A systematic review of meta-analyses of psychosocial treatment for attention-deficit/hyperactivity disorder

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.

Examining the Use of VR as a Study Aid for University Students with ADHD

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterized by patterns of inattention and impulsivity, which lead to difficulties maintaining concentration and motivation while completing academic tasks. University settings, characterized by a high student-to-staff ratio, make treatments relying on human monitoring challenging. One potential replacement is Virtual Reality (VR) technology, which has shown potential to enhance learning outcomes and promote flow experience. In this study, we investigate the usage of VR with 27 university students with ADHD in an effort to improve their performance in ctableompleting homework, including an exploration of automated feedback via a technology probe. Quantitative results show significant increases in concentration, motivation, and effort levels during these VR sessions and qualitative data offers insight into considerations like comfort and deployment. Together, the results suggest that VR can be a valuable tool in leveling the playing field for university students with ADHD.

Acceptance and utilization of web-based self-help for caregivers of children with externalizing disorders

BACKGROUND

Web-based self-help interventions for parents of children with ADHD and other externalizing disorders have been proven to be effective. In order to recommend individualized and optimized interventions, a better understanding of the acceptance and utilization of this innovative treatment approach is needed. Previous research has frequently employed subjective reports of utilization, but the validity of these studies may be limited.

METHODS

Data from the German WASH study were used. Participants (n = 276) were randomly assigned to the intervention condition (a) web-based self-help or (b) web-based self-help with optional telephone-based support calls. Data collection took place at baseline (T1) and 12 weeks later (T2). Utilization data were tracked using a log file generated for each participant at T2. Prediction models were calculated using CART (Classification and Regression Trees), a method known mostly from the field of machine learning.

RESULTS

Acceptance, of the intervention as defined in this paper was very high on objective (89.4% have taken up the intervention) and subjective measures (91.4% reported having used the intervention and 95.3% reported they would recommend the intervention to a friend). The average number of logins corresponded to recommendations. Predictors of acceptance and predictors of utilization were similar and included, e.g., child's externalizing symptoms, parental psychopathology, and above all additional telephone-based support by counselors.

CONCLUSIONS

Through a detailed identification of acceptance and utilization, and the predictors thereof, we were able to gain a better understanding of the acceptance and utilization of web-assisted self-help for a parent management intervention in the treatment of children with ADHD and ODD. These findings can be used to recommend web-based interventions to particularly suitable families. It should be noted that some form of support is required for an intensive engagement with the content of the program.

TRIAL REGISTRATION

The protocol of the study (German Clinical Trials Register DRKS00013456 conducted on January 3rd, 2018) was approved by the Ethics Committee of the University Hospital, Cologne.

Observation of human-animal interaction for research (OHAIRE) behavior coding in a randomized control trial of children with attention-deficit hyperactivity disorder (ADHD) and a canine-assisted intervention

Introduction

Diagnosed in about 10% of children in the United States, attention-deficit hyperactivity disorder (ADHD) is characterized by symptoms including inattention, hyperactivity, and impulsivity. Traditional interventions, such as pharmacological and psychological interventions, are often used in conjunction with integrative health options, such as animal-assisted interventions. The objective of this manuscript is to report behavior coding findings from a randomized control trial of children with ADHD.

Methods

As part of a larger randomized control trial focused on the efficacy of combining a canine-assisted intervention (live therapy dog or control stuffed dog) with cognitive behavioral therapy for children with ADHD, the current manuscript focuses on video-captured behavior observations (n = 35 children, approximately 322 minutes of data). Data were extracted and coded using the Observation of Human-Animal Interaction Research (OHAIRE) Coding System. Behavior codes are reported as summary scores for the following domains: animal social interaction and human social interaction (further separated into human-adult social interaction and human-peer social interaction). Repeated measures mixed models analyses were performed using SAS PROC GLIMMIX to evaluate group differences and change across the study period.

Results

There were no significant differences in how much children interacted with the live therapy dogs versus control stuffed dogs. With respect to human-to-human social interactions, children showed greater increases over time in human-directed social interactions in the presence of live therapy dogs compared to stuffed dogs (p = .020). Over the course of the 12-week intervention, children increased in interactions with both adults (p = .006) and their peers (p = .014); however, there were more increases over time in adult-directed social interactions in the live animal condition compared to the control stuffed animal condition (p < 0.0001).

Discussion & conclusions

Findings suggest changes in social interaction when participating in this canine-assisted intervention, specifically greater increases in human-to-human social interactions over time when a live therapy dog is present compared to a control stuffed dog. Children appear to engage relatively equally with both live and stuffed dogs; however, the impact of animals on human socialization differs based on if a live animal is present. Future studies should consider incorporating behavior coding analysis into studies of canine-assisted interventions to identify how human-animal interactions may be moderators or mechanisms for psychosocial outcomes.

Use of School-Based Interventions for ADHD, Professional Support, and Burnout Symptoms among Teachers in Iceland

OBJECTIVE

Effective school-based interventions for youth with ADHD are critical to their success. We examined whether teacher application of such interventions and perceptions of professional support related to greater well-being, including fewer burnout symptoms.

METHOD

Teachers in primary schools in Iceland were invited to participate in an online survey, including questions about professional support and the Maslach Burnout Inventory (MBI). The sample comprised N = 592 (88.5% female) participants.

RESULTS

Regression analyses indicated that use of recommended ADHD interventions was positively associated with MBI-Personal Achievement (PA). Greater satisfaction with professional support related to lower MBI-Emotional Exhaustion and MBI-Depersonalization, and higher MBI-PA. Level of professional support was positively associated with use of recommended interventions.

CONCLUSION

Effective interventions and support for students with ADHD may enhance teacher well-being. Icelandic teachers require further training and professional support in best practices for ADHD, to help promote teacher and student success.

Factors Influencing Long-Term Behavioral Intervention Outcomes in Preschool Children with Attention-Deficit Hyperactivity Disorder in Southeast China

Introduction

Previous studies have demonstrated the long-term effectiveness of behavioral interventions for attention-deficit hyperactivity disorder (ADHD) in preschool children. We continue to design a case‒control study to further investigate the factors influencing the long-term effect of behavioral intervention.

Methods

From May 2020 to August 2021, children who were newly diagnosed with ADHD and not receiving any treatment received a one-year behavioral intervention. A total of 86 children completed the behavioral intervention and assessment.

Results

50 children (58.140%) were in the effective group, and 36 children (41.860%) were in the ineffective group. Attention retention time (OR=0.559, 0.322-0.969), Swanson, Nolan, and Pelham total score (OR=1.186, 1.024-1.374) at baseline, performance score for parents (OR=0.631, 0.463-0.859), and teacher coordination (OR=0.032, 0.002-0.413) were the influencing factors of behavioral intervention effects. The area under the receiver operating curve was 0.979 (p<0.001). The comprehensive nomogram model showed that the discrimination and mean absolute error were 0.979 and 0.023, respectively.

Discussion

During behavioral intervention, the implementation skills of parents should be evaluated in a timely manner. The behavioral intervention effect can be predicted based on a child's attention retention time at baseline, teacher involvement, behavioral scale score, and performance score for parents, which can guide clinicians in adjusting personalized treatment plans and provide a basis for clinical decision-making. The treatment of ADHD in preschool children requires a systematic framework that integrates family, school, and society.

Enabling successful life engagement in young people with ADHD: new components beyond adult models of recovery

PURPOSE

To examine the lived experiences of young people successfully managing life with ADHD and investigate the applicability of adult models of Recovery to these individuals.

