Acceptability of behavioral and pharmacological treatments for attention-deficit/hyperactivity disorder: relations to child and parent characteristics

Parent preferences for adolescent depression treatment: The role of past treatment experience and biological etiological beliefs

BACKGROUND

Parents play a crucial role in facilitating depression treatment for adolescents, yet parental preferences for adolescent treatments are ill-understood. Past treatment experience and belief in a biological model of depression may impact preferences, and warrant investigation.

METHODS

Parents (N = 143) of teens (12-18 years) completed a survey assessing preference for adolescent depression treatments, treatment knowledge, and beliefs about the biological etiology of depression. Details about parents' and adolescents' past mental health concerns and treatment were obtained. Parents indicated degree of preference from 0 (Not at all preferable) - 10 (Highly preferable) for six treatment options (counselling, antidepressant medication, repetitive transcranial magnetic stimulation, electroconvulsive therapy, exercise, no treatment) for three adolescents vignettes depicting varying depression severity (Mild/Moderate, Severe, and Treatment-Resistant).

RESULTS

Mean preference ratings across all vignette severities were high for counselling (range: 8.57-9.38) and exercise (range: 9.04-9.25). Multiple regression revealed parental past experience of psychopharmacological treatment was significantly associated with current preference for adolescent antidepressant medication, with increased helpfulness and milder/fewer adverse events associated with stronger preference. Greater perceived helpfulness of past teen psychopharmacological treatment was significantly associated with greater current parental preference for adolescent antidepressant medication. Strength of biological beliefs and counselling preference were significantly positively associated.

LIMITATIONS

Sample was highly educated, predominately female, and majority treatment-utilizing limiting the generalizability of findings.

CONCLUSIONS

Parents' own past medication experiences and degree of biological etiological beliefs appear to be associated with current teen depression treatment preferences. Counselling and exercise were highly preferred across depression severity.

Changing Parental Knowledge and Treatment Acceptance for ADHD: A Pilot Study

This pilot study assessed the feasibility and potential effectiveness of a single-session workshop in modifying parental beliefs/knowledge about attention-deficit/hyperactivity disorder (ADHD) in children and impact on treatment acceptance/utilization. Concerns raised by school professionals about lack of treatment follow-through after ADHD diagnosis and parental misinformation about medication usage catalyzed this project. A single-group pre-post quasi-experimental design was used. Sixty-eight parents completed ADHD knowledge/belief scales and stress inventories, and pre-ADHD and post-ADHD information workshop. Follow-up calls were made after the workshop to assess treatment utilization. Parents/caregivers experienced significant knowledge and belief changes regarding medication efficacy, willingness to accept physician treatment recommendations, and rejection of non-empirically based treatments. Follow-up data showed that 41% of contacted participants met with physicians to discuss medication utilization and behavioral treatments. Brief, one-session psycho-educational workshops were feasible and impacted parental beliefs and behaviors regarding scientifically supported interventions for ADHD.

Deciphering Diversity of Mental Models in Neurodevelopmental Disorders: Knowledge Graph Representation of Public Data Using Natural Language Processing (Preprint)

Background

Understanding how individuals think about a topic, known as the mental model, can significantly improve communication, especially in the medical domain where emotions and implications are high. Neurodevelopmental disorders (NDDs) represent a group of diagnoses, affecting up to 18% of the global population, involving differences in the development of cognitive or social functions. In this study, we focus on 2 NDDs, attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), which involve multiple symptoms and interventions requiring interactions between 2 important stakeholders: parents and health professionals. There is a gap in our understanding of differences between mental models for each stakeholder, making communication between stakeholders more difficult than it could be.

Objective

We aim to build knowledge graphs (KGs) from web-based information relevant to each stakeholder as proxies of mental models. These KGs will accelerate the identification of shared and divergent concerns between stakeholders. The developed KGs can help improve knowledge mobilization, communication, and care for individuals with ADHD and ASD.

