Das ADHS-Summercamp – Entwicklung und Evaluation eines multimodalen Programms

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015.

OBJECTIVES

To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate.

SELECTION CRITERIA

We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non-serious, general behaviour, and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel-group trials and first-period data from cross-over trials formed the basis of our primary analyses. We undertook separate analyses using end-of-last period data from cross-over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach.

MAIN RESULTS

We included 212 trials (16,302 participants randomised); 55 parallel-group trials (8104 participants randomised), and 156 cross-over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross-over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male-female ratio was 3:1. Most trials were carried out in high-income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias.

PRIMARY OUTCOMES

methylphenidate versus placebo or no intervention may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -0.88 to -0.61; I² = 38%; 21 trials; 1728 participants; very low-certainty evidence). This corresponds to a mean difference (MD) of -10.58 (95% CI -12.58 to -8.72) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD-RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68).

SECONDARY OUTCOMES

methylphenidate may cause more adverse events considered non-serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher-rated general behaviour versus placebo (SMD -0.62, 95% CI -0.91 to -0.33; I² = 68%; 7 trials 792 participants; very low-certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI -0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The majority of our conclusions from the 2015 version of this review still apply. Our updated meta-analyses suggest that methylphenidate versus placebo or no-intervention may improve teacher-rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non-serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non-serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes.

Auch Du Hast Sommerferien

Zusammenfassung. Das Sommertherapiecamp (STC) ist ein multimodaler kognitiv-verhaltenstherapeutischer Intensivbehandlungsansatz für die Aufmerksamkeitsdefizit-/ Hyperaktivitätsstörung (ADHS). Der Artikel berichtet über Befunde einer Wirksamkeitsstudie für das STC mit Prä-Post-Design und Kontrollgruppenvergleich. Die Eltern von N = 31 Kindern (7 – 11 Jahre) mit einer ADHS-Diagnose füllten vor und nach dem dreiwöchigen STC folgende Symptom-Fragebögen aus: CBCL/4 – 18, DISYPS-II FBB-ADHS und FBB-SSV. N = 13 weitere Kinder der gleichen Grundgesamtheit, die in der selben Zeit unbehandelt blieben oder „treatment as usual“ erhielten, dienten als Kontrollgruppe. Die STC-Gruppe zeigte eine Verbesserung der ADHS-Symptomatik sowie eine Reduktion weiterer Verhaltensauffälligkeiten, während vergleichbare Effekte für die Kontrollgruppe nicht nachweisbar waren. Angesichts kleiner Stichproben sind diese Befunde vorerst vorsichtig zu interpretieren, liefern jedoch erste ermutigende Hinweise auf die Brauchbarkeit des STC.

Gruppentherapie

Zusammenfassung. Gruppentherapie-Angebote bilden ein stark vernachlässigtes Thema im Rahmen der Versorgung psychisch erkrankter Kinder und Jugendlicher. Solche Angebote sollten nicht nur für die Förderung sozialer Kompetenzen, sondern bei Aufmerksamkeits- und Motivationsproblemen, einem auffälligen Arbeitsverhalten oder posttraumatischen Belastungsstörungen verfügbar sein und genutzt werden. Von großer Bedeutung ist auch, das entsprechende Format der Gruppenbehandlung für die einzelnen Anforderungen zu spezifizieren. Aktuell reichen die Angebote von der gruppentherapeutischen Intensivtherapie, der Kombination von Einzel- und Gruppentherapie, Summer-Camp-Maßnahmen, Eltern-Kind-Gruppen oder das parallele Angebot von Gruppen für Kinder und Eltern. Generell sind Gruppentherapie-Angebote einer Einzeltherapie in ihrer Wirksamkeit nicht unterlegen und Vorgehensweisen mit einem noch nicht hinreichend genutztem Potenzial.

Peer Inclusion in Interventions for Children with ADHD: A Systematic Review and Meta-Analysis

Objective

To assess the effectiveness of peer inclusion in interventions to improve the social functioning of children with ADHD.

Methods

We searched four electronic databases for randomized controlled trials and controlled quasi-experimental studies that investigated peer inclusion interventions alone or combined with pharmacological treatment. Data were collected from the included studies and methodologically assessed. Meta-analyses were conducted using a random-effects model.