METHODS

Twenty-seven young people aged 15-31 years participated in qualitative interviews. Participants' success was indicated by employment, school attendance, absence of acute mental health episodes, or absence of chronic alcohol or drug use. Thematic analysis identified specific components of their life successes and challenges.

RESULTS

The emergent framework comprised four elements: (i) Recovernance (RE) (a portmanteau merging 'Recovery' and 'Maintenance'; ongoing adjustment to maintain one's personal best without an end point); (ii) Personal Optimization (PO) (continuously striving to maximize function and adjust one's goals given fluctuating impairments and internal resources); (iii) Self (S) (facing internal challenges and developing internal resilience); and (iv) Environment (E) (facing external challenges and fostering external resilience). These four elements yielded the acronym 'REPOSE'.

CONCLUSIONS

Recovery in young people with ADHD was not a linear journey, with many missteps leading to greater self-knowledge, life skills and mastery. Progress was leveraged on securely anchored internal and external resilience factors against the prospect of setbacks. Findings provide new concepts and novel lexicons to extend existing concepts in Recovery. Implications for rehabilitationCounselling and therapy for young people with ADHD should foster self-understanding, goal setting and self-vigilance as an ongoing process to build their capacity to tackle setbacks and adversities.Counselling and therapy for young people with ADHD focus on a strengths-based approach building internal and external resources, such as developing skills and establishing social connections that build infrastructure in the environment for meaningful participation.

Interventions for ADHD in childhood and adolescence: A systematic umbrella review and meta-meta-analysis

There are several meta-analyses of treatment effects for children and adolescents with attention deficit hyperactivity disorder (ADHD). The conclusions of these meta-analyses vary considerably. Our aim was to synthesize the latest evidence of the effectiveness of psychological, pharmacological treatment options and their combination in a systematic overview and meta-meta-analyses. A systematic literature search until July 2022 to identify meta-analyses investigating effects of treatments for children and adolescents with ADHD and ADHD symptom severity as primary outcome (parent and teacher rated) yielded 16 meta-analyses for quantitative analyses. Meta-meta-analyses of pre-post data showed significant effects for pharmacological treatment options for parent (SMD = 0.67, 95% CI 0.60 to 0.74) and teacher ADHD symptom ratings (SMD = 0.68, 95% CI 0.54 to 0.82) as well as for psychological interventions for parent (SMD = 0.42, 95% CI 0.33 to 0.51) and teacher rated symptoms (SMD = 0.25, 95% CI 0.12 to 0.38). We were unable to calculate effect sizes for combined treatments due to the lack of meta-analyses. Our analyses revealed that there is a lack of research on combined treatments and for therapy options for adolescents. Finally, future research efforts should adhere to scientific standards as this allows comparison of effects across meta-analyses.

Home-based brain-computer interface attention training program for attention deficit hyperactivity disorder: a feasibility trial

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a prevalent child neurodevelopmental disorder that is treated in clinics and in schools. Previous trials suggested that our brain-computer interface (BCI)-based attention training program could improve ADHD symptoms. We have since developed a tablet version of the training program which can be paired with wireless EEG headsets. In this trial, we investigated the feasibility of delivering this tablet-based BCI intervention at home.

METHODS

Twenty children diagnosed with ADHD, who did not receive any medication for the preceding month, were randomised to receive the 8-week tablet-based BCI intervention either in the clinic or at home. Those in the home intervention group received instructions before commencing the program and got reminders if they were lagging on the training sessions. The ADHD Rating Scale was completed by a blinded clinician at baseline and at week 8. Adverse events were monitored during any contact with the child throughout the trial and at week 8.

RESULTS

Children in both groups could complete the tablet-based intervention easily on their own with minimal support from the clinic therapist or their parents (at home). The intervention was safe with few reported adverse effects. Clinician-rated inattentive symptoms on the ADHD-Rating Scale reduced by 3.2 (SD 6.20) and 3.9 (SD 5.08) for the home-based and clinic-based groups respectively, suggesting that home-based intervention was comparable to clinic-based intervention.

CONCLUSIONS

This trial demonstrated that the tablet version of our BCI-based attention training program can be safely delivered to children in the comfort of their own home. Trial registration This trial is registered at clinicaltrials.gov as NCT01344044.

Are Reading Interventions Effective for At-Risk Readers with ADHD? A Meta-Analysis

OBJECTIVE

Utilizing a multi-level meta-analytic approach, this review is the first to systematically quantify the efficacy of reading interventions for school-aged children with ADHD and identify potential factors that may increase the success of reading-related interventions for these children.

METHOD

18 studies (15 peer-reviewed articles, 3 dissertations) published from 1986 to 2020 (N = 564) were meta-analyzed.

RESULTS

Findings revealed reading interventions are highly effective for improving reading skills based on both study-developed/curriculum-based measures (g = 1.91) and standardized/norm-referenced achievement tests (g = 1.11) in high-quality studies of children with rigorously-diagnosed ADHD. Reading interventions that include at least 30 hours of intervention targeting decoding/phonemic awareness meet all benchmarks to be considered a Level 1 (Well-Established) Evidence-Based Practice with Strong Research Support for children with ADHD based on clinical and special education criteria.

CONCLUSIONS

Our findings collectively indicate that reading interventions should be the first-line treatment for reading difficulties among at-risk readers with ADHD.

Explaining the Prospective Association of Positive and Negative Parenting Behaviors and Child ADHD Symptoms: Pathways Through Child Executive Function and Reward Responsivity

Objective: Parenting behavior is a well-established correlate of offspring ADHD. However, little is known about how parenting exerts its effects on offspring ADHD symptomatology. We examined whether prospective associations between positive and negative parenting behaviors and child ADHD symptoms are mediated by deficits in child executive function (EF) and reward responsivity (RR). Method: One hundred and thirty-five children with and without ADHD were assessed across two Waves, when children were mean ages 6 and 8 respectively. Children completed tasks on EF, and parents completed questionnaires about their parenting behaviors and their children's RR and ADHD symptoms. Results: Negative parenting behavior at Wave 1 was indirectly associated with offspring ADHD symptoms at Wave 2 via offspring EF. Conclusion: Individual differences in EF, but not RR, during early childhood may constitute a potential pathway by which negative parenting behaviors exerts its effects on subsequent offspring ADHD symptomatology. Treatment implications are discussed.

Therapeutic Approaches for ADHD by Developmental Stage and Clinical Presentation

Attention Deficit Hyperactivity Disorder is a neurodevelopmental disorder with three presentations: inattentive, hyperactive/impulsive and combined. These may represent an independent disease entity. Therefore, the therapeutic approach must be focused on their neurobiological, psychological and social characteristics. To date, there is no comprehensive analysis of the efficacy of different treatments for each presentation of ADHD and each stage of development. This is as narrative overview of scientific papers that summarize the most recent findings and identify the most effective pharmacological and psychosocial treatments by ADHD presentation and age range. Evidence suggests that methylphenidate is the safest and most effective drug for the clinical management of children, adolescents and adults. Atomoxetine is effective in preschoolers and maintains similar efficacy to methylphenidate in adults, whereas guanfacine has proven to be an effective monotherapy for adults and is a worthy adjuvant for the management of cognitive symptoms. The psychosocial treatments with the best results in preschoolers are behavioral interventions that include training of primary caregivers. In adolescents, the combination of cognitive and cognitive-behavioral therapies has shown the best results, whereas cognitive-behavioral interventions are the most effective in adults. Pharmacological and psychosocial treatments must be adjusted to the ADHD presentation and its neurocognitive characteristics through the patient's development.

