Systematic Review of Patients' and Parents' Preferences for ADHD Treatment Options and Processes of Care

Treatment Preferences of Adult Patients with Attention-Deficit/Hyperactivity Disorder - A Discrete Choice Experiment

Background

Understanding patient preferences for treatments may facilitate shared decision-making. This study assessed adult patient preferences for attention-deficit/hyperactivity disorder (ADHD) treatments in a sample of 600 patients in the United States (US).

Methods

A web-based discrete choice experiment (DCE) survey was conducted among treated adults with ADHD. Participants were recruited from Dynata's US panel (06/22/2023-07/06/2023). Attributes and levels, identified based on clinical inputs and published data, included efficacy and safety. Participants' preferences were estimated using conditional logistic regression. Willingness to trade-off and attributes' relative importance were calculated. Overall preferences for treatment profiles approximating centanafadine, lisdexamfetamine, atomoxetine, and viloxazine were estimated using adjusted total utilities. Results were stratified by current treatment status. Sensitivity analyses including participants who passed validity tests were conducted.

Results

Among the 600 participants (mean age 37.9 years; 66.2% female; 50.8% treated), all attributes had a statistically significant impact on preferences for ADHD treatments (p < 0.001); the most important attribute was improvement in ADHD symptoms (36%), followed by risks of nausea (25%), insomnia (20%), anxiety (8%), dry mouth (6%), and feeling jittery (5%). Together, safety attributes accounted for >60% of relative importance in decision-making. Participants were willing to forgo 0.59, 0.57, 0.49, 0.32, and 0.17 percentage points of symptom improvement to achieve one-percentage-point reduced risk of insomnia, nausea, anxiety, feeling jittery, and dry mouth, respectively. Centanafadine profile had consistently higher adjusted total utilities than its comparators. Similar results were obtained in the subgroup and sensitivity analyses.

Conclusion

Efficacy was the most important attribute for patients when making treatment decision, but taken together, AEs had greater relative importance than efficacy alone. Accordingly, a profile resembling that of centanafadine would be preferred by an average patient compared to key competitors due to its favorable safety profile. These findings may help improve treatment decision-making, enhance treatment satisfaction, and foster adherence.

An evaluation of intervention appropriateness from the perspective of parents: A peer-mediated, play-based intervention for children with ADHD

INTRODUCTION

A peer-mediated, play-based intervention has been developed to address social participation challenges experienced by children with ADHD. To facilitate implementation into clinical practice, interventions should be evaluated for appropriateness to the end-user, as well as effectiveness. Previous research demonstrated the approach is effective for improving children's social play skills. This study aimed to evaluate the appropriateness of the intervention for children with ADHD and their families.

METHODS

Parents of children with ADHD who participated in the play-based intervention were interviewed 1 month after completion. Parents were asked about their perspective of parent and children's experiences of the intervention, the perceived benefits for children and parents, the logistics of participating, and recommended adaptations to the intervention. Interviews were analysed thematically, and themes were mapped to the elements of the adopted definition of appropriateness to understand whether parents supported the appropriateness of the intervention for their families.

CONSUMER AND COMMUNITY INVOLVEMENT

Consumers were not directly involved in the decisions made about this study.

FINDINGS

One core theme, 'collaborative efforts', emerged from the data. Major themes comprising the core theme were 'on the same page', 'therapeutic relationship', and 'getting the job done'. Three sub-themes of 'engagement and motivation', 'the effort was worth it for the reward', and 'Rome wasn't built in a day' were nested within the major themes.

CONCLUSION

Parents largely supported the appropriateness of the intervention, indicating it addressed an important goal for their child, participation was a positive experience, and they perceived the intervention to be beneficial. Future adaptions of the intervention are needed to increase its ecological validity and to generalise the strategies to other social environments and playmates, such as peers at school.

PLAIN LANGUAGE SUMMARY

This study looked at an intervention that uses play with peers to help children with ADHD develop their play skills. The researchers wanted to know if parents thought the intervention was a good fit for their families and if it helped their children. Parents gave an interview a month after the intervention ended. They were asked about their thoughts on the intervention, how it helped their children and themselves, how easy it was to take part, and what changes could be made to make the intervention better. After analysing parents' answers, the researchers found parents mostly agreed that the intervention was a good fit. They said it helped their children to play with their peers, and they had a good time doing it. Parents thought the intervention was helpful, they liked that it was a joint effort between them and the occupational therapist, and they felt it was worth the effort. However, they also suggested some changes. They wanted the intervention to fit into other real-life social situations, such as school, so their children could use the skills they learned in other places. Overall, parents thought the intervention was helpful and suitable for their children and themselves, but some changes might make it more helpful.

ADHD Prevalence Rose, Yet Disparities Remain: Commentary on the 2022 National Survey of Children's Health

This is a commentary on Danielson and colleagues' report entitled "ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment," which provides updated prevalence rates related to ADHD diagnosis and treatment utilization using data from the 2022 National Survey of Children's Health (NSCH). This timely article is among the first to report on ADHD prevalence rates since the COVID-19 pandemic, and highlights important patterns related to ADHD diagnosis and treatment utilization. In this commentary, we contextualize these findings with consideration to the COVID-19 pandemic and within the existing literature on health disparities among youth with ADHD and their families. We end with recommendations for future work involving researchers, clinicians, and policymakers with the intention of reducing disparities in ADHD diagnosis and treatment in the U.S.

Single and Combined Effects of Multiple Intensities of Behavioral Modification and Methylphenidate for Children with ADHD in the Home Setting

Behavioral treatment, stimulants, and their combination are the recommended treatments for childhood attention-deficit/hyperactivity disorder (ADHD). The current study utilizes within-subjects manipulations of multiple doses of methylphenidate (placebo, 0.15, 0.30, and 0.60 mg/kg/dose t.i.d.) and intensities of behavioral modification (no, low, and high intensity) in the summer treatment program (STP) and home settings. Outcomes are evaluated in the home setting. Participants were 153 children (ages 5-12) diagnosed with ADHD. In alignment with experimental conditions implemented during the STP day, parents implemented behavioral modification levels in three-week intervals, child medication status varied daily, and the orders were randomized. Parents provided daily reports of child behavior, impairment, and symptoms and self-reported parenting stress and self-efficacy. At the end of the study, parents reported treatment preferences. Stimulant medication led to significant improvements across all outcome variables with higher doses resulting in greater improvement. Behavioral treatment significantly improved child individualized goal attainment, symptoms, and impairment in the home setting and parenting stress and self-efficacy. Effect sizes indicate that behavioral treatment combined with a low-medium dose (0.15 or 0.30 mg/kg/dose) of medication results in equivalent or superior outcomes compared to a higher dose (0.60 mg/kg/dose) of medication alone. This pattern was seen across outcomes. Parents overwhelmingly reported preferring treatment with a behavioral component as a first-choice treatment (99%). Results underscore the need to consider dosing as well as parent preference when utilizing combined treatment approaches. This study provides further evidence that combining behavioral treatment and stimulant medication may reduce the stimulant dose needed for beneficial effects.

Association Between Stimulant Treatment and Substance Use Through Adolescence Into Early Adulthood

Importance

Possible associations between stimulant treatment of attention-deficit/hyperactivity disorder (ADHD) and subsequent substance use remain debated and clinically relevant.

Objective

To assess the association of stimulant treatment of ADHD with subsequent substance use using the Multimodal Treatment Study of ADHD (MTA), which provides a unique opportunity to test this association while addressing methodologic complexities (principally, multiple dynamic confounding variables).

Design, Setting, and Participants

MTA was a multisite study initiated at 6 sites in the US and 1 in Canada as a 14-month randomized clinical trial of medication and behavior therapy for ADHD but transitioned to a longitudinal observational study. Participants were recruited between 1994 and 1996. Multi-informant assessments included comprehensively assessed demographic, clinical (including substance use), and treatment (including stimulant treatment) variables. Children aged 7 to 9 years with rigorously diagnosed DSM-IV combined-type ADHD were repeatedly assessed until a mean age of 25 years. Analysis took place between April 2018 and February 2023.

Exposure

Stimulant treatment of ADHD was measured prospectively from baseline for 16 years (10 assessments) initially using parent report followed by young adult report.

Main Outcomes and Measures

Frequency of heavy drinking, marijuana use, daily cigarette smoking, and other substance use were confidentially self-reported with a standardized substance use questionnaire.

