Self-regulation strategies support children with ADHD to overcome symptom-related behavior in the classroom

Psychological Treatments for Hyperactivity and Impulsivity in Children with ADHD: A Narrative Review

Treatment of the ADHD types (hyperactive-impulsive, inattentive, and combined) in children has rarely been studied separately, although their prognostic courses differ widely. In addition, data show that improvements in hyperactivity/impulsivity are hard to achieve. Thus, we focused on treatments tailored to hyperactivity/impulsivity. We examined meta-analyses and systematic reviews within the inter- and intra-individual treatments and found that psychoeducation and training for parents, school-based interventions, reinforcement strategies, and neurofeedback consistently showed small to moderate effect sizes in reducing hyperactivity/impulsivity in children. Conversely, emotional self-regulation, social skills, and cognitive trainings showed unsatisfactory results. In summary, we found that the quality of usual care can be surpassed when the designated interventions are purposefully combined into a multimodal treatment program.

Promoting Mental Health in Unaccompanied Refugee Minors: Recommendations for Primary Support Programs

During the last years, the number of refugees around the world increased to about 22.5 million. The mental health of refugees, especially of unaccompanied minors (70% between the ages of 16 and 18 years) who have been exposed to traumatic events (e.g., war), is generally impaired with symptoms of post-traumatic stress disorder, depression, and anxiety. Several studies revealed (1) a huge variation among the prevalence rates of these mental problems, and (2) that post-migration stressors (e.g., language barriers, cultural differences) might be at least as detrimental to mental health as the traumatic events in pre- and peri-flight. As psychotherapy is a limited resource that should be reserved for severe cases and as language trainings are often publicly offered for refugees, we recommend focusing on intercultural competence, emotion regulation, and goal setting and goal striving in primary support programs: Intercultural competence fosters adaptation by giving knowledge about cultural differences in values and norms. Emotion regulation regarding empathy, positive reappraisal, and cultural differences in emotion expression fosters both adaptation and mental health. Finally, supporting unaccompanied refugee minors in their goal setting and goal striving is necessary, as they carry many unrealistic wishes and unattainable goals, which can be threatening to their mental health. Building on these three psychological processes, we provide recommendations for primary support programs for unaccompanied refugee minors that are aged 16 to 18 years.

Impaired reward processing in the human prefrontal cortex distinguishes between persistent and remittent attention deficit hyperactivity disorder

Symptoms of attention deficit hyperactivity disorder (ADHD) in children often persist into adulthood and can lead to severe antisocial behavior. However, to-date it remains unclear whether neuro-functional abnormalities cause ADHD, which in turn can then provide a marker of persistent ADHD. Using event-related functional magnetic resonance imaging (fMRI), we measured blood oxygenation level dependent (BOLD) signal changes in subjects during a reversal learning task in which choice of the correct stimulus led to a probabilistically determined 'monetary' reward or punishment. Participants were diagnosed with ADHD during their childhood (N=32) and were paired with age, gender, and education matched healthy controls (N=32). Reassessment of the ADHD group as adults resulted in a split between either persistent (persisters, N=17) or remitted ADHDs (remitters, N=15). All three groups showed significantly decreased activation in the medial prefrontal cortex (PFC) and the left striatum during punished correct responses, however only remitters and controls presented significant psycho-physiological interaction between these fronto-striatal reward and outcome valence networks. Comparing persisters to remitters and controls showed significantly inverted responses to punishment (P<0.05, family-wise error corrected) in left PFC region. Interestingly, the decreased activation shown after punishment was located in different areas of the PFC for remitters compared with controls, suggesting that remitters might have learned compensation strategies to overcome their ADHD symptoms. Thus, fMRI helps understanding the neuro-functional basis of ADHD related behavior differences and differentiates between persistent and remittent ADHD.

Prevention of ADHD related problems: a universal preschool program

Purpose

– Early onset of behavioral disorders is predictive of long term adverse outcomes. There are some indicated and selective early prevention programs for attention deficit/hyperactivity disorder (ADHD), one of the most common behavioral disorders in childhood and adolescence. The purpose of this paper is to present a universal preschool program for preventing the development of ADHD related symptoms for children aged three to six.