Methods

We created 2 data sets by collecting the posts from web-based forums and PubMed abstracts related to ADHD and ASD. We utilized the Unified Medical Language System (UMLS) to detect biomedical concepts and applied Positive Pointwise Mutual Information followed by truncated Singular Value Decomposition to obtain corpus-based concept embeddings for each data set. Each data set is represented as a KG using a property graph model. Semantic relatedness between concepts is calculated to rank the relation strength of concepts and stored in the KG as relation weights. UMLS disorder-relevant semantic types are used to provide additional categorical information about each concept’s domain.

Results

The developed KGs contain concepts from both data sets, with node sizes representing the co-occurrence frequency of concepts and edge sizes representing relevance between concepts. ADHD- and ASD-related concepts from different semantic types shows diverse areas of concerns and complex needs of the conditions. KG identifies converging and diverging concepts between health professionals literature (PubMed) and parental concerns (web-based forums), which may correspond to the differences between mental models for each stakeholder.

Conclusions

We show for the first time that generating KGs from web-based data can capture the complex needs of families dealing with ADHD or ASD. Moreover, we showed points of convergence between families and health professionals’ KGs. Natural language processing–based KG provides access to a large sample size, which is often a limiting factor for traditional in-person mental model mapping. Our work offers a high throughput access to mental model maps, which could be used for further in-person validation, knowledge mobilization projects, and basis for communication about potential blind spots from stakeholders in interactions about NDDs. Future research will be needed to identify how concepts could interact together differently for each stakeholder.

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.

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

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

Parent and Youth Preferences in the Treatment of Youth Depression

Patient-centered care requires providing care that is responsive to patient preferences, needs, and values, yet data on parent and youth treatment preferences remains sparse. The present study (1) identifies variations in parent and youth preferences for depression treatment, and (2) explores relationships between parent and youth demographics and psychosocial functioning, and the preferences that parents and youth endorse. Participants were 64 youth and 63 parents awaiting randomization in a clinical trial evaluating psychosocial youth depression treatments. Parents preferred treatments that emphasize learning skills and strategies (82.5%) and include the parent in treatment at least some of the time (96.8%). Youth preferred that the therapist meet mostly with the youth alone (67.2%) but share at least some information with parents (78.1%). Youth (43.8%) tended to respond "don't know" to questions about their preferred therapeutic approach. Understanding parent and youth preferences, especially psychosocial treatment preferences, is needed to provide high-quality, patient-centered care.

Factors Associated with Parental Treatment Attitudes and Information-Seeking Behaviors for Childhood ADHD

Objective: Despite the association between childhood ADHD and long-term negative outcomes, there is a significant delay to treatment and a low rate of lifetime treatment contact for individuals with ADHD. Method: The current study examined (a) variables associated with parental treatment-seeking attitudes and information-seeking behaviors and (b) the relationship between these attitudes and behaviors in 87 non-treatment-seeking parents whose children had elevated ADHD symptoms. Results: Regressions indicated that attitudes toward ADHD treatment were associated with ADHD knowledge and misconceptions (ps < .01), susceptibility to ADHD stigma (p < .001), and satisfaction with past providers (ps < .01). Experience with past providers was significantly associated with information-seeking behavior (ps < .01). Conclusion: Parental knowledge of ADHD, low levels of stigma, and positive experiences with past providers were the strongest predictors of positive attitudes about ADHD treatment. Experience with past providers was the only factor related to treatment-seeking behavior. These results offer avenues to decreasing barriers to treatment in pediatric ADHD.

How to Improve Behavioral Parent and Teacher Training for Children with ADHD: Integrating Empirical Research on Learning and Motivation into Treatment

Attention deficit hyperactivity disorder [ADHD] is one of the most common psychiatric disorders of childhood with poor prognosis if not treated effectively. Recommended psychosocial evidence-based treatment for preschool and school-aged children is behavioral parent and teacher training [BPT]. The core elements of BPT are instrumental learning principles, i.e., reinforcement of adaptive and the ignoring or punishment of non-adaptive behaviors together with stimulus control techniques. BPT is moderately effective in reducing oppositional behavior and improving parenting practices; however, it does not reduce blinded ratings of ADHD symptoms. Also after training effects dissipate. This practitioner review proposes steps that can be taken to improve BPT outcomes for ADHD, based on purported causal processes underlying ADHD. The focus is on altered motivational processes (reward and punishment sensitivity), as they closely link to the instrumental processes used in BPT. Following a critical analysis of current behavioral treatments for ADHD, we selectively review motivational reinforcement-based theories of ADHD, including the empirical evidence for the behavioral predictions arising from these theories. This includes consideration of children's emotional reactions to expected and unexpected outcomes. Next we translate this evidence into potential ADHD-specific adjustments designed to enhance the immediate and long-term effectiveness of BPT programs in addressing the needs of children with ADHD. This includes the use of remediation strategies for proposed deficits in learning not commonly used in BPT programs and cautions regarding the use of punishment. Finally, we address how these recommendations can be effectively transferred to clinical practice.