Results

Seventeen studies met eligibility criteria. Studies investigated interventions consisting of peer involvement and peer proximity; no study included peer mediation. Most included studies had an unclear or high risk of bias regarding inadequate reporting of randomization, blinding, and control for confounders. Meta-analyses indicated improvements in pre-post measures of social functioning for participants in peer-inclusive treatment groups. Peer inclusion was advantageous compared to treatment as usual. The benefits of peer inclusion over other therapies or medication only could not be determined. Using parents as raters for outcome measurement significantly mediated the intervention effect.

Conclusions

The evidence to support or contest the efficacy of peer inclusion interventions for children with ADHD is lacking. Future studies need to reduce risks of bias, use appropriate sample sizes, and provide detailed results to investigate the efficacy of peer inclusion interventions for children with ADHD.

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children with ADHD find it difficult to pay attention, they are hyperactive and impulsive.Methylphenidate is the drug most often prescribed to treat children and adolescents with ADHD but, despite its widespread use, this is the first comprehensive systematic review of its benefits and harms.

OBJECTIVES

To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD.

SEARCH METHODS

In February 2015 we searched six databases (CENTRAL, Ovid MEDLINE, EMBASE, CINAHL, PsycINFO, Conference Proceedings Citations Index), and two trials registers. We checked for additional trials in the reference lists of relevant reviews and included trials. We contacted the pharmaceutical companies that manufacture methylphenidate to request published and unpublished data.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. At least 75% of participants needed to have an intellectual quotient of at least 70 (i.e. normal intellectual functioning). Outcomes assessed included ADHD symptoms, serious adverse events, non-serious adverse events, general behaviour and quality of life.

DATA COLLECTION AND ANALYSIS

Seventeen review authors participated in data extraction and risk of bias assessment, and two review authors independently performed all tasks. We used standard methodological procedures expected within Cochrane. Data from parallel-group trials and first period data from cross-over trials formed the basis of our primary analyses; separate analyses were undertaken using post-cross-over data from cross-over trials. We used Trial Sequential Analyses to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach for high risk of bias, imprecision, indirectness, heterogeneity and publication bias.

MAIN RESULTS

The studies.We included 38 parallel-group trials (5111 participants randomised) and 147 cross-over trials (7134 participants randomised). Participants included individuals of both sexes, at a boys-to-girls ratio of 5:1, and participants' ages ranged from 3 to 18 years across most studies (in two studies ages ranged from 3 to 21 years). The average age across all studies was 9.7 years. Most participants were from high-income countries.The duration of methylphenidate treatment ranged from 1 to 425 days, with an average duration of 75 days. Methylphenidate was compared to placebo (175 trials) or no intervention (10 trials). Risk of Bias.All 185 trials were assessed to be at high risk of bias. Primary outcomes. Methylphenidate may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.77, 95% confidence interval (CI) -0.90 to -0.64; 19 trials, 1698 participants; very low-quality evidence). This corresponds to a mean difference (MD) of -9.6 points (95% CI -13.75 to -6.38) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points; DuPaul 1991a). A change of 6.6 points on the ADHD-RS is considered clinically to represent the minimal relevant difference. There was no evidence that methylphenidate was associated with an increase in serious (e.g. life threatening) adverse events (risk ratio (RR) 0.98, 95% CI 0.44 to 2.22; 9 trials, 1532 participants; very low-quality evidence). The Trial Sequential Analysis-adjusted intervention effect was RR 0.91 (CI 0.02 to 33.2).

SECONDARY OUTCOMES

Among those prescribed methylphenidate, 526 per 1000 (range 448 to 615) experienced non-serious adverse events, compared with 408 per 1000 in the control group. This equates to a 29% increase in the overall risk of any non-serious adverse events (RR 1.29, 95% CI 1.10 to 1.51; 21 trials, 3132 participants; very low-quality evidence). The Trial Sequential Analysis-adjusted intervention effect was RR 1.29 (CI 1.06 to 1.56). The most common non-serious adverse events were sleep problems and decreased appetite. Children in the methylphenidate group were at 60% greater risk for trouble sleeping/sleep problems (RR 1.60, 95% CI 1.15 to 2.23; 13 trials, 2416 participants), and 266% greater risk for decreased appetite (RR 3.66, 95% CI 2.56 to 5.23; 16 trials, 2962 participants) than children in the control group.Teacher-rated general behaviour seemed to improve with methylphenidate (SMD -0.87, 95% CI -1.04 to -0.71; 5 trials, 668 participants; very low-quality evidence).A change of seven points on the Child Health Questionnaire (CHQ; range 0 to 100 points; Landgraf 1998) has been deemed a minimal clinically relevant difference. The change reported in a meta-analysis of three trials corresponds to a MD of 8.0 points (95% CI 5.49 to 10.46) on the CHQ, which suggests that methylphenidate may improve parent-reported quality of life (SMD 0.61, 95% CI 0.42 to 0.80; 3 trials, 514 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