Design/methodology/approach

– A total of 413 preschool children (experimental group (EG)=193; control group (CG)=220), and their teachers participated in the study. Children in the EG were randomized to two conditions: universal intervention (behavior modification (BM)=99) vs additional ADHD specific elements (BM+attention training; BM+AT=94) to evaluate effects of a universal intervention vs additional ADHD specific elements. The universal intervention trained general behavior modification (BM) techniques to enhance start behavior (i.e. following color based rules, positive participation in activities, enhancement of skills related to attentional function), and to extinguish stop behavior (i.e. hyperactive behavior such as uncontrolled running around, disturbing others, quarreling, etc.). These techniques were based on published intervention programs (Phelan and Schonour, 2004). The AT consisted of thirteen teacher led 45 minute based sessions in a small group format with an introductory play activity, 15 minutes picture based AT tasks (task analysis, action planning, action, reappraisal), a social interaction game, and a game to enhance perception of visual, auditory, olfactory, haptic, and gustatory senses. To determine effects, the Strength and Difficulties Questionnaire (SDQ) and the Behavior Rating for Preschoolers (VBV) were used. A high risk group with high scores on those measures was analyzed separately.

Findings

– Children in all three groups did not differ significantly at baseline in all relevant variables (ADHD symptoms measured with the SDQ and VBV, socio-economic status (SES), gender, age: MANCOVA: F 10,796=1.732, p=0.07) and none of the children had a diagnosis of ADHD. After training participation, children in the EG showed significantly less ADHD related problem behavior compared to children in the CG (F 8,1,506=2.717, p=0.006); this was especially so for the high risk group (F 4,754=2.60, p=0.035). Multi-level analyses revealed significant influences of age, gender, and SES on post-training symptom ratings (SDQ: t-statistic=3.03, p=0.003; VBV 3-6: t-statistic=4.151, p < 0.001).

Research limitations/implications

– This is a quasi-experimental study, since due to time restriction half the preschools did not want to participate in the experimental study. Thus, participating children were not randomly assigned to the experimental and control conditions, though children were randomly assigned to two different treatments within the intervention group (EG1/EG2). Due to the design of the study and to ensure high participation rates, only preschool teachers rated children’s behavior, though the predictive value of teacher ADHD symptoms exceeds parental ones. Finally, inclusion of parent training elements would most probably enhance effects.

Practical implications

– General BM techniques are easily taught and seem to positively influence children’s ADHD related symptoms while not harming children without such symptoms. Since studies showed that after a bogus instruction teacher expected children to exhibit ADHD symptoms and rated them as more disturbed (Rosenthal effect), a universal approach is less stigmatizing and possibly more effective, especially when interventions start early in life before symptoms result in full diagnoses.

Social implications

– This study established positive universal effects, and moderate to large effects for the subgroup of high risk children with ADHD related symptoms. General behavior management in preschools might thus be a possible strategy for preventive interventions of ADHD related symptoms.

Originality/value

– The is one of the first studies on a preventive ADHD preschool program. General BM techniques of this study were easily taught and implemented, and showed positive effects. Since selective and indicated interventions depend on high program fidelity, are harder to implement, and related to higher costs, general BM techniques as introduced in this study, might be an option for universal prevention strategies for ADHD related symptoms in preschool settings.

Schulbasierte Interventionen bei ADHS und Aufmerksamkeitsproblemen: Ein Überblick

Kinder mit einer Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) oder subklinischen Aufmerksamkeitsproblemen sind in ihrer schulischen Leistungsfähigkeit beeinträchtigt. Für Lehrkräfte stellen diese Beeinträchtigungen eine große Herausforderung dar. Im Zuge der Umsetzung der Behindertenrechtskonvention der Vereinten Nationen (UN) wird der Bedarf an effektiven Strategien zum Umgang mit diesen Verhaltensauffälligkeiten an allgemeinbildenden Schulen deutlich steigen. Ziel der vorliegenden Arbeit ist es, einen Überblick über effektive Klassen-, Lehrkraft- und Schüler-zentrierte Maßnahmen für Schüler mit Aufmerksamkeitsproblemen zu geben. Die aktuelle Studienlage zu Interventionen im Schulsetting bietet überwiegend Einzelfallstudien, die eine Generalisierung der Ergebnisse erschweren. Unter Berücksichtigung der Studienqualität können daher nur interdependente Gruppenverstärkerpläne (klassen-zentriert) als evidenzbasiert bezeichnet werden. Forschungsmethodische Einschränkungen und Forschungsperspektiven werden diskutiert.