The Relation Between Change in Symptoms and Functioning in Children with ADHD Receiving School-Based Mental Health Services

Etiological Networks of Attention-Deficit/Hyperactivity Disorder during Childhood and Adolescence

OBJECTIVE

The purpose of the current study was to use network analysis techniques to parse relations between attention-deficit/hyperactivity disorder (ADHD) symptom domains, domains of executive function, and temperament traits.

METHODS

Participants were 420 children aged 6-17 years (55% boys). The majority of the participants were Caucasian (72.86%) and 50% of the sample met diagnostic criteria for ADHD. Both parents and teachers provided ratings of participants' ADHD symptom severity. Parents completed questionnaires pertaining to participants' temperament traits, and participants completed well-validated laboratory measures of executive function.

RESULTS

Results suggested effortful control as demonstrating the strongest relations with ADHD, particularly the parent-reported inattentive symptom domain. Additionally, negative effects appeared to demonstrate weaker but still notable relations primarily with the parent-reported hyperactive/impulsive symptom domain. Measures of executive function did not appear to demonstrate relations with any measures of ADHD symptoms or temperament traits. The results were generally replicated in a distinct sample (n = 732, 7-13 years, 63% boys, 81% White), although differences emerged pertaining to the role of surgency (i.e., related to the hyperactive/impulsive symptom domain in the replication but not the primary sample).

CONCLUSIONS

Overall, findings provided support for the primary role of effortful control, as well as secondary roles for negative affect and surgency, as key risk markers for the characterization of ADHD. Additional exploration of the overlap between temperament and executive function, as pertaining to ADHD, may help clarify heterogeneity in phenotypes and suggest priorities for targeted interventions outside of traditional symptoms.

A post hoc analysis of the effect of viloxazine extended-release capsules on learning and school problems in children and adolescents with attention-deficit/hyperactivity disorder

Improvement in attention-deficit/hyperactivity disorder (ADHD) symptoms vs. placebo was reported in a series of pediatric clinical trials of viloxazine extended-release capsules (viloxazine ER; Qelbree™). This post hoc analysis of those studies evaluated the effect of viloxazine ER on learning and school problems (LSPs). We used data from four Phase 3 placebo-controlled trials of 100-600 mg/day viloxazine ER (N = 1354; 6-17 years of age). LSPs were evaluated using the School domain of the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P-S) and the Learning Problems content scale of the Conners 3rd Edition-Parent Short Form (C3PS-LP) at baseline and end of study (≥ Week 6). ADHD symptoms were assessed weekly using the ADHD Rating Scale 5th Edition. The analyses were performed using the general linear mixed model with participant as a random effect. The responder analyses were performed using the Chi-square test. Viloxazine ER demonstrated significantly greater improvements in WFIRS-P-S (p < 0.0001) and C3PS-LP (p = 0.0113) scores vs. placebo. The response rate for the WFIRS-P-S was significantly greater for viloxazine ER vs. placebo (p = 0.001), and the number needed to treat (NNT) was 10.3 (effect size 0.7). Conversely, response rates for C3PS-LP did not differ between groups (p = 0.9069). In addition to ADHD symptoms improvement demonstrated in previous studies, viloxazine ER significantly reduced LSPs in pediatric subjects with ADHD. The responder analyses and NNT estimates indicate that a substantial number of children and adolescents with ADHD treated with viloxazine ER improved in clinically assessed LSPs.

Data-Driven Methods for Predicting ADHD Diagnosis and Related Impairment: The Potential of a Machine Learning Approach

Current diagnostic criteria for ADHD include several symptoms that highly overlap in conceptual meaning and interpretation. Additionally, inadequate sensitivity and specificity of current screening tools have hampered clinicians' ability to identify those at risk for related outcomes. Using machine learning techniques, the current study aimed to propose a novel algorithm incorporating key ADHD symptoms to predict concurrent and future (i.e., five years later) ADHD diagnosis and related impairment levels. Participants were 399 children with and without ADHD; multiple informant measures of ADHD symptoms, global impairment, academic performance, and social skills were included as part of an accelerated longitudinal design. Results suggested eight symptoms as most important in predicting impairment outcomes five years later: (1) Has difficulty sustaining attention in tasks or play activities, (2) Does not follow through on instructions and fails to finish work, (3) Has difficulty organizing tasks and activities, (4) Avoids tasks (e.g., schoolwork, homework) that require sustained mental effort, (5) Is often easily distracted, (6) Is often forgetful in daily activities, (7) Fidgets with hands or feet or squirms in seat, and (8) Interrupts/intrudes on others. The algorithm comprising this abbreviated list of symptoms performed just as well as or significantly better than one comprising all 18 symptoms in predicting future global impairment and academic performance, but not social skills. It also predicted concurrent and future ADHD diagnosis with 81-93% accuracy. Continued development of screening tools will be key to ensuring access to clinical services for youth at risk for ADHD.

