Efficacy of psychosocial interventions for children with ADHD and emotion dysregulation: a systematic review

Improving the efficacy and effectiveness of evidence-based psychosocial interventions for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and impairing mental health disorder of childhood. Decades of empirical research has established a strong evidence-based intervention armamentarium for ADHD; however, limitations exist in regards to efficacy and effectiveness of these interventions. We provide an overview of select evidence-based interventions for children and adolescents, highlighting potential approaches to further improving the efficacy and effectiveness of these interventions. We conclude with broader recommendations for interventions, including considerations to moderators and under-explored intervention target areas as well as avenues to improve access and availability of evidence-based interventions through leveraging underutilized workforces and leveraging technology.

Illuminating the daily life experiences of adolescents with and without ADHD: protocol for an ecological momentary assessment study

INTRODUCTION

Adolescents with attention-deficit/hyperactivity disorder (ADHD) are at elevated risk of a range of difficulties, among which emotion regulation, peer and co-occurring mental health problems are prominent challenges. To better support adolescents with ADHD, ecologically valid interventions that can be embedded in daily life to target the most proximal antecedents of these challenges are needed. Ecological momentary assessment (EMA) designs are ideally suited to meeting this need.

METHODS AND ANALYSES

In the mental health in the moment ADHD study, we will use an EMA design to capture the daily life experiences of approximately 120 adolescents aged 11-14 years with a clinical diagnosis of ADHD and the same number of age-matched and gender-matched peers without a diagnosis of ADHD. We will combine this with comprehensive information gathered from online surveys. Analysing the data using techniques such as dynamic structural equation modelling, we will examine, among other research questions, the role of emotion regulation and peer problems in mediating the links between characteristics of ADHD and commonly co-occurring outcomes such as anxiety, depression and conduct problems. The results can help inform interventions to support improved peer functioning and emotion regulation for adolescents with ADHD.

ETHICS AND DISSEMINATION

This study received a favourable ethical opinion through the National Health Service ethical review board and the University of Edinburgh PPLS Research Ethics panel. The results will be disseminated through journal publications, conferences and seminar presentations and to relevant stakeholders, such as those with ADHD, their families and clinicians.

The role of social adversity on emotional dysregulation during infancy and early childhood

PURPOSE

The purpose of this study was to investigate if social adversity is associated with mother reported emotional dysregulation behaviors and trajectories during infancy and early childhood.

DESIGN & METHODS

A secondary data analysis from the Durham Child Health and Development study study included 206 child-mother dyads. Three models were used to explore the relationship between social adversity and mother reported emotional dysregulation during infancy (Infant Behavior Questionnaire-Revised) and early childhood (Child Behavior Checklist - Dysregulation Profile). Linear mixed effects models were adopted to investigate if social adversity was associated with mother reported emotional dysregulation longitudinally. Regression analysis was conducted to explore if social adversity was associated with maternal reported emotional dysregulation trajectory slope scores and maternal reported emotional dysregulation trajectory class. Maternal psychological distress and the child's sex assigned at birth were included as covariates in each analysis.

RESULTS

Infants with greater social adversity scores had significantly higher maternal reported fear responses across the first year of life. Social adversity was associated with maternal reported distress to limitations trajectory, dysregulated recovery class, and dysregulated distress to limitations class. During early childhood social adversity was significantly associated with maternal reported emotional dysregulation but not trajectories which showed little variability.

CONCLUSION & PRACTICAL IMPLICATIONS

Our results indicate that social adversity is associated with maternal reported emotional dysregulation during infancy and early childhood. Nursing and other professionals can participate in early screening to determine risk and provide intervention.

Interventions for Young Children's Mental Health: A Review of Reviews

To determine the efficacy of intervention programs for young children (4-9 years) with emerging mental health needs, we conducted a review of meta-analytic and systematic reviews of the intervention literature. Of 41,061 abstracts identified and 15,076 screened, 152 review articles met the inclusion criteria. We reviewed interventions across multiple disciplines targeting: (1) general mental health concerns; (2) internalizing symptoms; (3) externalizing symptoms; (4) anxiety; (5) depression; (6) trauma; (7) symptoms of attention-deficit/hyperactivity disorder; and (8) mental health concerns associated with autism spectrum disorder. Substantial evidence was found for the efficacy of behavioral and cognitive behavioral interventions for general mental health concerns, externalizing symptoms (generally, as well as ADHD, conduct, and other behavioral symptoms) and internalizing symptoms (generally, as well as anxiety) aged 4-9 years. Emerging evidence was identified for interventions targeting trauma symptoms, depression symptoms, and social, emotional and behavioral symptoms in autism spectrum disorder in children aged 4-9 years. Currently there is only limited emerging evidence regarding non-behavioral or non-cognitive behavioral interventions for programs targeting children ages 4-9 years where the aim is to deliver an evidence-based program to improve child social, emotional and/or behavioral functioning. Given the recent rises in mental health needs reported in children, targeted behavioral-and/or cognitive behavior therapy-based interventions should be made widely available to children (and their families) who experience elevated symptoms.