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

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

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.

Perceptions of ADHD Among Diagnosed Children and Their Parents: A Systematic Review Using the Common-Sense Model of Illness Representations

Research on children and parents' experiences of ADHD has grown in recent years, attracting attention to their subjective perception of ADHD as a disorder. Theoretical accounts of illness perception suggest that it is multi-dimensional, consisting of at least five core constructs (see the common-sense model of illness representations or CSM: Leventhal et al., in: Rachman (ed) Medical psychology, Pergamon, New York, vol 2, pp 7-30, 1980, in: Baum, Taylor, Singer (eds) Handbook of psychology and health: social psychological aspects of health, Earlbaum, Hillsdale, vol 4, pp 219-252, 1984). We suggest that the application of CSM in children/adolescents with ADHD and their parents may play an important role in understanding their coping behavior, treatment adherence, and emotional well-being. A systematic search identified 101 eligible studies that investigated the perception of ADHD among diagnosed children/adolescents and their parents. In general, these studies support the existence of the multiple facets of illness representations proposed by the CSM in both diagnosed youngsters and parents indicating substantial variability among both parents and youngsters on each of these facets. The comprehensive assessment of the representations of ADHD indicates imbalance attention to the different representations of ADHD in the literature; disproportional research attention has been paid to the perceived effectiveness of treatment (i.e., treatment control dimension) compared to other illness representations (e.g., timeline, consequence, and coherence), despite research showing their relevance to treatment adherence among other implications. The review identifies the limitation of existing relevant research, needed foci for future studies, specific testable hypotheses, and potential clinical implications of the multifaceted representations of ADHD among youngsters and carers alike.

Shared Decision-Making in Youth Mental Health Care: Using the Evidence to Plan Treatments Collaboratively

The shared decision-making (SDM) model is one in which providers and consumers of health care come together as collaborators in determining the course of care. The model is especially relevant to youth mental health care, when planning a treatment frequently entails coordinating both youth and parent perspectives, preferences, and goals. The present article first provides the historical context of the SDM model and the rationale for increasing our field's use of SDM when planning psychosocial treatments for youth and families. Having established the potential utility of SDM, the article then discusses how to apply the SDM model to treatment planning for youth psychotherapy, proposing a set of steps consistent with the model and considerations when conducting SDM with youth and families.

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.

Factors Associated With Parental Consent to use D-Cycloserine for Child Anxiety

This study examined factors influencing parent willingness to use D-Cycloserine (DCS) for treating child anxiety. N = 222 parents were given information about using DCS to treat anxiety. They were then asked to rate their willingness to allow their child to take DCS/antibiotics for mild anxiety, severe anxiety, or an infection. The associations between willingness to use DCS and parental trait anxiety, demographics, as well as specific concerns regarding the medication, were examined. Parents could also provide written responses regarding their attitudes to DCS, which were analysed for themes. Parents reported concerns regarding potential side-effects from DCS. More severe anxiety was associated with more willingness to consent; however, parents were more willing to use antibiotics to treat an infection than DCS to treat their child's anxiety. The degree of perceived benefit from DCS was most strongly associated with parents’ willingness to use it. Overall, parents expressed mixed views, reporting they would consider using DCS to treat their child; however, they had significant concerns about it. Results suggest providing parents with information explaining how DCS works, its risks and potential benefits may increase its acceptability.