School-based group intervention in attention and executive functions: Intervention response and moderators

Objective

This study investigated the effects of a school-based skill-training intervention in attention control and executive functions for pupils with hyperactivity-impulsivity (H-I) and cognitive control (CC) deficits. The main aim was to examine whether the intervention differently influenced H-I and CC, and whether cognitive abilities or conduct problems moderated response to the intervention.

Method

Elementary school pupils from 41 schools participated the study and were divided into an intervention group (n = 71) and a waitlist control group (n = 77). Intervention outcomes were assessed with an inventory assessing executive function difficulties (including H-I and CC) completed by classroom teachers.

Results

Significant intervention effects and positive changes were detected in CC but not in H-I. Significant intervention effects were found mainly among pupils with low levels of conduct problems.

Conclusions

The results suggest that a skill-training intervention has specific positive effects on CC, but conduct problems may diminish response to intervention.

Identifying and addressing conflicting results across multiple discordant systematic reviews on the same question: protocol for a replication study of the Jadad algorithm

INTRODUCTION

An increasing growth of systematic reviews (SRs) presents notable challenges for decision-makers seeking to answer clinical questions. In 1997, an algorithm was created by Jadad to assess discordance in results across SRs on the same question. Our study aims to (1) replicate assessments done in a sample of studies using the Jadad algorithm to determine if the same SR would have been chosen, (2) evaluate the Jadad algorithm in terms of utility, efficiency and comprehensiveness, and (3) describe how authors address discordance in results across multiple SRs.

METHODS AND ANALYSIS

We will use a database of 1218 overviews (2000-2020) created from a bibliometric study as the basis of our search for studies assessing discordance (called discordant reviews). This bibliometric study searched MEDLINE (Ovid), Epistemonikos and Cochrane Database of Systematic Reviews for overviews. We will include any study using Jadad (1997) or another method to assess discordance. The first 30 studies screened at the full-text stage by two independent reviewers will be included. We will replicate the authors' Jadad assessments. We will compare our outcomes qualitatively and evaluate the differences between our Jadad assessment of discordance and the authors' assessment.

ETHICS AND DISSEMINATION

No ethics approval was required as no human subjects were involved. In addition to publishing in an open-access journal, we will disseminate evidence summaries through formal and informal conferences, academic websites, and across social media platforms. This is the first study to comprehensively evaluate and replicate Jadad algorithm assessments of discordance across multiple SRs.

Meta-analysis: Which Components of Parent Training Work for Children With Attention-Deficit/Hyperactivity Disorder?

OBJECTIVE

Behavioral parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but it is unknown which of its components are most effective. This meta-regression analysis investigated which specific behavioral techniques that parents learn in parent training are associated with effects on parental outcomes.

METHOD

A search was performed for randomized controlled trials on parent training for children with ADHD, with positive parenting, negative parenting, parenting sense of competence, parent-child relationship quality, and parental mental health as outcome measures. After screening 23,026 publications, 29 studies contributing 138 effect sizes were included (N = 2,345). For each study, the dosage of 39 behavioral techniques was derived from intervention manuals, and meta-regression determined which techniques were related to outcomes.

RESULTS

Parent training had robust small- to medium-sized positive effects on all parental outcomes relative to control conditions, both for unblinded and probably blinded measures. A higher dosage of techniques focusing on the manipulation of antecedents of behavior was associated with better outcomes on parenting sense of competence and parental mental health, and a higher dosage of techniques focusing on reinforcement of desired behaviors was related to larger decreases in negative parenting. Higher dosages of psychoeducation were negatively related to parental outcomes.

CONCLUSION

Although techniques were not investigated in isolation, the results suggested that manipulation of antecedents of behavior and reinforcement techniques are key components of parent training for children with ADHD in relation to parental outcomes. These exploratory findings may help to strengthen and tailor parent training interventions for children with ADHD.

Attachment Representation Moderates the Effectiveness of Behavioral Parent Training Techniques for Children with ADHD: Evidence from a Randomized Controlled Microtrial

Behavioral parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but knowledge on the differential effects of behavioral techniques for specific subgroups of children is very limited. Attachment representations of children with ADHD may affect how receptive children are to changes in parenting. In this study, we investigated whether specific behavioral techniques were more or less effective for children with ADHD in relation to their attachment representations. We included parents of 74 children with ADHD (4-11 years, M = 8.15) who took part in a larger randomized controlled microtrial in which they were randomized to a two session training in antecedent-based techniques (i.e., stimulus control techniques: rules, instructions; n = 26), a two session training in consequent-based techniques (i.e., contingency management techniques: praise, rewards, ignoring; n = 25) or a waitlist control condition (n = 23). We examined whether attachment representation moderated the effectiveness of a) training versus waitlist, and b) antecedent- versus consequent-based techniques. Attachment representations were measured with a story stem task, the intervention outcome was daily parent-rated problem behaviors of the children. Attachment representation did not moderate the effects of the training compared to the waitlist. However, compared to antecedent-based techniques, consequent-based techniques were less effective for more securely and less disorganized attached children, and particularly effective for more disorganized attached children. This was the first study examining attachment as a moderator of behavioral techniques for ADHD. If replicated, the findings of this study can be used for treatment development and tailoring.

A prospective study of the decision tree prediction model for attention deficit hyperactivity disorder in preschool children

OBJECTIVES

To study the clinical value of attention time combined with behavior scale in the screening of attention deficit hyperactivity disorder (ADHD) in preschool children.

METHODS

A total of 200 preschool children with ADHD diagnosed in Fujian Maternal and Child Health Hospital from February 2019 to March 2020 were enrolled as the ADHD group. A total of 200 children who underwent physical examination in the hospital or kindergartens during the same period were enrolled as the control group. Attention time was recorded. Chinese Version of Swanson Nolan and Pelham, Version IV Scale-Parent Form (SNAP-IV) scale was used to evaluate symptoms. With clinical diagnosis as the gold standard, the decision tree analysis was used to evaluate the clinical value of attention time combined with behavior scale in the screening of ADHD.

RESULTS

Compared with the control group, the ADHD group had significantly higher scores of SNAP-IV items 1, 4, 7, 8, 10, 11, 14, 15, 16, 18, 20, 21, and 22 (P<0.05) and a significantly shorter attention time (P<0.05). The variables with statistically significant differences between the two groups in univariate analysis were used as independent variables to establish a decision tree model. The accuracy of the model in predicting ADHD was 81%, that in predicting non-ADHD was 69%, and the overall accuracy was 75%, with an area under the ROC curve of 0.816 (95% CI: 0.774-0.857, P<0.001).

CONCLUSIONS

The decision tree model for screening ADHD in preschool children based on attention time and assessment results of behavior scale has a high accuracy and can be used for rapid screening of ADHD among children in clinical practice.

Treatment with RehaCom computerized rehabilitation program improves response control, but not attention in children with attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder in children. ADHD impairs attention, response control, emotion regulation, and other cognitive functions. On the other hand, RehaCom is a cognitive rehabilitation software that has therapeutic effects on cognitive dysfunctions in many diseases such as stroke, multiple sclerosis, and schizophrenia. The goal of the present study was to investigate the effect of treatment with RehaCom on auditory and visual response control, and auditory and visual attention in children with ADHD. Forty patients were selected. The participants were assigned to control (n = 20) and experimental (n = 20) groups, while only the participants in the experimental group were trained by RehaCom for five weeks (ten 45-min sessions, two sessions per week). At weeks 0 and 5, performance of the participants of experimental group was compared with the participants of control group. The results showed that treatment with RehaCom significantly improved auditory and visual response control in children with ADHD, with no effect on auditory and visual attention. In conclusion, RehaCom may alter brain's structural and functional properties that are related to response control. We suggest that attention deficit in ADHD may be a result of more complicated dysfunctions in the brain, that are not affected by RehaCom.