Results

A total of 579 children (mean [SD] age at baseline, 8.5 [0.8] years; 465 [80%] male) were analyzed. Generalized multilevel linear models showed no evidence that current (B [SE] range, -0.62 [0.55] to 0.34 [0.47]) or prior stimulant treatment (B [SE] range, -0.06 [0.26] to 0.70 [0.37]) or their interaction (B [SE] range, -0.49 [0.70] to 0.86 [0.68]) were associated with substance use after adjusting for developmental trends in substance use and age. Marginal structural models adjusting for dynamic confounding by demographic, clinical, and familial factors revealed no evidence that more years of stimulant treatment (B [SE] range, -0.003 [0.01] to 0.04 [0.02]) or continuous, uninterrupted stimulant treatment (B [SE] range, -0.25 [0.33] to -0.03 [0.10]) were associated with adulthood substance use. Findings were the same for substance use disorder as outcome.

Conclusions and Relevance

This study found no evidence that stimulant treatment was associated with increased or decreased risk for later frequent use of alcohol, marijuana, cigarette smoking, or other substances used for adolescents and young adults with childhood ADHD. These findings do not appear to result from other factors that might drive treatment over time and findings held even after considering opposing age-related trends in stimulant treatment and substance use.

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.

Non-pharmacological interventions for attention-deficit hyperactivity disorder in children and adolescents

Attention-deficit hyperactivity disorder (ADHD) affects approximately 5% of children and adolescents globally and is associated with negative life outcomes and socioeconomic costs. First-generation ADHD treatments were predominantly pharmacological; however, increased understanding of biological, psychological, and environmental factors contributing to ADHD has expanded non-pharmacological treatment possibilities. This Review provides an updated evaluation of the efficacy and safety of non-pharmacological treatments for paediatric ADHD, discussing the quality and level of evidence for nine intervention categories. Unlike medication, no non-pharmacological treatments showed a consistent strong effect on ADHD symptoms. When considering broad outcomes (eg, impairment, caregiver stress, and behavioural improvement), multicomponent (cognitive) behaviour therapy joined medication as a primary ADHD treatment. With respect to secondary treatments, polyunsaturated fatty acids showed a consistent modest effect on ADHD symptoms when taken for at least 3 months. Additionally, mindfulness and multinutrient supplementation with four or more ingredients showed modest efficacy on non-symptom outcomes. All other non-pharmacological treatments were safe; clinicians might tolerate their use but should educate families of childrenand adolescents with ADHD on the disadvantages, including costs, burden to the service user, absence of proven efficacy relative to other treatments, and delay of proven treatment.

The Effect of Physical Activity Intervention on Motor Proficiency in Children and Adolescents with ADHD: A Systematic Review and Meta-analysis

Attention deficit hyperactivity disorder (ADHD) is a frequently diagnosed neurodevelopmental disorder in children and adolescents. The objective of this review was to synthesize empirical studies that investigated the effects of physical activity (PA) on motor proficiency in this population. A systematic review and meta-analysis were conducted following the cochrane guidelines for systematic reviews. In May 2022, a systematic search of eight electronic databases retrieved 476 results, which were screened independently by two reviewers. Based on the inclusion and exclusion criteria, 12 studies were selected for systematic review, and 10 were included in the meta-analysis. A beneficial effect of PA on overall motor proficiency (SMD = 1.12; 95% CI [0.63 to 1.61]; p < 0.05) was observed. Similar positive effects were found for motor proficiency composites, including object control, fine manual control, and body coordination. These results indicate that PA improves the motor proficiency of children and adolescents with ADHD.

Trends in amphetamine prescriptions given at discharge in emergency departments: A national analysis (2012-2019)

OBJECTIVES

In parallel with the opioid epidemic, there has been a resurgence in abuse, medical complications, and deaths related to amphetamines. The opioid epidemic began with increasing rates of prescription products that evolved overtime to include heroin and more recently, fentanyl analogues. Current trends in amphetamine prescriptions are less well described. We sought to determine if there has been a change in amphetamine prescriptions given at discharge in U.S. emergency departments (EDs) in recent years.

METHODS

We conducted a retrospective review of data provided by the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2012 to 2019. We computed total number of visits that were given amphetamine prescriptions (amphetamine salts, methylphenidate derivatives, and dexmethylphenidate) at discharge for each year. We computed the total number and rate of visits (of all ED visits) that had both amphetamines and opioids prescribed at discharge over the years. We computed data normality using Shapiro Wilke's test and used descriptive statistics such as mean to describe the data distribution as applicable. We used spearman's rho (SR) or pearson's correlation (PC) as applicable to describe trends in data. All p-values were one-tailed and were reported at a 0.05 significance level. All analyses were conducted in IBM SPSS version 28.

RESULTS/FINDINGS

From 2012 to 2019, there were an estimated 817,895 ED visits where an amphetamine prescription was given at discharge, with an overall strong increase in rate over time (SR = 0.71, p = 0.02). At the beginning of the study period (2012) there were 83,503 (0.06%) visits and in 2019 there were 186,539 (0.12%) visits (123% absolute increase). On average, there were 102,237 (SD: 52,725) visits with discharge amphetamine prescriptions per year. There was a strong, linear increase in number of visits that involved a discharge amphetamine salt prescription (PC = 0.92, p = 0.001). In 2012, there were a total of 23,676 visits and in 2019, a total of 124,773 visits (427% increase). There was no trend in visits where both an amphetamine and opioid were prescribed (PC: 0.61, p = 0.06).

CONCLUSION

There have been increases in discharge prescriptions for amphetamines in the ED over time. This was largely driven by prescriptions for amphetamine salts. Future research initiatives should continue to monitor this trend and in prescriptions and associated abuse in the setting of rising amphetamine abuse.

The Effects of Different Theta and Beta Neurofeedback Training Protocols on Cognitive Control in ADHD

Neurofeedback (NF) is an important treatment for attention deficit/hyperactivity disorder (ADHD). In ADHD, cognitive control deficits pose considerable problems to patients. However, NF protocols are not yet optimized to enhance cognitive control alongside with clinical symptoms, partly because they are not driven by basic cognitive neuroscience. In this study, we evaluated different EEG theta and/or beta frequency band NF protocols designed to enhance cognitive control. Participants were n = 157 children and adolescents, n = 129 of them were patients with ADHD (n = 28 typically developing (TD) controls). Patients with ADHD were divided into five groups in the order of referral, with four of them taking part in different NF protocols systematically varying theta and beta power. The fifth ADHD group and the TD group did not undergo NF. All NF protocols resulted in reductions of ADHD symptoms. Importantly, only when beta frequencies were enhanced during NF (without any theta regulation or in combination with theta upregulation), consistent enhancing effects in both response inhibition and conflict control were achieved. The theta/beta NF protocol most widely used in clinical settings revealed comparatively limited effects. Enhancements in beta band activity are key when aiming to improve cognitive control functions in ADHD. This calls for a change in the use of theta/beta NF protocols and shows that protocols differing from the current clinical standard are effective in enhancing important facets of cognitive control in ADHD. Further studies need to examine regulation data within the neurofeedback sessions to provide more information about the mechanisms underlying the observed effects.

Transcranial Direct Current Stimulation (tDCS) in children with ADHD: A randomized, sham-controlled pilot study

BACKGROUND

ADHD is a common neurodevelopmental disorder with a pediatric prevalence of 5.2%.While medication treatment for ADHD is effective, it does not address all symptoms and a small but notable subgroup does not respond to medications. Adverse effects limit its use and some parents and participants resist use of medication. Thus, limitations of medication treatment for ADHD motivate searching for other therapeutic options. Transcranial Direct Current Stimulation (tDCS) has been suggested as a treatment for children with ADHD, with mixed results to date. Protocol variables employed, including combined use of cognitive training (CT) and scheduling of sessions, may explain diverse findings to date. The aim of this study was to examine safety, feasibility and efficacy of tDCS combined with CT provided three-times-per week for one-month to treat children with ADHD.

METHODS

In a double blind, randomized, sham-controlled pilot study, 25 children with ADHD were randomized to receive 12 sessions of either anodal tDCS or sham-tDCS for 20 min combined with CT three-times-per-week for four weeks. The tDCS anode was over left dorsolateral prefrontal cortex (DLPFC) and cathode over vertex. Assessments were obtained prior to, after 6 sessions, 12 sessions and one-month after intervention.