Pilot Evaluation of the Medication Integration Protocol for Adolescents with ADHD in Behavioral Care: Treatment Fidelity and Medication Uptake

Although Attention-Deficit/Hyperactivity Disorder (ADHD) is prevalent among adolescents in outpatient behavioral care, one of the few evidence-based treatment options, stimulant medication, is significantly underutilized. The Medication Integration Protocol (MIP) is a family-based intervention designed to help behavior therapists assume a lead role in educating clients about ADHD in adolescents, promoting family-centered decisions about medication initiation, and integrating medication management activities within behavioral treatment planning. This pilot study evaluated treatment fidelity and medication utilization for inner-city teens receiving MIP (n = 14) compared to a matched Historical Control (HC) group (n = 21) in a community clinic. Observational analyses revealed that in comparison to HC, MIP demonstrated basic protocol fidelity with regard to adherence to the MIP protocol, therapeutic alliance with the adolescent, and clinical focus on ADHD in session. MIP showed greater psychiatric evaluation completion and ADHD medication initiation than HC. Next steps in the ongoing development of MIP are outlined.

Feasibility of School-Based ADHD Interventions: A Mixed-Methods Study of Perceptions of Adolescents and Adults

OBJECTIVE

Little is known about perceptions surrounding academic interventions for ADHD that determine intervention feasibility.

METHOD

As part of a longitudinal mixed-methods research project, representative school district samples of 148 adolescents (54.8%), 161 parents (59.4%), 122 teachers (50.0%), 46 health care providers (53.5%), and 92 school health professionals (65.7%) completed a cross-sectional survey. They also answered open-ended questions addressing undesirable intervention effects, which were analyzed using grounded theory methods.

RESULTS

Adolescents expressed significantly lower receptivity toward academic interventions than adult respondents. Stigma emerged as a significant threat to ADHD intervention feasibility, as did perceptions that individualized interventions foster inequality.

CONCLUSION

Findings suggest that adolescents' viewpoints must be included in intervention development to enhance feasibility and avoid interventions acceptable to adults, but resisted by adolescents.

Changing Academic Support in the Home for Adolescents with Attention-Deficit/Hyperactivity Disorder: A Family-Based Clinical Protocol for Improving School Performance

Attention-Deficit/Hyperactivity Disorder (ADHD) is highly prevalent among adolescent clinical populations and associated with myriad deficits in school functioning. Yet, behavior therapists have few developmentally appropriate tools for addressing school problems in this group. This article introduces a behavioral protocol designed to fill the gap: Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA). CASH-AA is a family-based intervention that targets home environment, adolescent skills, and family-school partnership characteristics in order to improve school performance. Protocol components are derived from three evidence-based approaches for adolescent behavior problems: family psychoeducation, clinical family interventions to heighten adolescent and caregiver motivation to change, and training interventions for homework planning and organization skills. CASH-AA contains four treatment modules: (1) Psychoeducation: ADHD and Academic Functioning; (2) Motivation & Preparation: Home Academic Environment; (3) Behavior Change: School Attendance and Homework Plan; (4) Collaboration: Therapist-Family-School Partnership. The protocol can be implemented as a stand-alone intervention for ADHD or an adjunct to other behavioral interventions for co-occurring disorders. Two case examples with markedly different treatment profiles are presented to illustrate the utility and flexibility of the protocol.

Consumer evaluation and satisfaction with individual versus group parent training for children with hyperkinetic disorder (HKD)

OBJECTIVES

The objective of this study was to investigate the social validity of cognitive-behavioural parent training (CBPT) delivered in two formats to parents who have children with hyperkinetic disorder (HKD) with and without medication.

DESIGN

Compared individual with group treatment as part of a multicentre randomized controlled trial.

METHOD

Obtained a broad range of evaluations and satisfaction ratings post-treatment and related them to pre-treatment and treatment factors.

RESULTS

Attendance rates were high in the individual and slightly less in the group training. Levels of satisfaction were high in both treatment arms with large numbers rating the outcomes, the trainers and the overall training very favourably. Medication showed no effect on parental evaluations. Evaluation of outcomes and satisfaction with the trainer emerged as strong predictors of overall programme satisfaction.

CONCLUSION

The social validity of cognitive-behavioural parent training for hyperkinetic children was supported by high levels of treatment acceptability across a range of indicators and for children with and without medication.