Associated predictors of functional impairment among adolescents with ADHD-a cross-sectional study

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) in adolescence is associated with functional impairment in several domains of life. To enable development of interventions that more effectively target functional impairment in this age group, the associations between clinical characteristics and impairment need to be clarified. The aim of this study was to investigate the associations between ADHD and functional impairment, if they varied by sex, and the potential impact of comorbid psychiatric symptoms on the associations.

METHODS

This was a cross-sectional study including adolescents with ADHD (n = 164) and a reference group of adolescents without ADHD (n = 106). Self-ratings and parental ratings of functional impairment in different life domains were used as outcomes in all analyses. Differences between groups were investigated with comparative analyses. General linear models (GLMs) were used to explore associations between ADHD symptoms and functional impairment in adolescents with ADHD, while adjusting for of comorbid symptoms, sex, and medication.

RESULTS

Adolescents with ADHD displayed higher levels of functional impairment than peers without ADHD, and girls with ADHD rated higher impairment than their male counterparts. The combined ADHD presentation was associated with the highest levels of self-reported impairment, while parental ratings indicated comparable levels of overall impairment across presentations. In the adjusted GLMs, symptoms of inattention were strongly associated with self- and parent-rated impairment in school, but symptoms of hyperactivity/impulsivity were not, whereas symptoms of both inattention and hyperactivity/impulsivity were modestly associated with self-rated impairment with friends. Further, both emotional and conduct problems were associated with impairment in daily life.

CONCLUSIONS

Our results suggest that attention difficulties, in particular, seem to impair academic functioning in adolescents with ADHD, and interventions targeting such difficulties are warranted. In addition, comorbid symptoms need to be assessed and treated, and self-reports of functioning should be included in research and clinical practice involving adolescents.

The Effect of Viloxazine Extended-Release Capsules on Functional Impairments Associated with Attention-Deficit/Hyperactivity Disorder (ADHD) in Children and Adolescents in Four Phase 3 Placebo-Controlled Trials

PURPOSE

The ADHD Rating Scale (ADHD-RS) assesses 18 symptoms of inattention and hyperactivity/impulsivity and has been used in many clinical trials to evaluate the treatment effect of drugs on ADHD. The fifth edition of this scale (ADHD-RS-5) also assesses the impact of inattention and hyperactivity/impulsivity symptoms on six domains of functional impairment (FI): family relationships, peer relationships, completing/returning homework, academic performance at school, controlling behavior at school, and self-esteem. Here, we report the effect of viloxazine extended-release capsules (viloxazine ER), a novel nonstimulant treatment for ADHD in children and adolescents (ages 6-17 years), on FI from a post hoc analysis of four randomized, double-blind, placebo-controlled Phase 3 clinical trials (N=1354).

PATIENTS AND METHODS

ADHD-RS-5 investigator ratings of ADHD symptoms and FIs were conducted at baseline and weekly post-baseline for 6-8 weeks in the four trials. Change from baseline (CFB) in ADHD-RS-5 FI scores (Total score [sum of 12 FI items] and Inattention and Hyperactivity/Impulsivity subscale scores [sum of 6 corresponding FI items]) and the 30% and 50% Responder Rates (ADHD-RS-5 FI Total score) were compared between viloxazine ER and placebo.

RESULTS

The reduction (improvement) in ADHD-RS-5 FI scores (Total and subscale scores) and the percentage of responders (30% and 50%) at Week 6 were significantly greater in each viloxazine ER dose group vs placebo. In the 100-400 mg/day viloxazine ER groups, improvements were found as early as Week 1 (100-mg/day) or Week 2 (200-, 400-mg/day) of treatment. Analysis of individual items of ADHD-related FIs demonstrated that the effect of viloxazine ER was observed across all domains of impairment.

CONCLUSION

Significant improvements observed in ADHD-related FIs are consistent with the reduction in inattention and hyperactivity/impulsivity symptoms demonstrated in the viloxazine ER Phase 3 pediatric trials. Therefore, viloxazine ER provides clinically meaningful improvement of ADHD symptoms and functioning in children and adolescents with ADHD, starting as early as Week 1-2 of treatment.