RESULTS

No significant post-intervention differences were found between those receiving tDCS or sham-tDCS. Both groups demonstrated significant improvement on questionnaire measures of ADHD and executive function with mixed results seen on computerized performance measures. Overall, adverse effects were mild with no significant difference between groups. However, three children, all from the tDCS group, experienced headaches with two requiring temporary cessation and one requiring removal from the study.

CONCLUSIONS

Anodal tDCS to the DLPFC using the above protocol in children with ADHD did not demonstrate additional treatment benefits beyond that of CT.

Impact of COVID-19 on Children's Attention Deficit Hyperactivity Disorder Symptomology, Daily Life, and Problem Behavior During Virtual Learning

To explore the impact of COVID-19 on daily life and problem behavior during virtual learning, we created and administered a survey to 64 school-aged children (in 2019, M = 9.84 years; SD = 0.55 years). Results indicated significant increases in hyperactivity (t = -2.259; p = .027) and inattention (t = -2.811; p = .007) from 2019 to 2020. Decreases in sleep were associated with increases in hyperactivity (B = -0.27; p = .04); increases in time exercising were associated with smaller increases in inattention (B = -0.34, p = .01); and higher levels of parent stress, specifically related to virtual learning, were associated with increases in child inattention (B = 0.57, p = .01). Furthermore, hyperactivity predicted problem behavior during virtual learning (B = 0.31, p = .03).

Methods to Summarize Discrete-Choice Experiments in a Systematic Review: A Scoping Review

BACKGROUND AND OBJECTIVE

Systematic reviews of discrete-choice experiments (DCEs) are being increasingly conducted. The objective of this scoping review was to identify and describe the methodologies that have been used to summarize results across DCEs.

METHODS

We searched the electronic databases MEDLINE and EMBASE from inception to March 18, 2021, to identify English-language systematic reviews of patient preferences that included at least two DCEs and extracted data on attribute importance. The methods used to summarize results across DCEs were classified into narrative, semi-quantitative, and quantitative (meta-analytic) approaches and compared. Approaches to characterize the extent of preference heterogeneity were also described.

RESULTS

From 7362 unique records, we identified 54 eligible reviews from 2010 to Mar 2021, across a broad range of health conditions. Most (83%) used a narrative approach to summarize findings of DCEs, often citing differences in studies as the reason for not formally pooling findings. Semi-quantitative approaches included summarizing the frequency of the most important attributes, the frequency of attribute statistical significance, or tabulated comparisons of attribute importance for each pair of attributes. One review conducted a meta-analysis using the maximum acceptable risk. While reviews often commented on the heterogeneity of patient preferences, few (6%) addressed this systematically across studies.

CONCLUSION

While not commonly used, several semi-quantitative and one quantitative approach for synthesizing results of DCEs were identified, which may be useful for generating summary estimates across DCEs when appropriate. Further work is needed to assess the validity and usefulness of these approaches.

Parental perspectives on attention-deficit/hyperactivity disorder treatments for children

This study investigated parental perspectives and experiences on the evaluation and treatment process associated with attention-deficit/hyperactivity disorder (ADHD). Five hundred sixty-eight parents of youth 2-28 years-old (M = 9.37; SD = 4.11) diagnosed with ADHD responded to a 14-item online survey about their child's diagnosis and treatment. Parents reported that they had tried an average of 4.49 interventions (SD = 2.63). Parents further shared factors in treatment selection, most helpful parenting strategies, and preferences for types of treatments and treatment targets. A majority of parents reported incorporating many non-traditional strategies (e.g., exercise, healthy eating, outdoor activities) with goals of improving their child's coping skills, study habits, and anger management. The findings show that treatment choices were often selected based on trust in the provider, research support, and the child's preference. Given parental preferences for non-traditional strategies, treatment development efforts should consider these strategies as a component of a broader multimodal treatment approach to ADHD.

Treatments for child and adolescent attention deficit hyperactivity disorder in low and middle-income countries: A narrative review

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that affects approximately 2-7 % of children globally and is associated with a myriad of difficulties that have long-term consequences. Most children and adolescents live in low- and middle-income countries (LMICs), but there are few reports and no consolidation of findings on ADHD treatment outcomes in this population. We conducted a review of ADHD treatment literature for children and adolescents living in LMICs.

METHODS

Studies were identified using databases (PsychoINFO, Pubmed, MEDLINER, EMBASE, Global Health, Academic Search Complete, Google Scholar). The initial search produced 139 articles. These were filtered for language, title, abstract, and full-text keyword identification to yield a final 20 articles to be included in this review.

RESULTS

Reports on outcomes of both psychological and pharmacological treatment were relatively sparse, particularly the former, which mostly referred to parent training and multimodal programs in pre-school children. Most evidence exists for the benefit of methylphenidate-IR with a few reports on other agents, including clonidine, atomoxetine, and lisdexamfetamine. Methylphenidate is the most common agent to treat ADHD in youth in LMICs. Younger age, combined subtype, and comorbid oppositional defiant disorder were associated with poorer treatment outcome.

CONCLUSION

Access to treatment for ADHD is overall limited in LMICs and varied among individual countries. Pharmacological treatments were generally more available than psychological interventions. Several barriers including stigma, cost, and lack of resources were reported to impact treatment acceptance. More research in LMICs is needed to improve and expand mental health services in these regions.

Parents' priorities and preferences for treatment of children with ADHD: Qualitative inquiry in the MADDY study

BACKGROUND

Parents' lived experiences of having a child with ADHD may shape their decision making regarding ADHD treatment options for their child. The aim of this study was to explore parents' experiences of living with a child with ADHD in the family and how their experiences influence their perspectives on treatment preferences and priorities.

METHODS

A phenomenological qualitative design was used. Semistructured interviews were conducted with parents of children with ADHD who were enrolled in a multisite randomized controlled trial. Interviews were transcribed verbatim, and transcripts at each site were double coded. Initial codes were derived directly from the text. Qualitative data were analysed with an inductive approach.

RESULTS

Twenty-three parents were interviewed: eight from Alberta, Canada; eight from Portland, Oregon, USA; and seven from Columbus, Ohio, USA. Among the parents, 69% were married, 86% completed college education and 52% reported household income over $80,000. Among the children, the mean age was 9.6 years (SD = 1.8 years), 78% were boys and 48% were never medicated for their ADHD. Two major themes emerged from the analysis. Theme 1 was 'impact of ADHD on families within and outside the home' with the following subthemes: 'reconfiguring the home life', 'trial-and-error of accommodations at school' and 'responding to social pressures to fit in'. Theme 2 was 'enabling appropriate and accessible treatments for families' with the following subthemes: 'finding the "right fit" with professionals and treatments' and 'factors influencing inequitable access to treatments'.

CONCLUSIONS

Parents described shared experiences and identified similar barriers, preferences and priorities for ADHD treatments regardless of demographic differences by site. Families desired access to family-centred, multimodal approaches to ADHD treatment. Further research is needed to identify the specific structural changes to healthcare, services and policies that will better support this approach.

Toward Precision Medicine in ADHD

Attention-Deficit Hyperactivity Disorder (ADHD) is a complex and heterogeneous neurodevelopmental condition for which curative treatments are lacking. Whilst pharmacological treatments are generally effective and safe, there is considerable inter-individual variability among patients regarding treatment response, required dose, and tolerability. Many of the non-pharmacological treatments, which are preferred to drug-treatment by some patients, either lack efficacy for core symptoms or are associated with small effect sizes. No evidence-based decision tools are currently available to allocate pharmacological or psychosocial treatments based on the patient's clinical, environmental, cognitive, genetic, or biological characteristics. We systematically reviewed potential biomarkers that may help in diagnosing ADHD and/or stratifying ADHD into more homogeneous subgroups and/or predict clinical course, treatment response, and long-term outcome across the lifespan. Most work involved exploratory studies with cognitive, actigraphic and EEG diagnostic markers to predict ADHD, along with relatively few studies exploring markers to subtype ADHD and predict response to treatment. There is a critical need for multisite prospective carefully designed experimentally controlled or observational studies to identify biomarkers that index inter-individual variability and/or predict treatment response.

Eliciting preferences for continuing medication among adult patients and parents of children with attention-deficit hyperactivity disorder

BACKGROUND

Adherence to medication for attention-deficit hyperactivity disorder (ADHD) is less than optimal. Previous studies have primarily focused on qualitative assessment of factors that influence medication adherence.