PRACTITIONER POINTS

Both forms of treatment delivery lead to high rates of consumer satisfaction. Consumer evaluations of CBPT appear independent of medication for HKD. Course satisfaction is clearly associated with two factors that trainers can affect: The parent-trainer relationship and parents' sense of achievement.

LIMITATIONS INCLUDE THE FOLLOWING

Far more mothers than fathers attended the trainings. Attitudes may differ in other cultures.

Child impairment and parenting self-efficacy in relation to mothers' views of ADHD treatments

OBJECTIVE

This study assessed the relations of child impairment and parenting self-efficacy with parental views of the acceptability and effectiveness of behavioral, medication, and combined treatments for child ADHD. Child impairment and parenting self-efficacy were also assessed in relation to the effectiveness views of specific behavioral treatment strategies.

METHOD

Ninety-five mothers of children with ADHD completed questionnaires assessing child impairment, parenting self-efficacy, perceptions of the overall acceptability and effectiveness of ADHD treatments, and views of the effectiveness of specific behavioral treatment strategies.

RESULTS

Hierarchical linear modeling using child impairment and parenting self-efficacy as predictors of treatment views suggests that mothers viewed combined treatments as most acceptable and effective when their child was more impaired, and mothers with higher parenting self-efficacy rated behavioral treatment strategies as more effective.

CONCLUSION

Child impairment and parenting self-efficacy are related to perceptions of the acceptability and/or effectiveness of ADHD treatments.

Factors influencing parental decision making about stimulant treatment for attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a pediatric psychological condition commonly treated with stimulant medications. Negative media reports and stigmatizing societal attitudes surrounding the use of these medications make it difficult for parents of affected children to accept stimulant treatment, despite it being first line therapy.

OBJECTIVE

The purpose of this study was to identify factors that influence parental decision making regarding stimulant treatment for ADHD.

METHODS

A systematic review of the literature was conducted to identify studies: 1) that employed qualitative methodology, 2) that highlighted treatment decision(s) about stimulant medication, 3) in which the decision(s) were made by the parent of a child with an official ADHD diagnosis, and 4) that examined the factors affecting the decision(s) made. Individual factors influencing parental treatment decision making, and the major themes encompassing these factors, were identified and followed by a thematic analysis.

RESULTS

Eleven studies reporting on the experiences of 335 parents of children with ADHD were included. Four major themes encompassing influences on parents' decisions were derived from the thematic analysis performed: confronting the diagnosis, external influences, apprehension regarding therapy, and experience with the healthcare system.

CONCLUSIONS

The findings of this systematic review reveal that there are multiple factors that influence parents' decisions about stimulant therapy. This information can assist clinicians in enhancing information delivery to parents of children with ADHD, and help reduce parental ambivalence surrounding stimulant medication use. Future work needs to address parental concerns about stimulants, and increase their involvement in shared decision making with clinicians to empower them to make the most appropriate treatment decision for their child.

Enhancing ADHD medication adherence: challenges and opportunities

Safe and effective medication for attention deficit hyperactivity disorder (ADHD) is available and recommended as first-line treatment for the core symptoms of inattention, overactivity and impulsiveness. Despite impaired functioning during adolescence, many discontinue medication treatment. For children, healthcare decisions are usually made by the parent; older youth make their own decisions. Beliefs and attitudes may differ widely. Some families understand that ADHD is a neurobiological condition and accept that medication is indicated, for others, such treatment is unacceptable. Converging evidence describes negative perceptions of the burden associated with medication use as well as concerns about potential short and long term adverse effects. Indeed experiences of adverse effects are a frequent explanation for discontinuation among youth. Ways to improve shared decision making among practitioners, parents and youth, and to monitor effectiveness, safety and new onset of concurrent difficulties are likely to optimize outcomes.

How parents make decisions to use medication to treat their child's ADHD: a grounded theory study

BACKGROUND

Despite evidence of efficacy, a substantial percentage of children with attention deficit hyperactivity disorder (ADHD) either do not begin medication prescribed for their core symptoms or fail to continue treatment.

OBJECTIVE

The purpose of this study was to understand (a) how parents decide to use medication to treat their child's ADHD and (b) the factors that influence their adherence to medication over time.