Efficacy of cognitive behavioral therapy on aggressive behavior in children with attention deficit hyperactivity disorder and emotion dysregulation: study protocol of a randomized controlled trial

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is frequently associated with emotional dysregulation (ED). ED is characterized by excessive and inappropriate emotional reactions compared to social norms, uncontrolled and rapid shifts in emotion, and attention focused on emotional stimuli. Few studies have evaluated non-pharmacological interventions to improve ED in children with ADHD. The current randomized controlled trial assesses the efficacy of a cognitive behavioral therapy (CBT) intervention compared with a theater-based intervention (TBI) in children with ADHD and ED.

METHODS

Sixty-eight 7- to 13-year-old children with ADHD and ED will be recruited and randomly assigned to the CBT or TBI group. CBT aims to reduce ED by teaching anger management strategies. TBI seeks to reduce ED by improving emotion understanding and expression through mimics and movement. In both groups, children participate in 15 1-h sessions, and parents participate in 8 sessions of a parent management program. The primary outcome measure is the change in the "Aggression" sub-score of the Child Behavior Checklist (CBCL). Secondary outcome measures include overall impairment (Children's Global Assessment Scale, Strengths and Difficulties Questionnaire), personality profile (Hierarchical Personality Inventory for Children), executive function (Behavioral Rating Inventory of Executive Function), quality of life (Kidscreen-27), parental stress (Parenting Stress Index, 4th edition), parental depression (Beck Depression Inventory-II), and impact of child disorders on the quality of the family life (Parental Quality of Life and Developmental Disorder).

DISCUSSION

Children with ADHD and ED are at risk of functional impairment and poor outcomes and have specific therapeutic needs. This randomized controlled trial wants to assess non-pharmacological treatment options for this population.

TRIAL REGISTRATION

Clinicaltrials.gov. NCT03176108 . Registered on June 5, 2017.

An Individual Participant Data Meta-analysis: Behavioral Treatments for Children and Adolescents With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Behavioral interventions are well established treatments for children with attention-deficit/hyperactivity disorder (ADHD). However, insight into moderators of treatment outcome is limited.

METHOD

We conducted an individual participant data meta-analysis (IPDMA), including data of randomized controlled behavioral intervention trials for individuals with ADHD <18 years of age. Outcomes were symptoms of ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) and impairment. Moderators investigated were symptoms and impairment severity, medication use, age, IQ, sex, socioeconomic status, and single parenthood.

RESULTS

For raters most proximal to treatment, small- to medium-sized effects of behavioral interventions were found for symptoms of ADHD, inattention, hyperactivity/impulsivity (HI), ODD and CD, and impairment. Blinded outcomes were available only for small preschool subsamples and limited measures. CD symptoms and/or diagnosis moderated outcome on ADHD, HI, ODD, and CD symptoms. Single parenthood moderated ODD outcome, and ADHD severity moderated impairment outcome. Higher baseline CD or ADHD symptoms, a CD diagnosis, and single parenthood were related to worsening of symptoms in the untreated but not in the treated group, indicating a protective rather than an ameliorative effect of behavioral interventions for these children.

CONCLUSION

Behavioral treatments are effective for reducing ADHD symptoms, behavioral problems, and impairment as reported by raters most proximal to treatment. Those who have severe CD or ADHD symptoms, a CD diagnosis, or are single parents should be prioritized for treatment, as they may evidence worsening of symptoms in the absence of intervention.

School-Based Interventions for Elementary School Students with Attention-Deficit/Hyperactivity Disorder

Children with attention-deficit/hyperactivity disorder experience significant academic, social, and behavioral impairments in elementary school settings. Although psychopharmacologic treatments can improve symptomatic behaviors, these rarely are sufficient for enhancing school performance. Thus, medication should be supplemented by one or more school interventions, including behavioral strategies, academic interventions, behavioral peer interventions, organizational skills training, and self-regulation strategies. Although all of these school interventions have been found effective, classroom behavioral strategies, organizational skills training, and self-regulation strategies have the strongest empirical support. Clinicians should collaborate with school mental health professionals to encourage implementation of effective school interventions across school years.

Family-based treatments for attention-deficit/hyperactivity disorder: A review of family functioning outcomes in randomized controlled trials from 2010 to 2019

This review details advances in randomized controlled trials of family-based treatments for attention-deficit/hyperactivity disorder (ADHD) conducted in the United States from 2010 to 2019, and the impact of these treatments on the domain of family functioning. Twenty-two studies were included in the review and three types of family treatments, integrated parent-child treatments, parent-directed treatments, and youth treatments with adjunctive parent involvement, were identified for children and adolescents. Studies point to considerable advancements in consideration of understudied and diverse populations, and results of the review show all three types of family interventions for ADHD should be considered well-established interventions addressing family functioning. Practical guidelines are offered, and future directions for research are discussed.

Long-term effectiveness of behavioural intervention in preschool children with attention deficit hyperactivity disorder in Southeast China - a randomized controlled trial

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is the most common behavioral disorder. Behavioural intervention in preschool children with ADHD is considered effective. This study discussed the long-term effectiveness of behavioural intervention in the context of nondrug therapy.

METHODS

The study was a prospective, randomised controlled trial in which 201 preschoolers diagnosed with ADHD who were not receiving any treatment were assigned to two groups from January 2018 to May 2019, 101 were assigned to the conventional group and 100 to the behavioural intervention group. The behavioural intervention group included parental training, behavioural therapy, attention training, relief therapy and game therapy, in addition to the conventional group offerings. Children were evaluated at a baseline, at the end of the 12-month intervention and six months after the intervention. The primary and secondary outcome variables included attention time, the impulse-hyperactivity and hyperactivity index from Conners parent symptom questionnaire (PSQ), full-scale attention quotient (FAQ) and full-scale response control quotient (FRCQ) from integrated visual and auditory comprehensive continuous performance tests. The attention time was observed and recorded by parents, and others were performe(PSQ)d by physicians in the clinic. All statistical analyses were conducted using SPSS V26.0 (IBM), including the descriptive statistics and mixed-effects models and so on.

RESULTS

The participants' mean age was (66.17±9.00) months in the behavioural group and (67.54±6.22) months in the conventional group .A total of 190 participants completed a follow-up six months after the intervention. The attention time, Conners parent symptom questionnaire (PSQ), full-scale attention quotient (FAQ) and full-scale response control quotient (FRCQ) increased significantly over time, and the behavioural group improvements were higher than those of conventional group. There was a significant main effect of time (pretest/posttest/follow-up) and group on all outcome measures (t =-12.549-4.069, p<0.05), and a significant interaction of time and group on attention time, impulsivity/hyperactivity, FAQ and FRCQ (t =-3.600-3.313, p<0.05).

CONCLUSION

Behavioural intervention can effectively improve behaviour management and relieve symptoms in children with ADHD. These effects lasted at least six months. This study provides a promising approach for improving clinical efficacy with preschool children with ADHD.