The results of meta-analyses suggest that methylphenidate may improve teacher-reported ADHD symptoms, teacher-reported general behaviour, and parent-reported quality of life among children and adolescents diagnosed with ADHD. However, the low quality of the underpinning evidence means that we cannot be certain of the magnitude of the effects. Within the short follow-up periods typical of the included trials, there is some evidence that methylphenidate is associated with increased risk of non-serious adverse events, such as sleep problems and decreased appetite, but no evidence that it increases risk of serious adverse events.Better designed trials are needed to assess the benefits of methylphenidate. Given the frequency of non-serious adverse events associated with methylphenidate, the particular difficulties for blinding of participants and outcome assessors point to the advantage of large, 'nocebo tablet' controlled trials. These use a placebo-like substance that causes adverse events in the control arm that are comparable to those associated with methylphenidate. However, for ethical reasons, such trials should first be conducted with adults, who can give their informed consent.Future trials should publish depersonalised individual participant data and report all outcomes, including adverse events. This will enable researchers conducting systematic reviews to assess differences between intervention effects according to age, sex, comorbidity, type of ADHD and dose. Finally, the findings highlight the urgent need for large RCTs of non-pharmacological treatments.

[Evaluation of the Musical Concentration Training with Pepe (MusiKo mit Pepe) for children with attention deficits]

OBJECTIVE

This study evaluates the Musical Concentration Training with Pepe ("MusiKo mit Pepe") for children aged 5 to 10 years with attention deficits.

METHOD

Using a pre-post-control design (N = 108), changes in attention capacity are measured by the Test of Attentional Performance for Children (KiTAP), whereas changes in the quality of life are assessed with the Children's Questionnaire (KINDL-R). Additionally, we utilized the Symptom Checklist for Attention Deficit Hyperactivity Disorders (FBB-ADHS) and for Conduct Disorder (FBB-SSV) of the Diagnostic System of Mental Disorders in Children and Adolescents II based on ICD-10 and DSM-IV as well as the Child Behavior Checklist and the Teacher's Report Form (CBCL, TRF).

RESULTS

Significant pre-post effects were found in both attention and quality of life for children treated by the training compared to controls. Moreover, significant reductions were detected in ADHD symptomatology in parents' and teachers' ratings, and in internal problems in parents' ratings. The effectiveness of the intervention was not affected by age, sex, intelligence, or migration background.

CONCLUSION

The music-based training "MusiKo mit Pepe" is an effective intervention for children with attention deficits, pending replication of these findings in future studies.

Behavioral interventions in attention-deficit/hyperactivity disorder: a meta-analysis of randomized controlled trials across multiple outcome domains

OBJECTIVE

Behavioral interventions are recommended as attention-deficit/hyperactivity disorder (ADHD) treatments. However, a recent meta-analysis found no effects on core ADHD symptoms when raters were probably blind to treatment allocation. The present analysis is extended to a broader range of child and parent outcomes.

METHOD

A systematic search in PubMed, Ovid, Web of Knowledge, ERIC, and CINAHAL databases (up to February 5, 2013) identified published randomized controlled trials measuring a range of patient and parent outcomes for children and adolescents diagnosed with ADHD (or who met validated cutoffs on rating scales).

RESULTS

Thirty-two of 2,057 nonduplicate screened records were analyzed. For assessments made by individuals closest to the treatment setting (usually unblinded), there were significant improvements in parenting quality (standardized mean difference [SMD] for positive parenting 0.68; SMD for negative parenting 0.57), parenting self-concept (SMD 0.37), and child ADHD (SMD 0.35), conduct problems (SMD 0.26), social skills (SMD 0.47), and academic performance (SMD 0.28). With probably blinded assessments, significant effects persisted for parenting (SMD for positive parenting 0.63; SMD for negative parenting 0.43) and conduct problems (SMD 0.31).