OBJECTIVE

This study aimed to quantify the factors that influence patient and parent preferences for continuing ADHD medication.

METHOD

A discrete-choice experiment was conducted to investigate preferences. Adults, and parents of children, with ADHD were presented with eight hypothetical choice tasks of three options (Medication A, Medication B, No Medication) described by six attributes related to medication outcomes. Preferences were estimated using a mixed multinomial logit model.

RESULTS

Overall, respondents' preferences (n = 216) for continuing medication were negative (mean [β] = -1.426, p < .001); however, a significant heterogeneity in preferences was observed amongst respondents (standard deviation = 0.805, p < .001). Improvements in education, aggressive behaviour, social behaviour and family functioning, and side effects and stigma, influenced respondents' decision to continue taking medication. The respondents were willing to continue medication if they experienced positive effects, but side effects (even moderate) were the strongest concern for not continuing medication. While side effects were the most important factor for both adult patients and parents of children with ADHD, improvement in education was relatively more important for adults and improvement in aggressive behaviour, social behaviour and family functioning was relatively more important for parents of children with ADHD. Parents were more likely to not continue a medication with severe side effects even at the highest level of improvement in education.

CONCLUSIONS

Side effects are the most important factor that influenced preferences for continuing medication for both adults with ADHD, as well as parents of children with ADHD. While overall the respondents preferred not to take/give medication, discrete-choice experiment showed that the relative importance of factors that influenced continuation of medications was different for the two groups.

PATIENT AND PUBLIC INVOLVEMENT

Adults, and parents of children, with ADHD participated in this study by completing the online questionnaire. The questionnaire was based on findings of research in the literature, as well as earlier focus groups conducted with adults, and parents of children, with ADHD. The face validity of the questionnaire was determined by asking parents of children, and adults, with ADHD (n = 3) to complete the survey and participate in a short discussion on their understanding of the questions and their recommendations on improving the clarity of the survey.

Extended-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a psychiatric diagnosis increasingly used in adults. The recommended first-line pharmacological treatment is central nervous system (CNS) stimulants, such as methylphenidate, but uncertainty remains about its benefits and harms.

OBJECTIVES

To assess the beneficial and harmful effects of extended-release formulations of methylphenidate in adults diagnosed with ADHD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases and four clinical trial registries up to February 2021. We searched 12 drug regulatory databases for clinical trial data up to 13 May 2020. In addition, we cross-referenced all available trial identifiers, handsearched reference lists, searched pharmaceutical company databases, and contacted trial authors.

SELECTION CRITERIA

Randomised, double-blind, parallel-group trials comparing extended-release methylphenidate formulations at any dose versus placebo and other ADHD medications in adults diagnosed with ADHD.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. We assessed dichotomous outcomes as risk ratios (RRs), and rating scales and continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs). We used the Cochrane risk of bias tool to assess risks of bias, and GRADE to assess the certainty of the evidence. We meta-analysed the data using a random-effects model. We assessed three design characteristics that may impair the trial results' 'generalisability'; exclusion of participants with psychiatric comorbidity; responder selection based on previous experience with CNS stimulants; and risk of withdrawal effects. Our prespecified primary outcomes were functional outcomes, self-rated ADHD symptoms, and serious adverse events. Our secondary outcomes included quality of life, ADHD symptoms rated by investigators and by peers such as family members, cardiovascular variables, severe psychiatric adverse events, and other adverse events.

MAIN RESULTS

We included 24 trials (5066 participants), of which 21 reported outcome data for this review. We also identified one ongoing study. We included documents from six drug regulatory agencies covering eight trials. Twenty-one trials had an outpatient setting and three were conducted in prisons. They were primarily conducted in North America and Europe. The median participant age was 36 years. Twelve trials (76% of participants) were industry-sponsored, four (14% of participants) were publicly funded with industry involvement, seven (10% of participants) were publicly funded, and one had unclear funding. The median trial duration was eight weeks. One trial was rated at overall unclear risk of bias and 20 trials were rated at overall high risk of bias, primarily due to unclear blinding of participants and investigators, attrition bias, and selective outcome reporting. All trials were impaired in at least one of the three design characteristics related to 'generalisability'; for example, they excluded participants with psychiatric comorbidity such as depression or anxiety, or included participants only with a previous positive response to methylphenidate, or similar drugs. This may limit the trials' usefulness for clinical practice, as they may overestimate the benefits and underestimate the harms. Extended-release methylphenidate versus placebo (up to 26 weeks) For the primary outcomes, we found very low-certainty evidence that methylphenidate had no effect on 'days missed at work' at 13-week follow-up (mean difference (MD) -0.15 days, 95% confidence interval (CI) -2.11 to 1.81; 1 trial, 409 participants) or serious adverse events (risk ratio (RR) 1.43, CI 95% CI 0.85 to 2.43; 14 trials, 4078 participants), whereas methylphenidate improved self-rated ADHD symptoms (small-to-moderate effect; SMD -0.37, 95% CI -0.43 to -0.30; 16 trials, 3799 participants). For secondary outcomes, we found very low-certainty evidence that methylphenidate improved self-rated quality of life (small effect; SMD -0.15, 95% CI -0.25 to -0.05; 6 trials, 1888 participants), investigator-rated ADHD symptoms (small-to-moderate effect; SMD -0.42, 95% CI -0.49 to -0.36; 18 trials, 4183 participants), ADHD symptoms rated by peers such as family members (small-to-moderate effect; SMD -0.31, 95% CI -0.48 to -0.14; 3 trials, 1005 participants), and increased the risk of experiencing any adverse event (RR 1.27, 95% CI 1.19 to 1.37; 14 trials, 4214 participants). We rated the certainty of the evidence as 'very low' for all outcomes, primarily due to high risk of bias and 'indirectness of the evidence'. One trial (419 participants) had follow-up at 52 weeks and two trials (314 participants) included active comparators, hence long-term and comparative evidence is limited.

AUTHORS' CONCLUSIONS

We found very low-certainty evidence that extended-release methylphenidate compared to placebo improved ADHD symptoms (small-to-moderate effects) measured on rating scales reported by participants, investigators, and peers such as family members. Methylphenidate had no effect on 'days missed at work' or serious adverse events, the effect on quality of life was small, and it increased the risk of several adverse effects. We rated the certainty of the evidence as 'very low' for all outcomes, due to high risk of bias, short trial durations, and limitations to the generalisability of the results. The benefits and harms of extended-release methylphenidate therefore remain uncertain.

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.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

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

ADHD is the most common neurodevelopmental disorder presenting to child and adolescent mental health, paediatric, and primary care services. Timely and effective interventions to address core ADHD symptoms and co-occurring problems are a high priority for healthcare and society more widely. While much research has reported on the benefits and adverse effects of different interventions for ADHD, these individual research reports and the reviews, meta-analyses and guidelines summarizing their findings are sometimes inconsistent and difficult to interpret. We have summarized the current evidence and identified several methodological issues and gaps in the current evidence that we believe are important for clinicians to consider when evaluating the evidence and making treatment decisions. These include understanding potential impact of bias such as inadequate blinding and selection bias on study outcomes; the relative lack of high-quality data comparing different treatments and assessing long-term effectiveness, adverse effects and safety for both pharmacological and non-pharmacological treatments; and the problems associated with observational studies, including those based on large national registries and comparing treatments with each other. We highlight key similarities across current international clinical guidelines and discuss the reasons for divergence where these occur. We discuss the integration of these different perspective into a framework for person/family-centered evidence-based practice approach to care that aims to achieve optimal outcomes that prioritize individual strengths and impairments, as well as the personal treatment targets of children and their families. Finally, we consider how access to care for this common and impairing disorder can be improved in different healthcare systems.

Leveraging Machine Learning to Identify Predictors of Receiving Psychosocial Treatment for Attention Deficit/Hyperactivity Disorder

This study aimed to identify factors associated with receiving psychosocial treatment for ADHD in a nationally representative sample. Participants were 6630 youth with a parent-reported diagnosis of ADHD from the 2016-2017 National Survey of Children's Health. Machine learning analyses were performed to identify factors associated with receipt of psychosocial treatment for ADHD. We examined potentially associated factors in the broad categories of variables hypothesized to affect problem recognition (e.g., severity, mental health comorbidities); the decision to seek treatment; service selection (e.g., insurance coverage) and service use. We found that three machine learning models unanimously identified parent-reported ADHD severity (mild vs. moderate/severe) as the factor that best distinguishes between children who receive psychosocial treatment for ADHD and those who do not. Receive operating characteristic curve analysis revealed the following model performance: classification and regression tree analysis (area under the curve; AUC = .68); an ensemble model (AUC = .71); and a deep, multi-layer neural network (AUC = .72), as well as comparison to a logistic regression model (AUC = .69). Further, insurance coverage of mental/behavioral health needs emerged as a salient factor associated with the receipt of psychosocial treatment. Machine learning models identified risk and protective factors that predicted the receipt of psychosocial treatment for ADHD, such as ADHD severity and health insurance coverage.