Multi-center nationwide study on pediatric psychiatric inpatients 2000-2018: length of stay, recurrent hospitalization, functioning level, suicidality, violence and diagnostic profiles

Inpatient treatment is an important part of child and adolescent psychiatric (CAP) care. This nationwide study explores the changes in length of stay, recurrent hospitalization, functioning level, suicidality, violence and diagnoses of CAP inpatients in Finland in 2000, 2011 and 2018. We obtained comprehensive questionnaire data on each study year from 93 to 95% of all CAP wards in Finland. We split the 1276 inpatients into two age groups in each study year: under 13 and 13-18. The median length of stay in inpatient treatment decreased from 82.0 days in 2000 to 20.5 days in 2018 (p < 0.001) and recurrent hospitalization increased from 38 to 46%. General functioning, which was evaluated by the Children's Global Assessment Scale, deteriorated by an average of six points between 2000 and 2018. Violent threats decreased from 21.5 to 16.6% and violent acts decreased from 26.9 to 20.3%. Suicidal threats decreased from 42.6 to 23.3% in those aged under 13 and remained stable among those aged 13-18. In the 13-18 group, there was an increase in the diagnoses of ADHD, from 5.0 to 16.9% and depression, from 25.1 to 41.7%. However, psychosis decreased from 23.2 to 12.6% in the older age group. In the whole cohort, anxiety disorders increased from 7.6 to 15.6%. The overall picture does not show that CAP inpatients have become more disturbed. While the general functioning of CAP inpatients deteriorated somewhat over the 2000-2018 study period, symptoms of suicidality and violence remained stable or decreased. There was also a continuous increase in short-term treatment.

Psychosocial Interventions for Attention-Deficit/Hyperactivity Disorder: Systematic Review with Evidence and Gap Maps

OBJECTIVE

To inform the scope of future systematic reviews, meta-analyses, and treatment outcome studies, this review aims to describe the extent of the evidence for psychosocial interventions for children and adolescents with attention-deficit/hyperactivity disorder, with particular attention to specific types of interventions, targets of outcome assessment, and risk of bias.

METHOD

A comprehensive search of relevant databases (i.e., Medline, PsychInfo, Education Resources Information Center, and ProQuest Dissertation Database) was conducted. Detailed information related to treatment type, outcome assessment, study design, and risk of bias was extracted by trained coders. Evidence and gap maps were created to summarize evidence within types of treatments and targets of outcome assessment. Indicators of risk of bias were assessed for selected combinations of treatments and outcome assessment.

RESULTS

We identified 185 eligible individual studies and 3817 effect sizes. Behavioral parent training and cognitive training (COG) were the most commonly studied stand-alone interventions. Treatment versus control comparisons for stand-alone interventions (s = 70) were less common than for complex interventions involving combinations of psychosocial interventions (s = 100). Combinations of behavioral and child training (e.g., COG, organizational training) interventions were the most frequently studied.

CONCLUSION

There is a considerable variability within this literature regarding combinations of treatments across outcome assessment targets. To address gaps in existing evidence, more primary studies assessing direct comparisons of isolated and combined treatment effects of specific types of psychosocial treatments relative to control and other treatments are needed. Future meta-analyses should take into account the complexity and breadth of available evidence.

A Review of Predictors of Psychosocial Service Utilization in Youth with Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood disorders. Professional practice guidelines recommend combined treatment, psychopharmacological and psychosocial, for youth with ADHD. There have been multiple reviews of pharmacological prescription practices and utilization, however, less is known about predictors of ADHD psychosocial service utilization. Given the importance of accessing psychosocial treatment in relation to improving functional impairment, this review synthesizes evidence on predictors of ADHD psychosocial intervention utilization in clinic, community, and school settings. Eighteen studies were identified and included in the review. Findings are summarized across informant profile factors, predisposing characteristics, and barriers and facilitators. The most robust findings were for the impact of symptom severity/impairment, the presence of comorbidities, and age on ADHD psychosocial service utilization. Race/ethnicity, sex, parental knowledge of the disorder and insurance coverage were also identified as key factors. Future avenues of research are provided, and clinical and policy implications targeted at reducing psychosocial treatment disparities in youth with ADHD are discussed.

Which Techniques Work in Behavioral Parent Training for Children with ADHD? A Randomized Controlled Microtrial

OBJECTIVE

Behavioral parent training (BPT) is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but little is known about the effects of separate techniques parents learn in BPT.

METHOD

In a three-armed randomized controlled microtrial including parents of 92 children (4-12 years) with ADHD, we examined the efficacy of two sessions parent training involving either stimulus control techniques (antecedent-based condition (AC)) or contingency management techniques (consequent-based condition (CC)), compared to a waitlist. Primary outcome was daily parent-rated problem behaviors, secondary outcomes were parent-rated symptoms of ADHD and oppositional defiant disorder (ODD), and mental health-care consumption. Measures were completed at baseline (T0), immediately after the training (T1), at two weeks (T2) and three months (T3) follow-up. We also explored whether child and parent characteristics moderated treatment effects.

RESULTS

Compared to the waitlist, in the AC, daily rated problem behaviors improved at T1 (d= .56) and T2 (d= .65); in the CC, these behaviors only improved at T2 (d= .53). Daily rated problem behaviors within both conditions remained stable between T2 and T3. In the AC compared to the other conditions, inattention symptoms decreased at T1 and T2. For both active conditions compared to waitlist, hyperactivity-impulsivity symptoms decreased only at T2 and ODD symptoms did not decrease. No moderators were identified. Mental health-care consumption after training was low and did not differ between the active conditions.

CONCLUSIONS

Brief training of parents in antecedent- or consequent-based techniques improves problem behaviors of children with ADHD. Antecedent-based techniques appear to be especially important to target inattention.

Does parent management training reduce behavioural and emotional problems in children with intellectual disability? A randomised controlled trial

BACKGROUND

Children with intellectual disability (ID) are more likely to develop behavioural and emotional problems. However, specific interventions for the treatment of these problems in children with ID have rarely been evaluated. Parent management training (PMT) has been shown to be effective in reducing behavioural and emotional problems for other mental disorders. Therefore, we developed and evaluated a special PMT intervention for parents of children with ID.

METHODS

The PMT was developed based on existing programs for children with other mental disorders. The effects of the PMT were analysed in a randomised controlled trial (intervention group: n = 21; waitlist control group: n = 21). The primary outcome was behavioural and emotional problems of children as rated by parents. Additionally, effects on parent-rated family burden and positive and negative parenting were assessed.

OUTCOME

For the primary outcome, a statistically significant reduction of behavioural and emotional problems of the children emerged, with moderate effects for disruptive/ antisocial behaviour and anxiety. Family burden was reduced as a trend, with a small effect size. There was a significant increase in positive parenting and no effect on negative parenting.

Exploring the Effects of Pharmacological, Psychosocial, and Alternative/Complementary Interventions in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder: Meta-Regression Approach

BACKGROUND

There have been various therapies for attention-deficit/hyperactivity disorder (ADHD), but the previous meta-analysis of ADHD efficacy remains unclear. This study aims to systemically meta-regress the effect sizes (ES) of psychostimulant pharmacotherapy (methylphenidate and lisdexamfetamine), non-stimulant pharmacotherapy (atomoxetine and alpha-2 agonists), psychosocial therapy (parental behavioral therapy [PBT]), combination therapy (psychostimulant plus PBT), and alternative/complementary interventions to determine the right treatment for ADHD.

METHODS

We searched various ADHD interventions from the MEDLINE and PubMed databases (National Center for Biotechnology Information) between January 1, 1980, and July 30, 2018. Following the meta-analysis of random effects, the meta-regression analyses were used to explore factors potentially influencing treatment efficacy. The confounding variables included type of treatment, type of study, age, type of symptom scale used, and year of publication.