CONCLUSION

In contrast to the lack of blinded evidence of ADHD symptom decrease, behavioral interventions have positive effects on a range of other outcomes when used with patients with ADHD. There is blinded evidence that they improve parenting and decrease childhood conduct problems. These effects also may feed through into a more positive parenting self-concept but not improved parent mental well-being.

[ADHD and conduct disorder: trends in diagnosis and therapy]

Since 2010 trends outlined in diagnosis and therapy in the German speaking countries in the area of externalizing disorders (ADHD, conduct disorder) are presented. In particular, publications of children and adolescent psychiatry and clinical psychology have been examined. It turns out that in the German-speaking countries, the concern with conduct disorder (including psychopathy) increased compared with the discussion of the significance of ADHD. This development reflects the important therapeutic challenge of conduct disorders.

[ADHD across the lifespan - an update on research and practice]

ADHD can be regarded as a lifespan disorder. From biopsychosocial vantage point, ADHD leads to age-specific impairments, high psychological distress and is associated with a high occurrence of comorbid disorders. For this review, we summarize actual findings from epidemiological, neuroscientific and clinical studies to present an overview of ADHD-research. We discuss the proposed revisions for DSM-V criteria by comparing them with the present DSM-IV-TR criteria, with a focus on the implications for research and practice. In the second part of this paper, we present new findings from socioeconomic, diagnostic and therapeutic perspectives. There is evidence for a high economic burden that is indirectly caused by ADHD (e.g., production loss, material costs, higher accident rates). Consequently, there is a high demand for comprehensive diagnostic and therapeutic approaches. We present a summary of the latest available diagnostic instruments and therapeutic manuals. The results of research and practice show a growing support for a lifespan perspective on ADHD psychopathology. The burdens resulting from ADHD are evident in all age groups, which has led to establishing age-specific diagnostic and therapeutic materials. Although there is a lack in ADHD-specific healthcare in adulthood, this should be realized by structural changes in healthcare services.

Das ADHS-Camp

Die Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) ist eine der am häufigsten gestellten Diagnosen im Bereich der Kinder- und Jugendlichenpsychotherapie. Verschiedene Studien belegen die Wirksamkeit multimodaler Maßnahmen und verweisen dabei auf die Bedeutung der Verhaltenstherapie, deren Wirksamkeit bereits in verschiedenen Studien belegt wurde. Da sich viele Therapieangebote über einen langen Zeitraum erstrecken, wurde das ADHS-Camp als zeitökonomisches, intensivtherapeutisches Vorgehen entwickelt und dessen Wirksamkeit im Rahmen dieser Studie auf Langzeiteffekte (6 und 12 Monate nach Abschluss der Therapie) überprüft. Dies geschah unter Einbezug funktionsorientierter (neuropsychologischer) und verhaltensorientierter Testverfahren, wobei letztere von Eltern und Lehrern beurteilt wurden. Über die Berechnung von MAN(C)OVAS mit Messwiederholung zeigte sich, dass das ADHS-Camp zu einer signifikanten Verbesserung sowohl auf funktioneller als auch verhaltensorientierter Ebene führt. Auf der Verhaltensebene sehen Eltern einen stärkeren Einfluss als die Lehrer. Um zu gewährleisten, dass die Effekte nicht durch normale Reifungsprozesse beeinflusst sind, wurde das Alter als Kovariate aufgenommen. Es zeigt sich, dass das ADHS-Camp als eine wirkungsvolle Maßnahme bewertet werden kann. Erzielte Verbesserungen der Problemlage sind sowohl auf der funktionellen als auch der Verhaltensebene zeitstabil. Dies unterstreicht die Relevanz intensivtherapeutischer Maßnahmen zur Behandlung von ADHS bei Kindern.

Intensivtherapie

Vor allem für prognostisch ungünstige Störungen (ADHS, Autismus-Spektrum-Störung, Störung des Sozialverhaltens), aber auch für die Angststörungen im Kindes- und Jugendalter liegen intensivtherapeutische Ansätze vor. Diese verhaltenstherapeutischen Ansätze versuchen in den letzten Jahren in sehr unterschiedlicher Weise (z. B. intensive Frühförderung, Summer-Camp-Ansätze, intensive Einzeltherapie) neue Wege zu gehen. Vielfach liegen erste Erfahrungen auf der Ebene von Einzelfällen oder erste Berichte zur prinzipiellen Machbarkeit einen solchen Ansatzes vor. Vor allem bei der Behandlung der Autismus-Spektrum-Störung existieren bereits umfassende Wirksamkeitsstudien.