How does therapist guided game-based intervention program effect motor skills in children with Attention Deficit Hyperactivity Disorder?: Single blind randomised study design

BACKGROUND

Virtual reality and game-based approaches to the rehabilitation process also brought an opportunity to design more accessible intervention programs.It was seen that many studies utilized trademarked and commercially available games, which were not originally designed as rehabilitation tools but were administrated by a rehabilitation professional to achieve the maximum therapeutic value.

AIMS

Study aims to investigate the effects of a Self-oriented game based program(SGBP)and Therapist Guided Game-based Intervention Program(TGGIP) on the motor skills of children with Attention Deficit Hyperactivity Disorder(ADHD).

METHODS AND PROCEDURES

This study was designed as a single-blind, randomized, controlled trial. A total of 176 children with ADHD participated in the study and were randomly divided into two groups (TGGIP and SGBP). Intervention in both groups was done with a telerehabilitation methodology.

OUTCOMES AND RESULTS

According to the within-group comparisons of pre- and post-intervention BOT2-BF scores, there were significant increases in all sub-scores and the total score(p < 0.05). The comparison of the BOT2-BF all sub-scores and the total score changes between the groups showed significantly higher in TGGIP.

CONCLUSION AND IMPLICATIONS

TGGIP was found to be more effective compared to SGBP in improving motor skills of children with ADHD.TGGIP that we designed acts as a facilitator for therapists in using trademarked and easily accessible games for structured and supervised virtual reality and game-based rehabilitation.

Reward modality modulates striatal responses to reward anticipation in ADHD: Effects of affiliative and food stimuli

Altered reward sensitivity has been proposed to underlie symptoms of attention deficit hyperactivity disorder (ADHD). Functional magnetic resonance imaging (fMRI) studies have reported hypoactivation to reward-predicting cues in the ventral striatum among individuals with ADHD, using experimental designs with and without behavioral response requirements. These studies have typically used monetary incentives as rewards; however, it is unclear if these findings extend to other reward types. The current study examined striatal responses to anticipation and delivery of both affiliative and food reward images using a classical conditioning paradigm. Data from 20 typically developing young adults, and 20 individuals diagnosed with ADHD were included in a region-of-interest analysis for a priori striatal regions. Consistent with findings from studies using monetary rewards, individuals with ADHD showed decreased activation to cues predicting affiliative rewards in the bilateral ventral and dorsal striatum and increased activation to the delivery of affiliative rewards in the ventral striatum. No group differences were found in striatal responses to food reward cues or images. These results suggest hyposensitivity to reward-predicting cues in ADHD extends to affiliative rewards, with important implications for understanding and managing the learning and social functioning of those with ADHD.

Differential diagnoses of irritability and temper loss in a 6-year-old

Irritability and temper loss are common concerns among young children seen for mental health diagnostic evaluations and represent features of nearly a dozen childhood mental health conditions. Thus, careful assessment of irritability and temper loss is essential for informing case conceptualization, diagnosis, and treatment recommendations. The current case study provides a clinical description of a 6-year-old Black male ("Tyler") seen in a tertiary pediatric medical center for concerns related to significant inattention, hyperactivity, impulsivity, oppositional behaviors, irritability, and severe temper loss displayed at home and school. The clinical description summarizes findings from rating scales and diagnostic evaluations, case conceptualization, as well as treatment recommendations. Detailed suggestions for clinicians regarding strategies for assessing irritability and temper loss and questions to consider when seeking clarification to inform differential diagnoses are provided.

Evaluation of a scalable online videogame-based biofeedback program to improve emotion regulation: A descriptive study assessing parent perspectives

Individuals and families increasingly turn to e-mental health apps for education, diagnosis, and treatment of mental health disorders and to promote mental wellness. These apps provide significant increases in convenience from existing services, since they can augment or replace services with on-demand access within the home. This raises important questions about self-selection of interventions. Who uses these applications? How do individuals perceive their own progress within applications? This study is a retrospective data analysis-based evaluation of a commercially available e-mental health program that includes biofeedback video games that help children build emotion regulation skills by demonstrating and prompting children to practice bodily focused emotion regulation techniques. The e-mental health program also provided parent psychoeducation-focused coaching at the time of the evaluation. Data collection instruments used to inform the retrospective study included parent intake surveys, gameplay engagement data, and notes from parent coaching calls. The evaluation revealed families presenting for common symptoms associated with emotion regulation deficits, as opposed to a wellness cohort looking for additional support. Families near-universally activated and engaged with the intervention, willing to carry out an extended "dose" of the e-mental health program in their home. Parents self-reported their perceptions of their children's emotion regulation progress, primarily in terms of children's increased use of emotion regulation skills, improved emotion awareness and communication, calmer demeanor, greater confidence, and improved relationships. More work is needed to understand the corresponding clinical progress from this in-home training, as well as its implications for how emotion regulation skills grow.