RESULTS

A total of 107 trials (n = 9883 participants) were included. After adjustment, compared with the psychostimulant therapy (28 trial, 2134 participants), non-stimulant pharmacotherapy (28 trials, 4991 participants) and alternative/complement intervention (25 trials, 1195 participants) were less effective by the ES of -0.384 (P = .004) and -0.419 (P = .028), respectively. However, compared with psychostimulant, PBT (19 trials, 1122 participants; ES = -0.308, P = .095) and the combination of psychostimulant and PBT (7 trials, 441participants; ES = -0.196, P = .209) did not differ significantly.

CONCLUSIONS

Psychostimulant therapy surpassed non-stimulant pharmacotherapy and alternative/complement intervention. Psychostimulant therapy, PBT, and the combination of psychostimulant therapy and PBT appear to be similar in efficacy according to this meta-regression.

Harnessing Home-School Partnerships and School Consultation to Support Youth With Anxiety

Youth with anxiety often experience significant impairment in the school setting. Despite the relevance and promise of addressing anxiety in schools, traditional treatment approaches to school-based anxiety often do not adequately address generalization to the school setting, or they require removing the student from the classroom to deliver time- and staff-intensive programs. Such programs often leave teachers and caregivers feeling ill-equipped to support the student with anxiety throughout the natural course of the school day. Given the heavy demands placed on teachers and documented burnout among school professionals, providing effective school supports requires collaborative partnerships among outpatient therapists/specialists, school personnel, and caregivers. Drawing from literature on collaborative models for externalizing problems, we offer recommendations for outpatient therapists and specialists working to implement evidence-based supports in school settings and promote home-school partnerships to benefit youth with anxiety in the school setting. Our recommendations touch upon several components of such school consultation, including (a) identification of key parties involved, (b) conducting a needs assessment, (c) collaborative goal setting and development of a fear hierarchy, (d) plan development and implementation (e.g., facilitating a school-based exposure mindset, promoting home-school communication, enhancing school relationships), and (e) progress monitoring and ongoing support. We conclude with a case example to bring these recommendations to life.

Effectiveness of Virtual Reality-Based Interventions for Children and Adolescents with ADHD: A Systematic Review and Meta-Analysis

This review aims to evaluate the effectiveness of virtual reality-based interventions (VR-based interventions) on cognitive deficits in children with attention deficit hyperactivity disorder (ADHD). A systematic review and meta-analysis were performed according to the PRISMA statement and the Cochrane Handbook guidelines for conducting meta-analyses. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the quality of the evidence. Clinical trials published up to 29 October 2020, were included. The meta-analysis included four studies, with a population of 125 participants with ADHD. The magnitude of the effect was large for omissions (SMD = −1.38; p = 0.009), correct hits (SMD = −1.50; p = 0.004), and perceptual sensitivity (SMD = −1.07; p = 0.01); and moderate for commissions (SMD = −0.62; p = 0.002) and reaction time (SMD = −0.67; p = 0.03). The use of VR-based interventions for cognitive rehabilitation in children with ADHD is limited. The results showed that VR-based interventions are more effective in improving sustained attention. Improvements were observed in attentional vigilance measures, increasing the number of correct responses and decreasing the number of errors of omission. No improvements were observed in impulsivity responses.

Long-Term Effectiveness of Guided Self-Help for Parents of Children With ADHD in Routine Care-An Observational Study

Objective:To assess long-term effectiveness of guided self-help for parents of children with ADHD under routine care conditions. Method: 6- to 12-year-old children diagnosed with ADHD were enrolled in an observational study on a 1-year telephone-assisted parent-administered behavioral intervention. N = 136 families who completed the intervention participated in a follow-up assessment. Pre-, post-, and follow-up data were analyzed by repeated measures ANOVA with planned contrasts. Clinical significance was analyzed according to the reliable change index. Results: Child ADHD symptoms (primary outcome), oppositional defiant disorder (ODD) symptoms, overall behavioral problems, and quality of life improved during the intervention. There was a further improvement in ADHD symptoms at follow-up, with a medium effect size. Improvements during treatment in ODD symptoms, overall behavioral problems, and quality of life were maintained at follow-up. Conclusion: The findings suggest that telephone-assisted self-help interventions may result in a long-term reduction of child behavior problems.

Identifying Neural Markers of Peer Dysfunction in Girls with ADHD

Very little research has prioritized girls with ADHD, despite accumulating evidence showing that girls with ADHD experience broader and more severe peer dysfunction relative to boys with ADHD. Attention to identifying the neural mechanisms underlying the peer difficulties of girls with ADHD is critical in order to develop targeted intervention strategies to improve peer functioning. New efforts to address the peer dysfunction of girls with ADHD are discussed.

Cognitive behavior therapy for externalizing disorders in children and adolescents in routine clinical care: A systematic review and meta-analysis

Various Cognitive Behavioral Therapy (CBT) programs for externalizing disorders in children and adolescents are supported by a substantial body of empirical evidence. Most of the research evidence comes from efficacy studies conducted in university settings, but there is less knowledge about the effect of these treatments in routine clinical care. The purpose of this meta-analysis was to investigate the effectiveness of CBT in non-university settings for Attention Deficit Hyperactivity Disorder (ADHD), Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD). Embase OVID, Ovid MEDLINE and PsycINFO were systematically searched for eligible studies published up to May 2020. In total, 51 treatment effectiveness studies involving 5295 patients were included. The average within-group effect size at post-treatment was significant (g = 0.91), and there were large effect sizes for both ADHD (g = 0.80) and CD/ODD (g = 0.98). At post treatment, remission rates were 38% for ADHD and 48% for CD/ODD, and the overall attrition rate was 14%. Benchmarking against efficacy studies showed that CBT in routine clinical care yields remission rates, within-group effect sizes and attrition rates that are very similar to those found in university settings. The findings support the transportability of CBT for externalizing disorders from university settings to routine clinical care. PROSPERO registration: CRD42020147524.

Effects of a modular teacher coaching program on child attention problems and disruptive behavior and on teachers’ self-efficacy and stress

Symptoms of attention-deficit/hyperactivity and oppositional defiant disorder are associated with a multitude of psychosocial developmental risks, e.g. academic underachievement. Various cognitive behavioral interventions have proven to be effective in reducing problem behavior in school settings. Drawing on this previous work and on our parent-focused preventive and therapeutic programs, we developed the school-based coaching for elementary school teachers of children with attention deficits or disruptive behavior problems (SCEP). Based on functional behavior assessment, SCEP addresses teachers of children with severe externalizing behavior problems in an individualized modular manner. It consists of a one-day training course and fortnightly one-to-one or team-coaching sessions. We analyzed the effects of SCEP in a within-subject control group design ( N = 60), with student attention problems and rule-breaking behavior during class as the primary outcome measure. SCEP was found to reduce problem behavior during lessons, with small to medium effect sizes ( d = 0.42–0.6). After the intervention, teachers reported changes in their use of praise and felt more confident managing the class ( d = 0.58). The results of SCEP are discussed in light of multi-tiered preventive approaches that suggest extensive individualized interventions based on functional behavior analysis for children with severe problem behavior.

Does Poverty Moderate Psychosocial Treatment Efficacy for ADHD? A Systematic Review

Objective: To determine the extent to which children in poverty show differential benefit versus non-impoverished peers when undergoing behavioral treatment for ADHD. Method: Multiple readers conducted a systematic review using four research databases, one national treatment database, and multiple recent reviews and meta-analyses to identify appropriate studies. Results: Of 1192 initial search results, only five studies met inclusion criteria and were fully abstracted. Conclusion: Results suggest mixed evidence that low-income children may benefit less, compared with peers from higher income families, from psychosocial treatment for ADHD. Findings point to the need for more consistent, more precise, and higher quality reporting of income information.