Störungen des Sozialverhaltens

In der Behandlung von Störungen des Sozialverhaltens haben sich insbesondere multimodale Programme als effektiv erwiesen. Diese Studie verfolgt das Ziel, die Wirksamkeit des multimodalen verhaltenstherapeutischen Intensivprogramms VIA in einem Wartegruppen-Design hinsichtlich spezifischer Effektivitätsmaße, aber auch hinsichtlich globaler Maße wie elterlicher Erziehungskompetenz, Lebensqualität und komorbide Verhaltensauffälligkeiten zu untersuchen. Da eine Reihe von Studien zeigt, dass sich insbesondere die Subgruppe der Patienten, die sich durch eine mangelnde emotionale und psychophysiologische Ansprechbarkeit kennzeichnen lassen, weniger von therapeutischen Interventionen profitieren, wurde zusätzlich der Frage nachgegangen, inwieweit kalt-unemotionale Persönlichkeitseigenschaften und die Cortisolreaktivität prädiktiv für einen positiven Verlauf sind. Die Ergebnisse dieser Studie weisen auf eine signifikante Reduktion spezifischer Symptome von Störungen des Sozialverhaltens in der Interventionsgruppe hin. Hinsichtlich globaler Maße der Therapiewirksamkeit konnte gezeigt werden, dass nach der VIA-Intervention mehr positive Erziehungsstrategien eingesetzt wurden, jedoch konnte keine Verbesserung der Lebensqualität nachgewiesen werden. Zusätzlich konnte in einer logistischen Regression gezeigt werden, dass sich Patienten mit einem positiven Verlauf–definiert bei einer 25 %igen Symptomreduktion–durch geringe kalt-unemotionale Persönlichkeitseigenschaften und eine hohe Cortisolreaktivität kennzeichnen lassen. Die Ergebnisse bestätigen, dass VIA ein effektiver Behandlungsansatz für Patienten mit Störungen des Sozialverhaltens darstellt. Jedoch sind für Patienten mit hohen kalt-unemotionalen Persönlichkeitseigenschaften zusätzliche therapeutische Interventionen, deren Fokus auf einer Förderung empathischen Verstehens und an einer Steigerung der emotionalen Ansprechbarkeit ansetzen, notwendig.

Behavioural treatment increases activity in the cognitive neuronal networks in children with attention deficit/hyperactivity disorder

Response cost and token approach (RCT) within the scope of a summer camp training is an effective treatment program for attention deficit hyperactivity disorder (ADHD). It is likely that intensive RCT training influences networks responsible for ADHD symptoms. Functional magnetic resonance imaging (fMRI) was carried out in 12 children with ADHD before and after the RCT program and in 12 healthy control children twice. For fMRI, a Go/No-go paradigm was used to investigate the influence of RCT training on attention and impulsivity. The No-go condition revealed only weak activation in the dorsal part of the anterior cingulate cortex (ACC), parietal and dorsolateral prefrontal cortex (DLPFC) before the training in children with ADHD compared to healthy children. However, this activation in these brain regions was significantly more pronounced after the training. This increase in hemodynamic response cannot be attributed merely to repetition of the measurement since the effect was not observed in healthy children. The increase in hemodynamic response in the ACC and right DLPFC was significantly associated with a reduction in response time variability and clinical symptoms in ADHD patients. After the RCT training, the children with ADHD demonstrated more pronounced activation of cortical structures which are typically related to response monitoring and self-control. It seems likely that children with ADHD learned more cognitive control in a continuous performance task as was revealed by both neuropsychological outcome and fMRI.

Long-term Effects of a Multimodal Behavioural ADHD Training: a fMRI Study

Several studies have demonstrated that behavioural therapy oriented interventions exert a positive influence on the clinical course of the attention-deficit hyperactivity disorder (ADHD). However, the long-term effects of the behavioral treatment in ADHD, especially those on neuronal mechanisms underlying this disorder, have been studied insufficiently. Functional MRI (Go-NoGo paradigm) was carried out in 9 children with ADHD before and 1.5 years after a response cost and token-based training. In the follow-up, patients were still characterized by a significant increase in activation in the anterior cingulate and in the precentral gyrus compared with recordings done before the training. It seems likely that the behavioural training elicits stable neuronal changes in children with ADHD which correspond with an improvement of neuropsychological functioning and clinical symptoms.