Adult Patient Preferences for Long-Acting ADHD Treatments: A Discrete Choice Experiment

BACKGROUND AND OBJECTIVE

Treatment for attention deficit hyperactivity disorder (ADHD) requires a multifaceted approach including psychosocial interventions and pharmacological treatment. This study evaluates preferences for specific attributes associated with different long-acting stimulant treatment among US adults with ADHD.

METHODS

Patients completed an online, cross-sectional survey, incorporating a discrete choice experiment to assess preferences for attributes.

RESULTS

Analyses included 200 adults with ADHD (mean age 33.0 years; 60% self-reporting moderate severity); the mean (SD) Adult ADHD Self-Report Scale-v1.1 score was 45.9 (12.4). Overall, patients valued speed of onset most and risk of rebound least. Three population groups with distinct preferences were identified: side effect-driven (n=69, 35%), quick onset-driven (n=47, 24%) and quick onset and long duration-driven (n=84, 42%).

CONCLUSION

This study shows differences in how adults with ADHD value and assess benefit-risk trade-offs when considering the desired attributes of stimulant treatments, highlighting the importance of patient-physician shared decision-making to optimize the desired benefits of individualized treatment.

Prioritising Targets for School-Based ADHD Interventions: A Delphi Survey

Many studies have investigated the effectiveness of school-based ADHD interventions at modifying different social, emotional and behavioural target outcomes. However, there is a lack of evidence about which targets stakeholders perceive to be most important. This study sought to obtain consensus on which outcomes are perceived to be most important. A total of 114 people with ADHD, educational professionals, parents of children with ADHD, clinicians and researchers participated in a Delphi survey with 3 rounds. The importance of 52 intervention targets was rated on a scale from 0 to 8 (8 being extremely important). Consensus was reached if >70% of a stakeholder group rated a target as between 6–8 and <15% rated it as 0–2. Targets were dropped from subsequent rounds if more than 50% of stakeholder groups rated it as 0–5. Targets that all four stakeholder groups reached consensus on in any round were automatically included in our final outcome set. Comments were analysed using Thematic Analysis. All four stakeholder groups reached consensus on the importance of seven targets: ability to pay attention, conflict with teachers and peers, executive functioning, global functioning and quality of life, inattention symptoms, organisation skills and self-esteem. Four overarching themes were identified: Complexity of ADHD, Relationships, School Context, and What ADHD means to me. School-based ADHD interventions should target outcomes identified as most important to those who stand to benefit from such interventions. Some outcomes prioritised by our participants have not yet been targeted in school-based ADHD interventions. Implications of our findings for intervention and research design are discussed.

A Phase III, Randomized, Placebo-controlled Trial to Assess the Efficacy and Safety of Once-daily SPN-812 (Viloxazine Extended-release) in the Treatment of Attention-deficit/Hyperactivity Disorder in School-age Children

PURPOSE

The limitations of current US Food and Drug Administration (FDA)-approved medications for the treatment of attention-deficit/hyperactivity disorder (ADHD) set the need for the development of novel, effective, and tolerable medications to treat this disorder. The purpose of this study was to evaluate whether treatment with SPN-812 (viloxazine extended-release) significantly reduces symptoms of ADHD in children.

METHODS

This study was a randomized, double-blind, placebo-controlled 6-week trial to assess the efficacy and safety of once-daily 100- and 200-mg SPN-812 in the treatment of ADHD in male and female children 6-11 years of age. Inclusion criteria required subjects to have a confirmed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, ADHD diagnosis, an ADHD-Rating Scale-5 (ADHD-RS-5) score ≥28, a Clinical Global Impression-Severity score ≥4, and for subjects to be free of ADHD medication ≥1 week before randomization. The primary efficacy endpoint was the change from baseline (CFB) at end of study (EOS) in ADHD-RS-5 Total score. Key secondary endpoints included Clinical Global Impression-Improvement (CGI-I) scores at EOS and CFB at EOS in the Conners 3-Parent Short Form (Conners 3-PS) Composite T-score and the Weiss Functional Impairment Rating Scale-Parent (WFIRS-P) Total average score. Safety assessments included adverse events (AEs), laboratory tests, vital signs, physical examinations, ECGs, and the Columbia-Suicide Severity Rating Scale. The primary efficacy endpoint was analyzed by using a mixed model for repeated measures; all secondary measures were analyzed by using an ANCOVA model.

RESULTS

A total of 477 subjects were randomized to treatment (intent-to-treat population, n = 460). The majority of subjects were male (63%) and either White (51.3%) or African American (43.7%). The demographic and baseline characteristics between the groups were similar. Statistically significant improvements in ADHD-RS-5 Total score were observed in both the 100- and 200-mg/day SPN-812 treatment groups compared to placebo at week 1 of treatment (P = 0.0004 and P = 0.0244, respectively), which was maintained through EOS (P = 0.0004 and P < 0.0001). Significant improvements were also observed at EOS in the CGI-I scale (P = 0.0020 and P < 0.0001), Conners 3-PS Composite T-score (P = 0.0003 and P = 0.0002), and WFIRS-P Total average score (P = 0.0019 and P = 0.0002) versus placebo. Treatment-related AEs reported in ≥5% of subjects included somnolence, decreased appetite, and headache. The discontinuation rate due to AEs was <5%.

IMPLICATIONS

SPN-812 significantly reduced ADHD symptoms in children and was well tolerated. SPN-812 may prove to be an effective treatment for children with ADHD. ClinicalTrials.gov identifier: NCT03247530.

Acceptability of transcranial direct current stimulation in children and adolescents with ADHD: The point of view of parents

Transcranial direct current stimulation (tDCS) is a novel treatment option for attention deficit hyperactivity disorder. To facilitate translation into clinical practice, we interviewed parents of children who have experienced experimental tDCS. A grounded theory approach using open, axial, and selective coding provided seven emergent themes for acceptability: tDCS provides hope for parents, safety tolerability and side effects of tDCS versus medication, burden of treatment, education and trust with care providers, cost and coverage, unestablished tDCS efficacy versus established medication effectiveness, perceived compliance of tDCS versus medication. Results suggest tDCS is acceptable but depends on evidence of effectiveness and regular availability.

The influence of mindfulness meditation on inattention and physiological markers of stress on students with learning disabilities and/or attention deficit hyperactivity disorder

BACKGROUND

Over recent decades, the number of students diagnosed with learning disabilities and/or attention deficit hyperactivity disorders has substantially increased. These students face various challenges and experience stress when receiving higher education.

AIMS

The purpose of this study was to compare two non-pharmacological interventions: mindfulness and device-guided slow breathing, with a control group.

METHODS

Seventy-three students (age = 25.76, std. dev = 3.10) with attention problems and/or learning disabilities were randomly assigned to three groups: mindfulness meditation, device guided breathing practice and waiting-list control. Before and after the intervention physiological and psychological measures were collected.

RESULTS

Our results show that only mindfulness practice improved awareness of the present moment and decreased hyperactivity and inattention. Furthermore, both mindfulness and practice with device-guided breathing were associated with stress reduction, as shown by an increase in the galvanic skin response only in the control group.

CONCLUSIONS

Implementation of the study results may lead to an advance in treating attention deficit disorders and learning disabilities, especially among higher education students.

Neurofeedback trains a superordinate system relevant for seemingly opposing behavioral control deficits depending on ADHD subtype

ADHD is one of the most prevalent neuropsychiatric disorders of childhood, but symptoms vary considerably between individuals. Therefore, different ADHD subtypes can be distinguished. Yet, it is widely elusive whether the specific subtype is critical to consider when examining treatment effects. Based on theoretical considerations, this could be the case for EEG theta/beta neurofeedback. We examine the effects of such an intervention on rapid response execution and inhibition processes using a Go/Nogo task in the inattentive (ADD) and the combined (ADHD-C) subtype. We show that a single neurofeedback protocol affects opposing deficits depending on the ADHD subtype - namely the execution (in ADD) and inhibition of action (in ADHD-C). No changes occurred in the healthy controls. These findings are discussed in relation to overarching principles of neural oscillations, particularly in the beta frequency band. The data suggest that theta/beta neurofeedback trains a superordinate system strongly related to the function of neural beta frequency oscillations to tune neural networks important for the sampling of sensory information used for behavioral control.