Clarifying ADHD and Sluggish Cognitive Tempo Item Relations with Impairment: A Network Analysis

Despite the pervasive nature of various forms of impairment associated with attention-deficit/hyperactivity disorder (ADHD), the precise nature of their associations with ADHD and related sluggish cognitive tempo (SCT), particularly at the heterogeneous item level, remains ambiguous. Using innovative network analysis techniques, we sought to identify and examine the concurrent validity of ADHD and SCT bridge items (i.e., those demonstrating the most robust relations with various forms of impairment) with respect to Overall, Home-School, and Community-Leisure impairment domains. Parents of a nationally representative sample of 1742 children (50.17% male) aged 6-17 years completed rating scales of ADHD, SCT, and impairment. Assessment of Bridge Expected Influence suggested eight bridge items primarily from impulsive and Task Completion (i.e., overlapping SCT and inattentive) domains that demonstrated relations with impairment in school performance, completing chores at home, interacting with family members, following rules, and playing sports. Sum scores only including bridge items exhibited relations with Overall, Home-School, and Community-Leisure impairment domains comparable to that of sum scores including all items. Bridge impairment areas were generally consistent across "Childhood" (6-11 years) and "Adolescence" (12-17 years). Problems listening and slowness emerged as bridge items in Childhood, whereas difficulties following through on instructions, problems waiting one's turn, and social withdrawal emerged in Adolescence. Given the comparable validity of ADHD- and SCT-related bridge items versus all items, bridge items, together, may be the most efficient indicators of impairment. Further clarification is needed across development to inform personalized assessment and intervention protocols that account for item-level heterogeneity in ADHD, SCT, and impairment phenotypes.

Culturally Appropriate Assessment of Functioning in Diverse Children: Development and Preliminary Validation of the FX-II Scale in Mexico

OBJECTIVE

We sought to develop and provide preliminary validation for a questionnaire evaluating functioning related to ADHD (i.e., the FX-II) with a particularly underserved group (i.e., Mexican youth).

METHOD

191 Mexican raters completed the FX-II alongside measures of ADHD symptoms, impairment, cultural values, and demographics: 127 raters were caregivers of treatment-naïve youth (i.e., community sample); 32 raters were caregivers and 32 raters were teachers of youth participating in a school-based program for attention/behavior concerns (i.e., clinical sample).

RESULTS

We created the 52-item FX-II Scale by adapting a culturally appropriate and psychometrically sound measure of impairment (i.e., the ADHD-FX) to assess functioning most relevant to Spanish-speaking families of children with ADHD (i.e., academic, social/emotional, and familial functioning). The FX-II demonstrated strong reliability, convergent and divergent construct validity, and predictive validity.

CONCLUSION

The FX-II appears to be a beneficial tool for evaluating functioning related to ADHD in Mexican children and future validation efforts in broader populations are warranted.

Is it possible to determine the level of functional impairment that distinguishes the patients with ADHD from those without ADHD?

INTRODUCTION

Functional impairment in attention deficit hyperactivity disorder (ADHD) can occur in many areas such as in family, social activities, and problems related to school and may also persist during adulthood. The Weiss Functional Impairment Rating Scale-Parent Form (WFIRS-P) is designed to measure the functional impairment related to ADHD symptoms. The aim of this study was to determine the level of functional impairment that distinguishes the patients with ADHD who were diagnosed through semi-structured interviews from those without ADHD.

METHOD

This study consists of ADHD patients who were diagnosed through semi-structured interview aged 5-18 years (n = 250) and same age gender-matched healthy controls (n = 250). A receiver operating characteristic (ROC) curve was constructed by calculating the sensitivity and specificity of the scale cut-off values.

RESULTS

An area under the curve (AUC) of 0.974 (95% CI 0.956-0.986) was found in this study. For WFIRS-P subdomains, AUC curves, which range from 0.76 to 0.95, were also having strong power for differentiation between groups. The optimal cut-off value for WFIRS-P using Youden's J Index is 0.32. There is no significant gender and age group differences in AUC for either the total or subdomain scores.

CONCLUSION

Our findings provide that Turkish version of WFIRS-P could be a reliable way of distinguishing the level of functional impairment in ADHD from controls.