[ADHD and conduct disorders - trends in the German-speaking countries]

Since 2009 trends in research and practice have been described for externalising disorders (ADHD and conduct disorders) in the German-speaking countries. In particular, publications of children and adolescent psychiatry and clinical child psychology have been examined and scientific contributions from the 32nd Congress of the German Society for Child and Adolescent Psychiatry have been included. In the German-speaking countries studies regarding conduct disorders (including bullying and psychopathy) have noticeably increased in complexity and differentiation and caught up with the extensive discussion about ADHD.

Was wissen wir über Langzeiteffekte von Methylphenidatbehandlung auf die Hirnentwicklung von Kindern und Jugendlichen mit einer Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS)?

Obwohl Psychostimulanzien zu den Behandlungsmethoden der ersten Wahl bei Kindern mit einer Aufmerksamkeitsdefizit/-Hyperaktivitätsstörung (ADHS) im Kindes- und Jugendalter gehören, sind mögliche Langzeitfolgen einer Stimulanzientherapie noch nicht ausreichend erforscht. Während eine kurzzeitige positive Wirkung von Stimulanzien auf Aufmerksamkeitsleistungen als gesichert gilt, sind die langfristigen Auswirkungen insbesondere einer Medikation in der frühen Kindheit sowie einer Dauermedikation noch weitestgehend unbekannt. Verschiedene Studien ergaben Hinweise auf einen Einfluss einer Dauermedikation mit Stimulanzien sowohl auf die strukturelle als auch auf funktionelle Hirnentwicklung. Des Weiteren sollten mögliche unerwünschte kognitive und motivationale Nebenwirkungen einer Medikation mit Methylphenidat genauer in Betracht gezogen werden. Insgesamt zeigt sich die Datenlage heterogen und es mangelt an Studien mit ausreichend großen Fallzahlen.

Editorial

Das heutige Wissen um die adulte Neurogenese verdeutlicht, dass eine Wechselwirkung biologischer und umweltbezogener Faktoren lebenslang zu strukturellen Veränderungen führen kann. Dies erschwert die Suche nach eindeutigen Ursache-Wirkungsprinzipien. Hinzu kommt, dass für viele psychische Störungen ein hohes Maß an Heterogenität vorliegt und für diverse Subtypen auch unterschiedliche Ursachen/Folgen anzunehmen sind. Neuropsychologische Befunde erweitern unsere Krankheitsmodelle bei der Betrachtung biopsychosozialer Risiko- und Schutzfaktoren.

Wirksamkeit verhaltenstherapeutischer Maßnahmen auf die Aufmerksamkeits- und Exekutiv- funktionen bei Kindern und Jugendlichen mit ADHS

Die Studie beschäftigt sich mit der Frage, ob und inwieweit lernpsychologische Techniken die Exekutivfunktionen bei Kindern und Jugendlichen mit ADHS innerhalb eines multimodalen Therapieprogramms günstig beeinflussen können. 45 Kinder und Jugendliche mit ADHS nahmen an einem zweiwöchigen ADHS-Summercamp teil, in dem ein stringentes Response-Cost-Token-Vorgehen (RCT) sowie ein gezieltes Aufmerksamkeitstraining eingesetzt wurden. In einem Prä-Post-Design wurden die Aufmerksamkeits- und Exekutivfunktionen der Kinder mit Hilfe der Testbatterie zur Aufmerksamkeitsprüfung (TAP) und des Trail-Making-Tests (TMT) erfasst. Sechs Wochen nach dem Training ließen sich signifikante neuropsychologische Leistungsverbesserungen bezüglich der Aufmerksamkeitsregulation und der Inhibitionskontrolle feststellen. Da jegliche Medikation vor Beginn der Maßnahme und somit auch zur Testung abgesetzt wurde, lassen sich die Effekte vorwiegend auf das RCT und das Aufmerksamkeitstraining zurückführen. Die Studie zeigt erneut, dass der Einsatz spezifischer lernpsychologischer Techniken die neuropsychologischen Funktionen von Kindern mit ADHS verbessern kann.