Management of Emotion Dysregulation and Outbursts in Children and Adolescents

PURPOSE OF REVIEW

Emotion dysregulation and outbursts are very common reasons for referral to child and adolescent mental health services and a frequent cause of admission to hospitals and residential programs. Symptoms of emotion dysregulation and outburst are transdiagnostic, associated with many disorders, have the potential to cause severe impairment and their management presents a major challenge in clinical practice.

RECENT FINDINGS

There are an increasing number of psychosocial interventions that demonstrate promise in improving emotion dysregulation and outbursts. Acute care systems to manage the most severely ill patients have limited best practice guidelines but program advancements indicate opportunities to improve care models. Pharmacotherapy may be of assistance to psychosocial interventions but must be used with caution due to potential adverse effects. Much remains to be discovered however evidence informed, targeted treatments for specific populations show potential for future improvements in outcomes.

Regulating Together: Emotion Dysregulation Group Treatment for ASD Youth and Their Caregivers

Individuals with autism spectrum disorder (ASD) experience behavioral and emotional symptoms hypothesized to arise from emotion dysregulation (ED), difficulty modulating emotional experience, expression, and intensity in an acceptable and contextually appropriate manner. We developed Regulating Together (RT)-an intensive-outpatient, caregiver-assisted group program to meet the ASD + ED intervention critical need. A within-subjects trial was conducted (5-week-control lead-in period, 5-week-treatment, and 5-and 10-weeks-post-treatment follow-ups). Forty-four youth with ASD + ED (25 8-12, 19 13-18 yr-olds, 88% male, mean FSIQ of 96) participated. Improvements were found in reactivity, emotion regulation knowledge, and flexibility post-treatment and 10-weeks post-treatment. A reduction in inpatient hospitalization rates by 16% from the 12 months pre-RT to 12 months post-RT was observed. RT shows promise to reduce ED in ASD.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

A review of Cochrane reviews on pharmacological treatment for attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is one of the most frequent childhood psychiatric problems.

Objective

The objective of this study was to identify, synthesize the results, and critically evaluate all Cochrane systematic reviews (SRs) on the pharmacological interventions for children and adolescents (up to age 18) diagnosed with ADHD.

Methods

The search was performed in the Cochrane Database of Systematic Reviews (via Wiley) in July 2020.

Results

The search strategy resulted in four SRs of high methodological quality, analyzing 51 randomized clinical trials (9,013 participants). Compared to placebo, treatment with tricyclic antidepressants (TCAs) (desipramine), amphetamine, and methylphenidate showed improvement in symptoms such as difficulty concentrating, impulsivity, and hyperactivity in the short term (up to 6 months). There was an increase in the occurrence of adverse events, such as reduced appetite, difficulty sleeping, and abdominal pain. Insufficient evidence was found to support the effects of supplementation with polyunsaturated fatty acids.

Conclusions

The use of TCAs, amphetamine, and methylphenidate in children and adolescents with ADHD seems to present positive effects and higher rates of minor adverse events when compared to placebo.

Emotional Dysregulation in Children and Adolescents With Psychiatric Disorders. A Narrative Review

Background: Emotional dysregulation (ED) is a transdiagnostic construct defined as the inability to regulate the intensity and quality of emotions (such as, fear, anger, sadness), in order to generate an appropriate emotional response, to handle excitability, mood instability, and emotional overreactivity, and to come down to an emotional baseline. Because ED has not been defined as a clinical entity, and because ED plays a major role in child and adolescent psychopathology, we decided to summarize current knowledge on this topic based on a narrative review of the current literature. Methods: This narrative review is based on a literature search of peer-reviewed journals. We searched the databases ERIC, PsycARTICLES, PsycINFO and PSYNDEX on June 2, 2020 for peer reviewed articles published between 2000 and 2020 in English language for the preschool, school, and adolescent age (2-17 years) using the following search terms: "emotional dysregulation" OR "affect dysregulation," retrieving 943 articles. Results: The results of the literature search are presented in the following sections: the relationship between ED and psychiatric disorders (ADHD, Mood Disorders, Psychological Trauma, Posttraumatic Stress Disorder, Non-suicidal Self-Injury, Eating Disorders, Oppositional Defiant Disorder, Conduct Disorder, Disruptive Disruptive Mood Dysregulation Disorder, Personality Disorders, Substance Use Disorder, Developmental Disorders, Autism Spectrum Disorder, Psychosis and Schizophrenia, and Gaming Disorder), prevention, and treatment of ED. Conclusion: Basic conditions of ED are genetic disposition, the experience of trauma, especially sexual or physical abuse, emotional neglect in childhood or adolescence, and personal stress. ED is a complex construct and a comprehensive concept, aggravating a number of various mental disorders. Differential treatment is mandatory for individual and social functioning.