DESIGN

Grounded theory guided data collection and analysis. Sixteen semistructured interviews with parents (13 mothers, 3 fathers) of children with ADHD were conducted.

RESULTS

The substantive theory developed from the data demonstrates that in seeking to help their child and restore a sense of stability around family life, parents engage in a process of "doing what helps most" in deciding to use medication to treat their child's ADHD.

CONCLUSIONS

Interventions to support and guide parents throughout the decisional process are critical to meet the needs of families of children with ADHD.

Training cognition in ADHD: current findings, borrowed concepts, and future directions

With both its high prevalence and myriad of negative outcomes, Attention-Deficit/Hyperactivity Disorder (ADHD) demands a careful consideration of the efficacy of its treatment options. Although the benefits of medication have a robust empirical background, nonpharmaceutical interventions evoke particular interest, as they are often viewed more favorably by parents. This review pays special attention to the use of working memory and recent cognitive training attempts in ADHD, describing its cognitive, behavioral, and biological effects in relation to current neurological theory of the disorder. While these treatments have demonstrated positive effects on some measures, there are limitations, as studies have failed to demonstrate generalization to critical measures, such as teacher-rated classroom behaviors, and have provided limited but growing evidence of functionally significant improvements in behavior. There is also a clear lack of research on the effects of training on reward systems and self-control. These limitations may be addressed by broadening the scope and procedures of the training and incorporating research concepts from other fields of study. First, it is important to consider the developmental trajectories of brain regions in individuals with the disorder, as they may relate to the effectiveness of cognitive training. Notions from behavioral economics, including delay discounting and framing (i.e., context) manipulations that influence present orientation, also have applications in the study of cognitive training in ADHD. In considering these other domains, we may find new ways to conceptualize and enhance cognitive training in ADHD and, in turn, address current limitations of interventions that fall in this category.

Parent perspectives on the decision to initiate medication treatment of attention-deficit/hyperactivity disorder

OBJECTIVES

Despite substantial evidence supporting the efficacy of stimulant medication for children with attention-deficit/hyperactivity disorder (ADHD), adherence to stimulant treatment is often suboptimal. Applying social/cognitive theories to understanding and assessing parent attitudes toward initiating medication may provide insight into factors influencing parent decisions to follow ADHD treatment recommendations. This report describes results from formative research that used focus groups to obtain parent input to guide development of a provider-delivered intervention to improve adherence to stimulants.

METHODS

Participants were caregivers of children with ADHD who were given a stimulant treatment recommendation. Focus groups were recorded and transcribed verbatim. Data were analyzed by inductive, grounded theory methods as well as a deductive analytic strategy using an adapted version of the Unified Theory of Behavior Change to organize and understand parent accounts.

RESULTS

Five groups were conducted with 27 parents (mean child age=9.35 years; standard deviation [SD]=2.00), mean time since diagnosis=3.33 years (SD=2.47). Most parents (81.5%) had pursued stimulant treatment. Inductive analysis revealed 17 attitudes facilitating adherence and 25 barriers. Facilitators included parent beliefs that medication treatment resulted in multiple functional gains and that treatment was imperative for their children's safety. Barriers included fears of personality changes and medication side effects. Complex patterns of parent adherence to medication regimens were also identified, as well as preferences for psychiatrists who were diagnostically expert, gave psychoeducation using multiple modalities, and used a chronic illness metaphor to explain ADHD. Theory-based analyses revealed conflicting expectancies about treatment risks and benefits, significant family pressures to avoid medication, guilt and concern that their children required medication, and distorted ideas about treatment risks. Parents, however, took pride in successfully pursuing efforts to manage their child behaviorally and to avoid medication when possible.

CONCLUSIONS

Focus group data identified social, cognitive, and affective influences on treatment decision making. Results support prior research comparing family/social functioning, physician characteristics, and adherence. Findings suggest that parent attitudes to psychiatric care need to be assessed comprehensively at initial evaluation to aid the development of psychoeducational messages, and a more careful consideration about how parents interpret and respond to adherence-related questioning.