Care Management for Youth With Comorbid Developmental and Mental Health Conditions: A Discrete Choice Experiment Pilot Study

OBJECTIVE

Caregivers of a child with a coexisting cognitive/intellectual and an emotional/behavior/developmental disability have difficult decisions regarding care management options for their child. This study aimed to pilot and refine an instrument to elicit caregivers' preferences in managing their child's care needs.

METHODS

Subjects were 38 caregivers of a child aged 21 and younger with a coexisting cognitive/intellectual and an emotional/behavior/developmental disability. A mixed-methods design was used to develop and pilot a discrete choice experiment (DCE) to elicit care management preferences for their child. Six attributes of care management decisions were tested in the DCE: medication use, parental custody, time cost, social interactions, medication effects, and school placement. Subjects completed a paper-and-pencil survey after which a debriefing discussion was held to obtain feedback that would aid in refining the attribute descriptions. Conditional logistic regression generated mean scores for each attribute. Comments from the debriefing sessions were audio-recorded and used to modify the attribute descriptions.

RESULTS

The majority (84%) of subjects were aged 40 years or older and a female caregiver. Common diagnoses of the children were autism spectrum disorder (55%) and attention-deficit/hyperactivity disorder (76%). Subjects preferred using fewer medications and maintaining decision-making authority as opposed to delegating authority to a third party. Medication effects on the child's mood were more important than effects on personality or body weight.

CONCLUSIONS

The DCE was sensitive to caregivers' preferences for managing their child's coexisting cognitive/intellectual and emotional/behavior/developmental disability. Findings may help providers gauge treatment in a broader context of health outcomes.

Application and Perceived Effectiveness of Complementary and Alternative Intervention Strategies for Attention-Deficit/Hyperactivity Disorder: Relationships with Affiliate Stigma

This cross-sectional questionnaire survey study was designed to examine the complementary and alternative intervention strategies (CAIS) employed by caregivers for their children’s attention-deficit/hyperactivity disorder (ADHD) and the associations of affiliate stigma with the employment and rated effectiveness of these strategies in Taiwan. A total of 400 caregivers of children with ADHD participated. CAIS that the caregivers employed and their effectiveness rated by the caregivers were surveyed. Associations of affiliate stigma with the application and rated effectiveness of the strategies were determined using logistic regression analysis. The results indicated that sensory integration (30.3%), exercise training (29.3%), sugar restriction (20.5%), and omega fatty acid supplementation (11.3%) were the most common CAIS that the caregivers employed. Caregivers with stronger affiliate stigma were more likely to employ sensory integration, exercise training, and omega fatty acid supplementation but also rated them as ineffective in treating their children’s ADHD. Various CAIS were employed by the caregivers to manage their children’s ADHD. Affiliate stigma was significantly associated with the application and rated ineffectiveness of several CAIS.

Caregivers' Priorities and Observed Outcomes of Attention-Deficit Hyperactivity Disorder Medication for Their Children

OBJECTIVE

To document variability among caregivers' priorities when considering medication to treat their Children's attention-deficit hyperactivity disorder (ADHD) and explore associations between these priorities and medication-related improvements.

METHODS

Caregivers of children, ages 4 to 14 years, diagnosed with ADHD were recruited from outpatient clinics and support groups across Maryland. A survey gathered data on caregiver-reported concerns when considering ADHD medication, demographic characteristics, and observed and desired improvements in their child's ADHD. A validated Best-Worst Scaling instrument assessed priorities among 16 concerns when considering ADHD medication. Latent class analysis identified subgroups with similar ADHD medication concerns. Differences in self-reported medication-related improvements were examined across subgroups.

RESULTS

The 184 participants (mean = 42 yrs) were primarily the biological mother, 68% white and 25% black. Their children were mostly male (73%) and using medication (81%). Overall, the most important ADHD medication concerns were the child becoming a successful adult (p < 0.0001), school behavior improvements (p < 0.0001), and better grades (p < 0.0001). Others thinking badly of the child was a significantly less important concern (p < 0.0001). Three subgroups were identified: short-term outcomes-oriented group (39%), long-term outcomes-oriented group (37%), and side effects/safety-oriented group (27%). Relative to the other 2 groups, a smaller proportion of the side effects/safety-oriented group desired these improvements (p < 0.2618).

CONCLUSION

Most caregivers prioritize short- and long-term outcomes when considering ADHD medication. However, those most concerned with long- or short-term outcomes tended to desire additional improvements in their child's ADHD.

Best-Worst Scaling to Prioritize Outcomes Meaningful to Caregivers of Youth with Mental Health Multimorbidities: A Pilot Study

OBJECTIVE

Health care decision-making for youth with mental health multimorbidity is guided by outcomes that are considered most meaningful and important. The study objective was to pilot test a best-worst scaling (BWS) instrument designed to assess trade-offs among caregiver-defined, meaningful health care outcomes.

METHODS

A BWS was designed with continuous stakeholder involvement to elicit caregiver-defined outcomes in 4 domains: school, behavioral, social, and independence. Four attributes were identified for each outcome domain, for a total of 16 attributes. Using a balanced incomplete block design, a BWS instrument was developed with 16 choice task questions displaying 6 attributes at a time. A convenience sample was selected from Maryland caregivers of children who were 21 years old or younger and had a developmental delay and a comorbid mental health condition. Participants completed a survey that included demographics and the BWS instrument. Conditional logit was used to estimate utility scores and 95% confidence intervals (CI) for each attribute, which were ranked in order of importance. Attribute statements were refined after a respondent debriefing session.

RESULTS

A total of 38 caregivers participated in the pilot study. Child safety to self was the most important outcome (1.01, CI, 0.78-1.24). This was followed by securing support for an Individualized educational plan in school (0.77, CI, 0.54-1.01) and the child being able to stay in school all day (0.53, CI, 0.29-0.77).

CONCLUSION

BWS scenarios that resemble real-life decision-making can be a useful tool to identify preferences for health care outcomes.

Treatment strategies for ADHD: an evidence-based guide to select optimal treatment

Attention-deficit/hyperactivity disorder (ADHD) is a common and impairing disorder affecting children, adolescents, and adults. Several treatment strategies are available that can successfully ameliorate symptoms, ranging from pharmacological to dietary interventions. Due to the increasing range of available options, an informed selection or prioritization of treatments is becoming harder for clinicians. This review aims to provide an evidence-based appraisal of the literature on ADHD treatment, supplemented by expert opinion on plausibility. We outline proposed mechanisms of action of established pharmacologic and non-pharmacologic treatments, and we review targets of novel treatments. The most relevant evidence supporting efficacy and safety of each treatment strategy is discussed. We review the individualized features of the patient that should guide the selection of treatments in a shared decision-making continuum. We provide guidance for optimizing initiation of treatment and follow-up of patients in clinical settings.

Discrete Choice Experiments in Health Economics: Past, Present and Future

OBJECTIVES

Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges.

METHODS

A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated.

RESULTS

Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels.

CONCLUSIONS

The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.

Does Giving Parents Their Choice of Interventions for Child Behavior Problems Improve Child Outcomes?

Empowering consumers to be active decision-makers in their own care is a core tenet of personalized, or precision medicine. Nonetheless, there is a dearth of research on intervention preferences in families seeking interventions for a child with behavior problems. Specifically, the evidence is inconclusive as to whether providing parents with choice of intervention improves child/youth outcomes (i.e., reduces externalizing problems). In this study, 129 families presenting to community mental health clinics for child conduct problems were enrolled in a doubly randomized preference study and initially randomized to choice or no-choice conditions. Families assigned to the choice condition were offered their choice of intervention from among three different formats of the Parent Management Training-Oregon Model/PMTO (group, individual clinic, home based) and services-as-usual (child-focused therapy). Those assigned to the no-choice condition were again randomized, to one of the four intervention conditions. Intent-to-treat analyses revealed partial support for the effect of parental choice on child intervention outcomes. Assignment to the choice condition predicted teacher-reported improved child hyperactivity/inattention outcomes at 6 months post-treatment completion. No main effect of choice on parent reported child outcomes was found. Moderation analyses indicated that among parents who selected PMTO, teacher report of hyperactivity/inattention was significantly improved compared with parents selecting SAU, and compared with those assigned to PMTO within the no-choice condition. Contrary to hypotheses, teacher report of hyperactivity/inattention was also significantly improved for families assigned to SAU within the no-choice condition, indicating that within the no-choice condition, SAU outperformed the parenting interventions. Implications for prevention research are discussed.