The Transition of Youth with ADHD into the Workforce: Review and Future Directions

Previous research suggests that a majority of children with attention-deficit/hyperactivity disorder (ADHD) continue to experience increased impairment across multiple life domains into adulthood. A systematic review of the occupational impairments, and associated educational and financial difficulties, faced by individuals with childhood ADHD was conducted. Systematic searches from PsycINFO and PubMed databases and other sources (i.e., books and consultants with experts) yielded 35 relevant articles that described 19 longitudinal studies on adults with a history of ADHD or related symptoms. Multiple studies indicated that those with a history of ADHD had more educational impairment and were less likely to graduate from high school and college than their peers without a history of ADHD. Subsequently, they faced lower occupational attainment, had more job instability, and demonstrated more impaired job performance, and these outcomes were largely consistent regardless of sex, medication history, or symptom persistence. Similar results were found in clinical and representative national studies in both U.S. and abroad, although older studies tended to indicate less occupational impairment. In addition, ADHD was associated with a number of financial challenges, including lower annual income, more reliance on public aid, and increased risk for homelessness. Future research should use more varied informant sources and utilize innovative measures of occupational impairment at both a macro- and micro-level of analyses. In addition, studies of effective supports and interventions in occupational settings for individuals with ADHD are needed.

Behavior Modification Is Associated With Reduced Psychotropic Medication Use in Children With Aggression in Inpatient Treatment: A Retrospective Cohort Study

OBJECTIVE

There are few data to guide management of agitated and aggressive psychiatrically hospitalized children. Available studies do not account for setting, age, sex, diagnosis, admission reason, or clinical intervention. Seclusion, restraint, and physical holds (S/R/H) are usually the only outcome measure. In this study, we examine changes in PRN (pro re nata, or "as needed") psychotropic medication use to manage severe aggression on a children's psychiatric inpatient unit, comparing rates before and after a behavior modification program (BMP) was discontinued.

METHOD

We compare 661 children (aged 5-12 years) in 5 cohorts over 10 years, 510 (77%) of whom were admitted for aggressive behavior. PRN use per 1,000 patient-days was the primary outcome measure, but S/R/H was also examined. We use the following as predictors: BMP status, full- or half-time child and adolescent psychiatrist (CAP) oversight, diagnosis, age, length of stay, and neuroleptic use.

RESULTS

Children admitted for aggression had high rates of externalizing disorders (79%), low rates of mood (27%) and anxiety (21%) disorders, and significantly higher rates of PRN and S/R/H (p < .001) use. Rate of PRN use was significantly lower (p < .001) when the BMP was present (mean [SD], 163 [319] per 1,000 patient-days) than when it was absent (483 [569]; p < .001). Higher PRN use was predicted by BMP absence, neuroleptic treatment, and young patient age (p < .001), and by half-time CAP oversight (p = .002).

CONCLUSION

In this sample of young children with primarily externalizing disorders, data support the effectiveness of a BMP in lowering rates of PRN and S/R/H use.

A Commercial Insurance Claims Analysis of Correlates of Behavioral Therapy Use Among Children With ADHD

OBJECTIVE

The study examined factors associated with uptake of behavioral therapy among children with attention-deficit hyperactivity disorder (ADHD).

METHODS

Insurance claims data from 2008-2014 (MarketScan) were reviewed to examine associations between behavioral therapy use and demographic, patient, family, and provider factors. The association between ADHD medication use and future uptake of behavioral therapy was examined with logistic regression adjusted for covariates found to affect behavioral therapy use.

RESULTS

Among 827,396 youths with ADHD, under 50% received any billable behavioral therapy services over the 7 years. ADHD severity, gender, region of residence, assessment year, comorbid behavioral disorders, and behavioral therapy use by siblings were significantly associated with behavioral therapy use (p<0.001). Parent psychopathology and sibling medication use was not. Children prescribed ADHD medication were 2.5 times less likely than those not prescribed medication to use behavioral therapy, even after adjustment for severity of behavioral health symptoms and other covariates (odds ratio [OR]= 0.41, 95% confidence interval [CI]=.40-.41, p<0.001). Effects of medication use were stronger for future uptake of behavioral therapy (OR=0.25, 95% CI =0.24-0.25, p<.001). The impact of medication use on behavioral therapy use was equally strong for children under age 6 and for older children and did not weaken after release of 2011 guidelines recommending behavioral therapy as the initial ADHD treatment for young children.

CONCLUSIONS

Multiple systems, family, patient and provider factors affected behavioral therapy uptake. ADHD medication was a robust and potentially modifiable factor. It may be advisable to engage families in behavioral therapy prior to initiation of ADHD medication.

Should We Subtype ADHD According to the Context in Which Symptoms Occur? Criterion Validity of Recognising Context-Based ADHD Presentations

ADHD symptoms show considerable individual variation in the contexts in which they are expressed. It has previously been proposed that subtyping individuals according to the contexts in which symptoms are expressed may be clinically useful. We examined context-based patterns of ADHD symptoms in a longitudinal cohort study of n = 1388 children, as well as context-specific and context-general predictors of symptoms. Participants were community-ascertained and provided ADHD symptom data at ages 7, 9, and 11. Using growth mixture modelling we identified five inattention and five hyperactivity/impulsivity categories that differed in the developmental patterns of symptoms reported by parent and teacher informants. We found some evidence that context-specific predictors were related to context-specific expressions. Specifically, after controlling for other risk factors for ADHD symptoms, relationships with teachers predicted school-specific (teacher-reported) but not home-specific (parent-reported) symptom levels. However, no subtypes defined by exclusively home-based symptoms emerged, suggesting that while symptoms may sometimes be specific to the school context, they are only rarely confined to the home context. Subtyping by context could be informative; however, further work will required to uncover the nature of any etiological, functional, or outcome differences between those who show symptom expression in different contexts.

[The prevention of externalizing disturbances]

The prevention of externalizing disturbances Abstract. Objectives: Externalizing disturbances (attention deficit-hyperactivity disorders, oppositional defiant disorders, conduct disorders) in children and adolescents have a high prevalence, are stable over time, and precipitate a high individual and economic burden. Method: This review article presents the state of research based on selected current meta-analyzes and systematic reviews. Additionally, evidenced-based German-language prevention programs are discussed. Results: As in treatment, a multimodal approach to prevention is recommended which aims at reducing externalizing symptoms in specific settings. Interventions that focus on the specific environment in the family and the (pre-)school are preferable. Child-focused interventions are especially important in the context of peer-related problematic behavior because parent-based or teacher-based interventions may be less able to affect peer interactions. Conclusions: Comprehensive parent-based and (pre-)school-based preventive interventions of externalizing disturbances should be implemented. These should also include child-based approaches and additional parent-based group interventions. The effects of these interventions should be tested in large-scale studies.