Willingness to use ADHD treatments: a mixed methods study of perceptions by adolescents, parents, health professionals and teachers

Little is known about factors that influence willingness to engage in treatment for attention deficit/hyperactivity disorder (ADHD). From 2007 to 2008, in the context of a longitudinal study assessing ADHD detection and service use in the United States, we simultaneously elicited ADHD treatment perceptions from four stakeholder groups: adolescents, parents, health care professionals and teachers. We assessed their willingness to use ADHD interventions and views of potential undesirable effects of two pharmacological (short- and long-acting ADHD medications) and three psychosocial (ADHD education, behavior therapy, and counseling) treatments. In multiple regression analysis, willingness was found to be significantly related to respondent type (lower for adolescents than adults), feeling knowledgeable, and considering treatments acceptable and helpful, but not significantly associated with stigma/embarrassment, respondent race, gender and socioeconomic status. Because conceptual models of undesirable effects are underdeveloped, we used grounded theory method to analyze open-ended survey responses to the question: "What other undesirable effects are you concerned about?" We identified general negative treatment perceptions (dislike, burden, perceived ineffectiveness) and specific undesirable effect expectations (physiological and psychological side effects, stigma and future dependence on drugs or therapies) for pharmacological and psychosocial treatments. In summary, findings indicate significant discrepancies between teens' and adults' willingness to use common ADHD interventions, with low teen willingness for any treatments. Results highlight the need to develop better treatment engagement practices for adolescents with ADHD.

A discrete choice conjoint experiment to evaluate parent preferences for treatment of young, medication naive children with ADHD

The current study examined treatment preferences of 183 parents of young (average age = 5.8 years, SD = 0.6), medication naive children with ADHD. Preferences were evaluated using a discrete choice experiment in which parents made choices between different combinations of treatment characteristics, outcomes, and costs. Latent class analysis yielded two segments of parents: (a) medication avoidant parents constituted 70.5% of the sample whose treatment decisions were strongly influenced by a desire to avoid medication, and (b) outcome oriented parents constituted 29.5% of the sample whose treatment decisions were most influenced by a desire for positive treatment outcomes. Parents in the outcome oriented segment were more stressed and depressed, had lower socioeconomic status and education, were more likely to be single parents, and had more disruptive and impaired children. Simulations predicted that parents would prefer treatments with behavior therapy over treatments with stimulant medication only.

Medication refusal in children with oppositional defiant disorder or conduct disorder and comorbid attention-deficit/hyperactivity disorder: medication history and clinical correlates

Abstract Objective: This study examines the characteristics of 96 children with attention-deficit/hyperactivity disorder (ADHD) and their families who refused a recommendation for medication as part of their treatment for disruptive disorders.

METHODS

The ADHD cases were taken from a sample of 139 youth (age 6-11) who were recruited for a clinical trial that compared the administration of a modular psychosocial treatment in an outpatient clinic or community settings. Medication management was an optional treatment module for children with ADHD in both conditions. Children who were (vs. were not) taking medication at intake, and children who accepted (vs. refused) medication recommendations during the study were compared on diagnostic and clinical measures related to child, school, parent, and family domains of functioning.

RESULTS

Parents of 30% of the children refused study medication for ADHD. Parental medication acceptability and intake correlated highly with both medication history and study refusal of medication. Increased parental self-efficacy and emotional support for their youth correlated with medication refusal. No demographics and few child or school factors were associated with medication refusal. Medication use was associated with reductions in some key ADHD symptoms, but did not affect disruptive behaviors as did the psychosocial interventions.

CONCLUSION

Medication refusers remain poorly understood but certain correlates, such as parental self-efficacy, parental emotional support for their youth, and medication acceptability, warrant further evaluation.

Treatment planning for children with attention-deficit/hyperactivity disorder: treatment utilization and family preferences

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common condition that often results in child and family functional impairments. Although there are evidence-based treatment modalities available, implementation of and persistence with treatment plans vary with patients. Family preferences also vary and may contribute to variability in treatment utilization.

OBJECTIVE

The objective of this study is to describe the evidence-based treatments available for ADHD, identify patterns of use for each modality, and examine patient and parent treatment preferences.

METHOD

Literature review.

