participants were excluded if they had previously taken any ADHD medications but remained eligible if they had previously taken or were currently taking other psychotropic drugs. The primary outcome was height velocity (height velocity SD score; estimated from at least two consecutive height measurements, and normalised with reference to the mean and SD of a population of the same age and sex).

FINDINGS

Between Feb 01, 2012, and Jan 31, 2016, 1410 participants were enrolled (756 in methylphenidate group, 391 in no-methylphenidate group, and 263 in control group). 1070 (76·3%) participants were male, 332 (23·7%) were female, and for eight gender was unknown. The average age for the cohort was 9·28 years (SD 2·78; IQR 7-11). 1312 (93·0%) of 1410 participants were White. The methylphenidate and no-methylphenidate groups differed in ADHD symptom severity and other characteristics. After controlling for the effects of these variables using propensity scores, there was little evidence of an effect on growth (24 months height velocity SD score difference -0·07 (95% CI -0·18 to 0·04; p=0·20) or increased risk of psychiatric or neurological adverse events in the methylphenidate group compared with the no-methylphenidate group. Pulse rate and systolic and diastolic blood pressure were higher in the methylphenidate group compared with the no-methylphenidate group after 24 months of treatment. No serious adverse events were reported during the study.

INTERPRETATION

Our results suggest that long-term treatment with methylphenidate for 2 years is safe. There was no evidence to support the hypothesis that methylphenidate treatment leads to reductions in growth. Methylphenidate-related pulse and blood pressure changes, although relatively small, require regular monitoring.

FUNDING

EU Seventh Framework Programme.

Dexmedetomidine alleviates host ADHD-like behaviors by reshaping the gut microbiota and reducing gut-brain inflammation

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders that affects children and even continues into adulthood. Dexmedetomidine (DEX), a short-term sedative, can selectively activate the α2-adrenoceptor. Treatment with α2-adrenergic agonists in patients with ADHD is becoming increasingly common. However, the therapeutic potential of DEX for the treatment of ADHD is unknown. Here, we evaluated the effect of DEX on ADHD-like behavior in spontaneously hypertensive rats (SHRs), a widely used animal model of ADHD. DEX treatment ameliorated hyperactivity and spatial working memory deficits and normalized θ electroencephalogram (EEG) rhythms in SHRs. We also found that DEX treatment altered the gut microbiota composition and promoted the enrichment of beneficial gut bacterial genera associated with anti-inflammatory effects in SHRs. The gut pathological scores and permeability and the level of inflammation observed in the gut and brain were remarkably improved after DEX administration. Moreover, transplantation of fecal microbiota from DEX-treated SHRs produced effects that mimicked the therapeutic effects of DEX administration. Therefore, DEX is a promising treatment for ADHD that functions by reshaping the composition of the gut microbiota and reducing inflammation in the gut and brain.

Diagnosis and management of ADHD: a pediatric perspective on practice and challenges in Switzerland

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders in childhood. In Switzerland, the complex diagnosis and treatment are being carried out by adolescent-/child psychiatrists, and pediatricians. Guidelines recommend a multimodal therapy for patients with ADHD. However, it has been questioned whether health professionals follow this approach or favor drug therapy. This study aims to provide insights into the practice of pediatricians in Switzerland regarding diagnosis and treatment of ADHD and their perceptions of these processes.

METHOD

An online survey (self-report) about current practices of diagnosis and management as well as challenges regarding ADHD was distributed to office-based pediatricians in Switzerland. One hundred fifty-one pediatricians participated. Results show that therapy options were almost always discussed with parents and older children. Exchange with parents (81%) and level of child's suffering (97%) were central when selecting therapy options.

RESULTS

Therapies about which pediatricians informed most often were: pharmacological therapy, psychotherapy, and multimodal therapy. Challenges voiced were the subjectivity of diagnostic criteria and dependence on third parties, low availability of psychotherapy, and a rather negative public attitude towards ADHD. Needs that were expressed were further education for all professionals, support for coordination with specialists and schools as well as improvement of information on ADHD.

CONCLUSIONS

Pediatricians do consider a multimodal approach when treating ADHD and take the families` and children's opinions into account. Improvements of the availability of child and youth psychotherapy, the strengthening of the interprofessional cooperation with therapists and schools, and efforts to increase public knowledge about ADHD are proposed.

[Pharmacotherapy and psychotherapy of children with attention deficit hyperactivity disorder]

The article presents a review of scientific publications devoted to the main psychotherapeutic approaches that have shown their effectiveness in correcting behavior in children with attention-deficit/hyperactive disorder (ADHD). The principles of psychotherapeutic methods are outlined to reduce the severity of the main symptoms of ADHD and improve the social adaptation of children with this disease. Approaches to the drug therapy of ADHD and the results of studies on the effectiveness of various drugs used to treat this pathology are considered.

Immersive virtual reality for improving cognitive deficits in children with ADHD: a systematic review and meta-analysis

Virtual reality (VR) shows great potential in treating and managing various mental health conditions. This includes using VR for training or rehabilitation purposes. For example, VR is being used to improve cognitive functioning (e.g. attention) among children with attention/deficit-hyperactivity disorder (ADHD). The aim of the current review and meta-analysis is to evaluate the effectiveness of immersive VR-based interventions for improving cognitive deficits in children with ADHD, to investigate potential moderators of the effect size and assess treatment adherence and safety. The meta-analysis included seven randomised controlled trials (RCTs) of children with ADHD comparing immersive VR-based interventions with controls (e.g. waiting list, medication, psychotherapy, cognitive training, neurofeedback and hemoencephalographic biofeedback) on measures of cognition. Results indicated large effect sizes in favour of VR-based interventions on outcomes of global cognitive functioning, attention, and memory. Neither intervention length nor participant age moderated the effect size of global cognitive functioning. Control group type (active vs passive control group), ADHD diagnostic status (formal vs. informal) and novelty of VR technology were not significant moderators of the effect size of global cognitive functioning. Treatment adherence was similar across groups and there were no adverse effects. Results should be cautiously interpreted given the poor quality of included studies and small sample.

Remote assessment of ADHD in children and adolescents: recommendations from the European ADHD Guidelines Group following the clinical experience during the COVID-19 pandemic

The COVID-19 pandemic led ADHD services to modify the clinical practice to reduce in-person contact as much as possible to minimise viral spread. This had far-reaching effects on day-to-day clinical practice as remote assessments were widely adopted. Despite the attenuation of the acute threat from COVID, many clinical services are retaining some remote practices. The lack of clear evidence-based guidance about the most appropriate way to conduct remote assessments meant that these changes were typically implemented in a localised, ad hoc, and un-coordinated way. Here, the European ADHD Guidelines Group (EAGG) discusses the strengths and weaknesses of remote assessment methods of children and adolescents with ADHD in a narrative review based on available data and expert opinions to highlight key recommendations for future studies and clinical practice. We conclude that going forward, despite remote working in clinical services functioning adequately during the pandemic, all required components of ADHD assessment should still be completed following national/international guidelines; however, the process may need adaptation. Social restrictions, including changes in education provision, can either mask or exacerbate features associated with ADHD and therefore assessment should carefully chart symptom profile and impairment prior to, as well as during an ongoing pandemic. While remote assessments are valuable in allowing clinical services to continue despite restrictions and may have benefits for routine care in the post-pandemic world, particular attention must be paid to those who may be at high risk but not be able to use/access remote technologies and prioritize these groups for conventional face-to-face assessments.