Children's Reward and Punishment Sensitivity Moderates the Association of Negative and Positive Parenting Behaviors in Child ADHD Symptoms

Atypical reward processing, including abnormal reward responsivity and sensitivity to punishment, has long been implicated in the etiology of ADHD. However, little is known about how these facets of behavior interact with positive (e.g., warmth, praise) and negative (e.g., hostility, harsh discipline) parenting behavior in the early expression of ADHD symptoms in young children. Understanding the interplay between children's reward processing and parenting may be crucial for identifying specific treatment targets in psychosocial interventions for ADHD, especially given that not all children benefit from contingency-based treatments (e.g., parent management training). The study consisted of a sample of kindergarten children (N = 201, 55% male) and their parents, who completed questionnaires about their parenting practices, their child's behaviors and participated in an observed parent-child play task in the laboratory. Children's reward responsivity and sensitivity to punishment were positively associated with child ADHD symptoms. However, children with high reward responsivity had more symptoms of ADHD but only under conditions of low negative parenting (self-reported and observed) and high self-reported positive parenting, compared to children with low reward responsivity. Children with high sensitivity to punishment had more ADHD symptoms relative to children with low sensitivity to punishment, but only under conditions in which observed praise was infrequent. Results provide evidence that individual differences in sensitivity to reward/punishment may be an important of marker of risk for ADHD, but also highlights how children's responses to positive and negative parenting behavior may vary by children's sensitivities. Clinical and treatment implications are discussed.

Group cognitive behavioral therapy for children and adolescents with ADHD

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

The Effects of Attention Problems on Psychosocial Functioning in Childhood Brain Tumor Survivors: A 2-Year Postcraniospinal Irradiation Follow-up

OBJECTIVE

To examine the psychosocial outcomes and impact of attention problems in survivors of pediatric brain tumor.

STUDY DESIGN

The survivors' cognitive functioning was measured using the Wechsler Intelligence Scale for Children. The Child Behavior Checklist-Attention Problems scale was used to screen for attention problems, and participants were classified as having attention problems (n=15) or normal attention (n=36). Psychosocial functioning was examined with the Korean Personality Rating scale for Children (K-PRC) at precraniospinal radiation and at 2-year follow-up.

RESULTS

The attention problem group showed significantly higher depression and externalizing symptoms (delinquency, hyperactivity) and more significant impairment in family relationships than did the normal attention group at baseline. At follow-up, the attention problem group demonstrated significantly more delinquency and impaired family and social relationships. With the K-PRC scores, except for the somatization, social relationship subscale, there were significant differences between groups, but not in terms of treatment by time interaction or within time. At follow-up, multiple linear regressions showed that age at diagnosis significantly predicted K-PRC somatization (B=-1.7, P=0.004) and social relationships (B=-1.7, P=0.004), baseline full-scale intelligence quotient predicted K-PRC depression (B=-0.4, P=0.032) and somatization (B=-0.3, P=0.015), and attention problems at baseline predicted K-PRC depression (B=-15.2, P=0.036) and social relationships (B=-11.6, P=0.016).

CONCLUSION

Pediatric brain tumor survivors, in particular, patients with attention problems, had worse psychosocial functioning at baseline and follow-up. Attention problems at baseline need to be carefully evaluated in assessing psychosocial functioning of pediatric brain tumor survivors.

Diet and ADHD, Reviewing the Evidence: A Systematic Review of Meta-Analyses of Double-Blind Placebo-Controlled Trials Evaluating the Efficacy of Diet Interventions on the Behavior of Children with ADHD

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is a debilitating mental health problem hampering the child's development. The underlying causes include both genetic and environmental factors and may differ between individuals. The efficacy of diet treatments in ADHD was recently evaluated in three reviews, reporting divergent and confusing conclusions based on heterogeneous studies and subjects. To address this inconsistency we conducted a systematic review of meta-analyses of double-blind placebo-controlled trials evaluating the effect of diet interventions (elimination and supplementation) on ADHD.

METHODS

Our literature search resulted in 14 meta-analyses, six of which confined to double-blind placebo-controlled trials applying homogeneous diet interventions, i.e. artificial food color (AFC) elimination, a few-foods diet (FFD) and poly-unsaturated fatty acid (PUFA) supplementation. Effect sizes (ES) and Confidence intervals (CI) of study outcomes were depicted in a forest plot. I2 was calculated to assess heterogeneity if necessary and additional random effects subgroup meta-regression was conducted if substantial heterogeneity was present.

RESULTS

The AFC ESs were 0.44 (95% CI: 0.16-0.72, I2 = 11%) and 0.21 (95% CI: -0.02-0.43, I2 = 68%) [parent ratings], 0.08 (95% CI: -0.07-0.24, I2 = 0%) [teacher ratings] and 0.11 (95% CI: -0.13-0.34, I2 = 12%) [observer ratings]. The FFD ESs were 0.80 (95% CI: 0.41-1.19, I2 = 61%) [parent ratings] and 0.51 (95% CI: -0.02-1.04, I2 = 72%) [other ratings], while the PUFA ESs were 0.17 (95% CI: -0.03-0.38, I2 = 38%) [parent ratings], -0.05 (95% CI: -0.27-0.18, I2 = 0%) [teacher ratings] and 0.16 (95% CI: 0.01-0.31, I2 = 0%) [parent and teacher ratings]. Three meta-analyses (two FFD and one AFC) resulted in high I2 without presenting subgroup results. The FFD meta-analyses provided sufficient data to perform subgroup analyses on intervention type, resulting in a decrease of heterogeneity to 0% (diet design) and 37.8% (challenge design).

CONCLUSION

Considering the small average ESs PUFA supplementation is unlikely to provide a tangible contribution to ADHD treatment, while further research is required for AFC elimination before advising this intervention as ADHD treatment. The average FFD ES is substantial, offering treatment opportunities in subgroups of children with ADHD not responding to or too young for medication. Further FFD research should focus on establishing the underlying mechanisms of food (e.g. incrimination of gut microbiota) to simplify the FFD approach in children with ADHD.

Access to diagnosis, treatment, and supportive services among pharmacotherapy-treated children/adolescents with ADHD in Europe: data from the Caregiver Perspective on Pediatric ADHD survey

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood psychiatric disorders and negatively impacts caregivers' lives. Factors including barriers to accessing care, dissatisfaction with support services, and lack of caregiver resources may contribute to this.

OBJECTIVES

To report caregivers' experiences of ADHD diagnosis, behavioral therapy (BT), and supportive care for children/adolescents with ADHD.

METHODS

The Caregiver Perspective on Pediatric ADHD (CAPPA) survey included caregivers of children/adolescents (6-17 years) from ten European countries who were currently receiving/had received ADHD pharmacotherapy in the previous 6 months. Caregivers reported experiences of obtaining an ADHD diagnosis, access to BT, availability of caregiver resources, and level of health care/school support. Pan-EU and country-specific descriptive statistics are reported; responses were compared across countries.

RESULTS

Of 3,616 caregivers, 66% were female. Mean age of children/adolescents was 11.5 years; 80% were male. Mean time from the first doctor visit to diagnosis was 10.8 (95% confidence interval 10.2, 11.3) months; 31% of caregivers reported the greatest degrees of difficulty in obtaining an ADHD diagnosis; 44% of children/adolescents did not receive BT. Forty-seven percent of caregivers reported that sufficient resources were available, 44% were "very satisfied"/"satisfied" with medical care, and 50% found health care providers "very supportive"/"somewhat supportive". Mainstream schools were attended by 82% of children/adolescents. Of those, 67% of caregivers thought schools could help more with the child/adolescent's ADHD and 48% received extra help/special arrangement. Results varied significantly between countries (P<0.001, all parameters).

CONCLUSION

Almost a third of caregivers reported a high degree of difficulty in obtaining an ADHD diagnosis for their child/adolescent, less than half felt that sufficient resources were available, and gaps in support from health care providers/schools were identified. Findings underscore the need to improve access to diagnosis and provision of supportive services to enable better standards of care, and potentially reduce the impact of child/adolescent ADHD on caregivers' lives.