RESULTS

Treatment options differ on benefits and risks/costs. Therefore, treatment decisions are preference sensitive and depend on how an informed patient/parent values the tradeoffs between options. Literature on patient and parent ADHD treatment preferences is based on quantitative research assessing the construct of treatment acceptability and qualitative and quantitative research that assesses preferences from a broader perspective. After a child is diagnosed with ADHD, a variety of factors influence the initial selection of treatment modalities that are utilized. Initial parent and child preferences are shaped by their beliefs about the nature of the child's problems and by information (and misinformation) received from a variety of sources, including social networks, the media, and health care providers. Subsequently, preferences become further informed by personal experience with various treatment modalities. Over time, treatment plans are revisited and revised as families work with their health care team to establish a treatment plan that helps their child achieve goals while minimizing harms and costs.

CONCLUSIONS

Studies have not been able to determine the extent to which utilization rates are consistent with the underlying distribution of informed patient/parent treatment preferences. There are challenges to ensure that patient/parent preferences are consistently well informed, elicited, and discussed in the treatment planning process. Interventions are needed to promote such interactions.

Parenting cognitions and treatment beliefs as predictors of experience using behavioral parenting strategies in families of children with attention-deficit/hyperactivity disorder

We tested a model of mothers' parenting efficacy and attributions for child ADHD behaviors as predictors of experiences with behavioral treatment. The model proposed that mothers' beliefs regarding the acceptability and effectiveness of behavioral strategies would intervene between mothers' cognitions about parenting and child behavior and their treatment experiences. Participants were 101 mothers of 5- to 10-year-old children (82% male) with ADHD. Mothers reported their parenting efficacy and attributions for child behavior, and then received a single session of treatment teaching 2 behavior management strategies. Then, mothers reported their beliefs regarding the acceptability and effectiveness of these strategies. A follow-up phone interview 1 week later assessed mothers' experiences in using the behavioral strategies. The overall model fit the data. Attributions of child ADHD behavior as more pervasive, enduring, and within the child's control were related to seeing behavioral treatment as more acceptable, but neither attributions nor treatment acceptability predicted treatment experience. However, mothers with higher parenting efficacy viewed the behavioral strategies as more likely to be effective, and this pathway significantly predicted positive treatment experience. Implications for understanding the variables that contribute to parental decision-making and treatment participation for childhood ADHD are considered.

Parental angst making and revisiting decisions about treatment of attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral conditions of childhood and adolescence. Despite availability of effective treatment options, initiation of treatment is variable and persistence with therapeutic regimens is poor.

OBJECTIVE

We sought to better understand how parents make decisions about treatment for their child or adolescent with ADHD.

METHODS

We conducted a qualitative study among parents of children and adolescents; 52 parents participated in 1 of 12 focus groups. Parents answered questions about decision-making, information sharing, and sources of conflict and uncertainty. Sessions were audiotaped and transcribed verbatim. Themes were coded independently by 4 of the investigators, who then agreed on common themes.

RESULTS

Parents in our study made decisions about treatment for their child with ADHD in the midst of experiencing a variety of emotions as they witnessed child functional impairments at home and at school. In addition, parents felt stress as a result of their daily efforts to manage their child's struggles. Multiple factors influenced the decision to initiate medication. Subsequently, revisiting the decision to give their child medicine for ADHD was common. Many parents contrasted time on and off medicine to help inform management decisions. Trials stopping medication were almost always parent- or child-initiated.

CONCLUSIONS

Decisions about medication use for children and adolescents with ADHD are made and frequently revisited by their parents. Choices are often made under stressful conditions and influenced by a variety of factors. Striking a balance between benefits and concerns is an ongoing process that is often informed by contrasting time on and off medication. Development of strategies to support families across the continuum of decisions faced while managing ADHD is warranted.

Improving psychostimulant adherence in children with ADHD

Attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder of childhood, characterized by excessive inattention, hyperactivity and impulsivity. Effective medication exists for the condition, yet suboptimal long-term effects persist for children with ADHD. Poor adherence is a common issue for individuals with chronic conditions, including children and those with psychiatric conditions, and ADHD is no exception. This review examines the available evidence regarding patterns of long-term use of stimulant medication and the predictors of medication discontinuation among children with ADHD, and suggests future clinical and research directions for improving adherence in children with ADHD.