Sharing of ADHD Information between Parents and Teachers Using an EHR-Linked Application

BACKGROUND

Appropriate management of attention-deficit/hyperactivity disorder (ADHD) involves parents, clinicians, and teachers. Fragmentation of interventions between different settings can lead to suboptimal care and outcomes. Electronic systems can bridge gaps across settings. Our institution developed an email-based software to collect ADHD information from parents and teachers, which delivered data directly to the clinician within the electronic health record (EHR).

OBJECTIVE

We sought to adapt our institution's existing EHR-linked system for ADHD symptom monitoring to support communication between parents and teachers and then to assess child characteristics associated with sharing of ADHD information.

METHODS

We updated our software to support automated sharing of ADHD information between parents and teachers. Sharing was optional for parents but obligatory for teachers. We conducted a retrospective cohort study involving 590 patients at 31 primary care sites to evaluate a system for sharing of ADHD-specific health information between parents and teachers. We used multivariable logistic regression to estimate associations between child characteristics and parental sharing. We further investigated the association between child characteristics and viewing of survey results delivered through the electronic communication system.

RESULTS

Most parents (64%) elected to share survey results with teachers at the first opportunity and the vast majority (80%) elected to share all possible information. Parents who elected to share usually continue sharing at subsequent opportunities (89%). Younger child age and performance impairments were associated with increased likelihood of sharing. However, parents viewed only 16% of teacher submitted surveys and teachers only viewed 30% of surveys shared by parents.

CONCLUSION

This study demonstrates that electronic systems to capture ADHD information from parents and teachers can be adapted to support communication between them, and that parents are amenable to sharing ADHD information with teachers. However, strategies are needed to encourage viewing of shared information.

A comparative study on the neurophysiological mechanisms underlying effects of methylphenidate and neurofeedback on inhibitory control in attention deficit hyperactivity disorder

In Attention Deficit Hyperactivity Disorder (AD(H)D), treatments using methylphenidate (MPH) and behavioral interventions like neurofeedback (NF) reflect major therapeutic options. These treatments also ameliorate executive dysfunctions in AD(H)D. However, the mechanisms underlying effects of MPH and NF on executive functions in AD(H)D (e.g. the ability to inhibit prepotent responses) are far from understood. It is particularly unclear whether these interventions affect similar or dissociable neural mechanisms and associated functional neuroanatomical structures. This, however, is important when aiming to further improve these treatments. We compared the neurophysiological mechanisms of MPH and theta/beta NF treatments on inhibitory control on the basis of EEG recordings and source localization analyses. The data show that MPH and theta/beta NF both increase the ability to inhibit pre-potent responses to a similar extent. However, the data suggest that MPH and NF target different neurophysiological mechanisms, especially when it comes to functional neuroanatomical structures associated with these effects. Both treatments seem to affect neurophysiological correlates of a ‘braking function’ in medial frontal areas. However, in case of the NF intervention, inferior parietal areas are also involved. This likely reflects the updating and stabilisation of efficient internal representations in order to initiate appropriate actions. No effects were seen in correlates of perceptual and attentional selection processes. Notably, reliable effects were only obtained after accounting for intra-individual variability in the neurophysiological data, which may also explain the diversity of findings in studies on treatment effects in AD(H)D, especially concerning neurofeedback.

•

Neurophysiological mechanisms of methylphenidate (MPH) and neurofeedback (NF) in ADHD are compared.

•

Both treatments improve inhibition, but have different underlying neurophysiological mechanisms.

•

Both treatments affect the neurophysiological correlates of a ‘breaking function’ in medial frontal areas.

•

NF also affects inferior parietal areas and likely the updating of internal representations.

•

Distinctive effects are only seen when accounting for intra-individual variability.

Racial-Ethnic Differences in Patterns of Discontinuous Medication Treatment Among Medicaid-Insured Youths With ADHD

OBJECTIVE

This study examined the association between race-ethnicity and patterns of medication gaps and discontinuities among Medicaid-insured children initiating pharmacotherapy for attention-deficit hyperactivity disorder (ADHD).

METHODS

Medicaid claims data from nine states were used to identify racial-ethnic differences in patterns of ADHD medication treatment among 102,669 children initiating ADHD medication. Multinomial logistic regression with state indicators was used to estimate these differences, with adjustment for individual and contextual confounders.

RESULTS

Approximately three-fifths of the sample did not receive continuous medication treatment as defined by HEDIS guidelines; among them, one-fifth discontinued treatment with no subsequent reinitiation (early termination), less than one-tenth reinitiated pharmacotherapy following a single medication gap, more than three-tenths experienced discontinuous pharmacotherapy with two gaps, and more than four-tenths experienced discontinuous pharmacotherapy with three or more gaps. Compared with white children, black children had a 25% relative increase in the likelihood of early termination and Hispanic children had a 21% relative increase (p<.001); their relative increases in the likelihood of two medication gaps were 41% and 29%, respectively (p<.001), and for three or more gaps they were 56% and 40%, respectively (p<.001).

CONCLUSIONS

Black and Hispanic children were much more likely than white children to be classified as discontinuing ADHD medication treatment, according to HEDIS. The differences predominantly occurred because youths from minority groups were more likely to experience multiple medication gaps, rather than complete discontinuation. Future studies should examine reasons for these multiple gaps to inform interventions to improve ADHD treatment continuity.

Proof-of-concept study of an at-home, engaging, digital intervention for pediatric ADHD

OBJECTIVE

Pharmacological and behavioral therapies have limited impact on the distinct neurocognitive impairments associated with ADHD, and existing cognitive training programs have shown limited efficacy. This proof-of-concept study assessed treatment acceptability and explored outcomes for a novel digital treatment targeting cognitive processes implicated in ADHD.

METHOD

Participants included 40 children with ADHD and 40 children without ADHD. Following psychiatric screening, ADHD ratings, and baseline neuropsychological measures, participants completed 28-days of at-home treatment. Neuropsychological assessment was repeated at end-of-study along with treatment satisfaction measures.

RESULTS

Eighty-four percent of treatment sessions were completed and ratings showed strong intervention appeal. Significant improvements were observed on a computerized attention task for the ADHD group and a highly impaired ADHD High Severity subgroup. There was no change for the non-ADHD group. Spatial working memory also improved for the ADHD group and the ADHD High Severity subgroup.

CONCLUSION

Findings provide preliminary support that this treatment may improve attention, working memory, and inhibition in children with ADHD. Future research requires larger-scale randomized controlled trials that also evaluate treatment impact on functional impairments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01943539.

Development of Guanfacine Extended-Release Dosing Strategies in Children and Adolescents with ADHD Using a Physiologically Based Pharmacokinetic Model to Predict Drug-Drug Interactions with Moderate CYP3A4 Inhibitors or Inducers

BACKGROUND

Guanfacine extended-release (GXR) is an orally administered, non-stimulant treatment for children and adolescents with attention-deficit/hyperactivity disorder (ADHD) and is primarily metabolized by the 3A4 isozyme of cytochrome P450 (CYP3A4). The results of clinical pharmacokinetic (PK) studies indicate that guanfacine is sensitive to drug-drug interactions (DDIs) perpetrated by strong inhibitors and inducers of CYP3A4.

OBJECTIVE

The aim was to provide guidance on the possible requirement for GXR dose adjustment in children and adolescents with ADHD by predicting DDIs following co-administration with moderate CYP3A4 inhibitors and inducers.

METHODS

A physiologically based PK model for GXR orally administered to healthy adults was developed based on physicochemical, in vitro and clinical PK data. The model was validated using clinical PK data for co-administration of GXR with ketoconazole (strong CYP3A4 inhibitor) or rifampicin (strong CYP3A4 inducer).