Zur Komorbidität von aggressivem Verhalten und ADHS

Bei Kindern und Jugendlichen treten aggressives Verhalten und ADHS häufig gemeinsam auf und führen vielfach zu erheblichen psychosozialen Belastungen. Durch eine Metaanalyse wird eine verlässliche Maßzahl zum komorbiden Auftreten von ADHS und aggressivem Verhalten bestimmt. Anhand der Datenbanken PsycINFO und Pubmed wurden Studien identifiziert, die neben den relevanten Suchbegriffen ausgewählte Einschlusskriterien erfüllten, unter anderem „Allgemeinbevölkerung“ und „strukturierte Interviewverfahren“. In die Berechnung gingen acht epidemiologische Studien ein (N = 29980). Die metaanalytische Betrachtung bestätigt die hohe Komorbidität von ADHS und aggressivem Verhalten mit einem mittleren Odds Ratio von 21. Dieses Ergebnis wird für die Ätiologie und den Krankheitsverlauf diskutiert. Relevante Schlussfolgerungen für Diagnostik und Therapie werden aufgezeigt.

Evidenzbasierte psychotherapeutische Interventionen für Kinder und Jugendliche mit aggressivem Verhalten

Bei der Behandlung von Kindern und Jugendlichen mit aggressivem Verhalten ist in den vergangenen Jahren vor allem im englischsprachigen Ausland ein Trend zum Einsatz evidenzbasierter psychotherapeutischer Interventionen zu verzeichnen. In diesem Beitrag werden–getrennt für Kindes- und Jugendalter–die am besten evaluierten Therapieprogramme (u. a. Multisystemic Therapy, Functional Family Therapy, The Incredible Years) für diese Indikation dargestellt. Es werden aktuelle Fragen der Implementation und Disseminierung evidenzbasierter Interventionen für aggressive Kinder und Jugendliche diskutiert (z. B. Qualitätssicherung, Therapietreue). Abschließend werden Perspektiven für eine Implementation evidenzbasierter Interventionen in Deutschland aufgezeigt.

Früh beginnende bipolare Störungen, ADHS oder Störung der Affektregulation?

Die Arbeit gibt einen Überblick über die Hintergründe der Kontroverse und leitet daraus konkrete Schlussfolgerungen für die klinische Praxis ab. Bei der Diagnostik früher bipolarer Störungen ist vorrangig auf das Auftreten von abgrenzbaren Episoden mit eindeutigen Stimmungsänderungen und Veränderungen von Verhalten und Kognition zu achten. Das Mischbild aus ADHS und begleitender affektiver Dysregulation sollte nicht im Sinne einer beginnenden bipolaren Störung interpretiert werden, bedarf aber stärkerer Beachtung, insbesondere bei der Entwicklung geeigneter psycho- und pharmakotherapeutischer Ansätze. Erläutert werden zudem Gemeinsamkeiten und Unterschiede von bipolaren Störungen mit Schizophrenie, Depression, ADHS, Borderline-Persönlichkeitsstörung und Substanzmissbrauch.

MIPAS-Family-evaluation of a new multi-modal behavioral training program for pediatric headaches: clinical effects and the impact on quality of life

Several meta-analyses have demonstrated that the combination of electrical muscle activity and Temperature Biofeedback could be regarded as gold standard in chronic pediatric headaches. However, these techniques seem to be uneconomical and furthermore they are not directed to improve the social competence as well as resolve possible impairments in daily activities of the child. Therefore, multi-modal behavioral techniques have been proposed, but no studies comparing these with the gold standard were conducted. The present study compared the impact of a new multi-modal behavioral education and training program--MIPAS-Family--with a combined Biofeedback treatment, evaluating clinical efficacy as well as the effect on the quality of life (QoL) of children with chronic headaches. Thirty-four children and adolescents with recurrent headache, ranging from 7 to 16 years, were randomly assigned to the MIPAS-Family (N = 19) or the Biofeedback (N = 15) condition. All patients were diagnosed by the criteria of the International Headache Society. The children and their parents completed headache diaries, diaries of daily living activities and a QoL questionnaire (KINDL). Both groups showed significant improvements concerning the headache intensity and headache duration. We found no significant differences in the main headache parameters between both treatments. After the treatments, the children were less disturbed by their headaches in the domains school, homework, and leisure time. In conclusion, MIPAS-Family is as effective as Biofeedback but it is more cost-effective and addresses the whole family and the daily activities.

Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS)

Bei ADHS liegt eine lebenslange psychische Erkrankung vor, die durch multimodale Vorgehensweisen erfolgreich zu behandeln ist. Entwicklungs- und neuropsychologische Grundlagen besitzen vor allem im Bereich der Ursachendiskussion und psychologischen Diagnostik eine große Bedeutung.