Targeting Functional Impairments in the Treatment of Children and Adolescents with ADHD

The diagnostic criteria for attention-deficit hyperactivity disorder (ADHD) require both symptoms and impairment to be present. Impairment in functioning is commonly the primary reason for referral, and is also a better predictor of long-term outcomes than ADHD symptoms. And yet, only recently has research begun to examine the impact of ADHD treatments on functional impairment using efficient and psychometrically sound outcome measures. In this article, we identify several noteworthy multidimensional measures of functional impairment (ADHD FX, Barkley Functional Impairment Scale [BFIS], Impairment Rating Scale [IRS], Weiss Functional Impairment Rating Scale [WFIRS]) utilized in recent clinical trials for ADHD, and describe their psychometric properties and clinical utility. We also review existing evidence on the impact of pharmacological and behavioral treatments on different domains of functional impairment in ADHD youth as measured by these specific measures. Further research is needed to evaluate longitudinal effects of ADHD treatments on functional impairment, and the use of these measures in adaptive treatment designs.

Improved but still impaired: symptom-impairment correspondence among youth with attention-deficit hyperactivity disorder receiving community-based care

OBJECTIVE

To explore correspondences between the trajectories of symptoms and impairments in youth with attention-deficit hyperactivity disorder (ADHD) being treated by in primary care settings.

METHODS

Parents of youth (n = 1976) rated their child's symptoms of inattention and hyperactivity/impulsivity, and impairment across a variety of domains. Multilevel models were estimated to characterize the trajectories of symptoms and impairment and to determine whether changes in symptom dimension trajectories corresponded to changes in impairment trajectories over time.

RESULTS

Results indicated that symptom dimensions initially improved, then leveled off, and then decreased minimally. However, impairment domains remained largely stable (i.e., neither improved nor worsened). Improvement in inattention symptoms were associated with improved ratings of writing impairment, and improved ratings of hyperactivity/impulsivity symptoms were associated with improved relationship with peers.

CONCLUSIONS

Youths with ADHD who are treated by their community pediatrician tend to initially improve in their symptom presentation, although this symptom reduction plateaus and is not associated with corresponding improvements in most areas of impairment.

Pharmacological and psychosocial treatments for adolescents with ADHD: an updated systematic review of the literature

Smith, Waschbusch, Willoughby, and Evans (2000) reviewed a small treatment literature on ADHD in adolescents and concluded that methylphenidate stimulant medication was a well-established treatment and behavior therapy (BT) demonstrated preliminary efficacy. This review extends and updates the findings of the prior one based on the previous 15years of research. Studies published since 1999 were identified and coded using standard criteria and effect sizes were calculated where appropriate. Highlights of the last 15years of research include an expansion of pharmacological treatment options and developmentally appropriate psychosocial treatment packages for adolescents with ADHD. Additionally, nonstimulant medications (e.g., atomoxetine) are now approved for the treatment of ADHD in adolescence. The review concludes that medication and BT produce a similar range of therapeutic effects on the symptoms of adolescents with ADHD. However, results suggest that BT may produce greater overall benefits on measures of impairment. There was no evidence that cognitive enhancement trainings, such as working memory training or neurofeedback improved the functioning of adolescents with ADHD. Whether to use medication, BT, or their combination to treat an adolescent with ADHD is complicated and we provide evidence-informed guidelines for treatment selection. The reviewed evidence does not support current American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry professional guidelines, which state that stimulant medication is the preferred treatment for adolescents with ADHD. Recommendations for assessment, practice guidelines, and future research are discussed.

Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder

The purpose of this research was to update the Pelham and Fabiano ( 2008 ) review of evidence-based practices for children and adolescents with attention-deficit/hyperactivity disorder. We completed a systematic review of the literature published between 2007 and 2013 to establish levels of evidence for psychosocial treatments for these youth. Our review included the identification of relevant articles using criteria established by the Society of Clinical Child and Adolescent Psychology (see Southam-Gerow & Prinstein, in press ) using keyword searches and a review of tables of contents. We extend the conceptualization of treatment research by differentiating training interventions from behavior management and by reviewing the growing literature on training interventions. Consistent with the results of the previous review we conclude that behavioral parent training, behavioral classroom management, and behavioral peer interventions are well-established treatments. In addition, organization training met the criteria for a well-established treatment. Combined training programs met criteria for Level 2 (Probably Efficacious), neurofeedback training met criteria for Level 3 (Possibly Efficacious), and cognitive training met criteria for Level 4 (Experimental Treatments). The distinction between behavior management and training interventions provides a method for considering meaningful differences in the methods and possible mechanisms of action for treatments for these youth. Characteristics of treatments, participants, and measures, as well as the variability in methods for classifying levels of evidence for treatments, are reviewed in relation to their potential effect on outcomes and conclusions about treatments. Implications of these findings for future science and practice are discussed.