RESULTS

Model predictions indicated that co-administration of GXR with the moderate CYP3A4 inhibitors erythromycin 500 mg three times a day or fluconazole 200 mg daily (q.d.) increased the guanfacine area under the plasma concentration-time curve (AUC) by 2.31-fold or 1.98-fold, respectively, compared with GXR monotherapy. The moderate CYP3A4 inducer efavirenz 400 mg or 600 mg q.d. was predicted to reduce guanfacine AUC to 58 or 33% of its value for GXR monotherapy, respectively.

CONCLUSION

Without the requirement for additional clinical studies, the following GXR dose recommendations were developed and approved for US labeling for use in children and adolescents with ADHD: (1) decrease GXR to 50% of the usual target dose when it is co-administered with strong or moderate CYP3A4 inhibitors; (2) consider titrating GXR up to double the usual target dose over 1-2 weeks when it is co-administered with strong or moderate CYP3A4 inducers.

Methods to perform systematic reviews of patient preferences: a literature survey

BACKGROUND

Systematic reviews are a commonly used research design in the medical field to synthesize study findings. At present-although several systematic reviews of patient preference studies are published-there is no clear guidance available for researchers to conduct this type of systematic review. The aim of our study was to learn the most current practice of conducting these systematic reviews by conducting a survey of the literature regarding reviews of quantitative patient preference studies.

METHODS

Our survey included systematic reviews of studies that used a stated quantitative preference design to elicit patient preferences. We identified eligible reviews through a search of the PubMed database. Two investigators with knowledge of the design of patient preference studies independently screened the titles and abstracts, and where needed, screened the full-text of the reviews to determine eligibility. We developed and pilot-tested a form to extract data on the methods used in each systematic review.

RESULTS

Our search and screening identified 29 eligible reviews. A large proportion of the reviews (19/29, 66%) were published in 2014 or after; among them, nine reviews were published in 2016. The median number of databases searched for preference studies was four (interquartile range = 2 to 7). We found that less than half of the reviews (13/29, 45%) clearly reported assessing risk of bias or the methodological quality of the included preference studies; not a single review was able to perform quantitative synthesis (meta-analysis) of the data on patient preferences.

CONCLUSION

These results suggest that several methodological issues of performing systematic reviews of patient preferences are not yet fully addressed by research and that the methodology may require future development.

A Latent Class Analysis to Identify Variation in Caregivers' Preferences for their Child's Attention-Deficit/Hyperactivity Disorder Treatment: Do Stated Preferences Match Current Treatment?

OBJECTIVES

To investigate variation in caregiver preferences for their child's attention-deficit/hyperactivity disorder (ADHD) care and to determine if their stated preferences align with current care management.

METHODS

Caregivers of a child aged 4-14 years and in care for ADHD were recruited from pediatric outpatient clinics and advocacy groups across the state of Maryland. Participants completed a survey collecting demographics, the child's treatment, and caregiver preferences-elicited using a best-worst scaling experiment (case 2). Latent class analysis was used to identify distinct preference segments and bivariate analyses were used to compare the association between segment membership with what the child was currently receiving for their ADHD.

RESULTS

Participants (n = 184) were predominantly White (68%) and the child's mother (84%). Most children had ADHD for 2 or more years (79%). Caregiver preferences were distinguished by two segments: continuous medication (36%) and minimal medication (64%). The two groups had very different preferences for when medication was administered (p < 0.001), but they had similar preferences for provider-oriented and non-medication interventions (p > 0.05 for the caregiver behavior training, provider communication, provider specialty, and out-of-pocket costs). One third of the sample did not receive the preferred individualized education program and 42% of the minimal medication group reported using medication 7 days a week all year round.

CONCLUSIONS

Although behavior management training and school accommodations aspects of an ADHD care plan are more important to caregivers than evidence-based medication, fewer families had access to educational accommodations. Further research is needed to clarify how stated preferences for care align with treatments used in actual practice settings.

Caregiver Treatment Preferences for Children with a New Versus Existing Attention-Deficit/Hyperactivity Disorder Diagnosis

OBJECTIVES

Parental experiences with managing their child's attention-deficit/hyperactivity disorder (ADHD) can influence priorities for treatment. This study aimed to identify the ADHD management options caregivers most prefer and to determine if preferences differ by time since initial ADHD diagnosis.

METHODS

Primary caregivers (n = 184) of a child aged 4-14 years old in care for ADHD were recruited from January 2013 through March 2015 from community-based pediatric and mental health clinics and family support organizations across the state of Maryland. Participants completed a survey that included child/family demographics, child clinical treatment, and a Best-Worst Scaling (BWS) experiment to elicit ADHD management preferences. The BWS comprised 18 ADHD management profiles showing seven treatment attributes, where the best and worst attribute levels were selected from each profile. A conditional logit model using effect-coded variables was used to estimate preference weights stratified by time since ADHD diagnosis.

RESULTS

Participants were primarily the mother (84%) and had a college or postgraduate education (76%) with 75% of the children on stimulant medications. One-on-one caregiver behavior training, medication use seven days a week, therapy in a clinic, and an individualized education program were most preferred for managing ADHD. Aside from caregiver training and monthly out-of-pocket costs, caregivers of children diagnosed with ADHD for less than two years prioritized medication use lower than other care management attributes and caregivers of children diagnosed with ADHD for two or more years preferred school accommodations, medication, and provider specialty.

CONCLUSIONS

Preferences for ADHD treatment differ based on the duration of the child's ADHD. Acknowledging that preferences change over the course of care could facilitate patient/family-centered care planning across a range of resources and a multidisciplinary team of professionals.

Attribute Development Using Continuous Stakeholder Engagement to Prioritize Treatment Decisions: A Framework for Patient-Centered Research

OBJECTIVES

To develop a methodological approach for selecting, validating, and prioritizing attributes for health care decision making.

METHODS

Participants (n = 48) were recruited from community support groups if they had a child aged 26 years or younger diagnosed with a coexisting mental health condition and cognitive impairment. Six in-depth interviews eliciting care management experiences were transcribed and coded into themes following the principles of grounded theory and the constant comparative method. Six focus groups involving 42 participants assessed the relevance, priority, and meaning and inter-relationship among the themes. The positive predictive value and sensitivity assessed agreement on thematic meaning. A final list was selected from the top priorities with good agreement as candidate attributes. Attribute levels reflecting the range of experiences in care management decisions emerged from the verbatim passages within each coded theme.

RESULTS

Participants were the child's mother (73%), white (77%), married (69%), and on average 48 years old. The children were on average 14 years old; 44% had an intellectual disability, 25% had autism, and more than half had anxiety or attention-deficit/hyperactivity disorder. All 14 attributes identified from the in-depth interviews were deemed relevant. The positive predictive value exceeded 90%, and the sensitivity ranged from 64% to 89%. The final set of attributes formed the framework for care management decisions consisting of six attributes (medication, behavior, services, social, treatment effects, and school) each with three levels.

CONCLUSIONS

A systematic approach grounded in qualitative methods produced a framework of relevant, important, and actionable attributes representing competing alternatives in clinical decisions.

Using Best-Worst Scaling to Measure Caregiver Preferences for Managing their Child's ADHD: A Pilot Study

BACKGROUND

Management of attention-deficit/hyperactivity disorder (ADHD) is a trade-off between caregivers' concerns about the benefits versus the risks of evidence-based treatment. Few studies have used choice-based methods to assess what treatment attributes matter most to caregivers.

OBJECTIVE

The aim was to develop and to pilot an instrument to elicit caregivers' preferences for evidence-based management of their child's ADHD.

METHODS

Mixed methods were used to develop a Best-Worst Scaling (BWS) instrument, and quantitative methods were used to pilot the instrument. Primary caregivers of children with ADHD from two community organizations were recruited for the development (n = 21) and pilot (n = 37) phase. The instrument was a BWS case 2, where 18 management profiles are presented one at a time, with respondents indicating the one best and one worst feature of each profile. Profiles were developed using a main effects orthogonal array. The mean of best-minus-worse scores was estimated, and attribute importance was based on the sum of maximum minus minimum scores for each attribute. Feasibility of eliciting stated preferences was evaluated with t tests and 95 % confidence intervals.

RESULTS

Seven attributes (medication, therapy, school, caregiver training, provider specialty, provider communication, and out-of-pocket costs) with three levels each were identified. All mean scores were significant except for pediatrician management of the child's ADHD (p = 0.089). Caregiver training had the highest relative importance, followed by medication and provider communication.

CONCLUSIONS

The BWS instrument was a relatively simple measure, caregivers completed it independently, and it distinguished the relative importance of different attributes in managing a child's ADHD.