A two-site randomized clinical trial of integrated psychosocial treatment for ADHD-inattentive type

The Emotional Impact of Family Involvement during Homework in Children with Neurodevelopmental Disorders: A Systematic Review

Neurodevelopmental disorders can be studied from two distinct perspectives: an internal approach, which examines the causes and consequences of these disorders; and a contextual approach, which considers the role of the family in the lives of children and adolescents. Research has demonstrated that the most significant form of family involvement in families raising a child with NDD is through homework. This involvement has been shown to have an emotional impact on children with neurodevelopmental disorders such as ADHD or dyslexia. The objective of this study is to review published articles on homework and neurodevelopmental disorders, with particular attention to the role of the family and the emotional health of children and families.

METHOD

The review followed the PRISMA guidelines. The final sample consisted of 11 articles, with samples ranging from less than 30 participants to more than 100 at the international level.

RESULTS

The results demonstrate the complex methodological and bibliometric picture of the final sample, as well as the many emotional and contextual variables that influence the relationship between homework and neurodevelopmental disorders.

CONCLUSIONS

Future research should consider how emotional health affects the engagement of families with children with neurodevelopmental disorders.

Efficacy and safety of transcranial pulse stimulation in young adolescents with attention-deficit/hyperactivity disorder: a pilot, randomized, double-blind, sham-controlled trial

Background

This is the first study to evaluate the efficacy and safety of transcranial pulse stimulation (TPS) for the treatment of attention-deficit/hyperactivity disorder (ADHD) among young adolescents in Hong Kong.

Methods

This double-blind, randomized, sham-controlled trial included a TPS group and a sham TPS group, encompassing a total of 30 subjects aged 12-17 years who were diagnosed with ADHD. Baseline measurements SNAP-IV, ADHD RS-IV, CGI and executive functions (Stroop tests, Digit Span) and post-TPS evaluation were collected. Both groups were assessed at baseline, immediately after intervention, and at 1-month and 3-month follow-ups. Repeated-measures ANOVAs were used to analyze data.

Results

The TPS group exhibited a 30% reduction in the mean SNAP-IV score at postintervention that was maintained at 1- and 3-month follow-ups.

Conclusion

TPS is an effective and safe adjunct treatment for the clinical management of ADHD.

Clinical trial registration

ClinicalTrials.Gov, identifier NCT05422274.

Parental Cognitions, Treatment Engagement, and Child Outcomes of ADHD Behavioral Treatment among Asian American Families

Asian American (AA) families remain critically underrepresented in clinical trials for ADHD interventions. Little is known about AA families' engagement in and outcomes of behavioral treatment (BT). Comparing AA families to other minoritized (OM) families and White families, this study examined parental cognitions, treatment engagement, and child outcomes of BT for ADHD inattentive type (ADHD-I). Path analyses were conducted utilizing data from a randomized controlled trial of BT for ADHD-I (N = 199 children, ages 7-11). Racial/ethnic differences in pretreatment parental self-competence and treatment expectations were examined for AA (n = 29) compared to OM (n = 35) and White (n = 135) parents. Two additional path models were conducted to examine the relations among race/ethnicity, pretreatment parental cognitions, treatment engagement, and posttreatment child outcomes. Direct effects of race/ethnicity and parental cognitions on posttreatment child outcomes as well as their indirect effects via treatment engagement were estimated. At pretreatment, AA parents endorsed lower parental self-competence and treatment expectations compared to OM and White parents. At posttreatment, AA parents reported fewer improvements in ADHD symptoms than White parents and lower global psychosocial improvement than OM parents. For all parents, treatment expectations positively predicted parent- and observer-rated treatment engagement, which in turn predicted child global psychosocial improvement. Path analyses indicated that the relationship between treatment expectations and posttreatment child global improvement was fully mediated by treatment engagement. These findings suggest that treatment expectations impede AA parents' engagement and success in BT. Implications for cultural adaptations of BT to improve AA families' treatment experience are discussed.

Treating Executive Function in Youth With Attention Deficit Hyperactivity Disorder: A Review of Pharmacological and Non-Pharmacological Interventions

INTRODUCTION

Executive function (EF) deficits are common in youth with ADHD and pose significant functional impairments. The extent and effect of interventions addressing EF in youth with ADHD remain unclear.

METHODS

We conducted a systematic literature review using PRISMA guidelines. Included studies were randomized controlled trials of interventions to treat EF in youth with ADHD.

RESULTS

Our search returned 136 studies representing 11,443 study participants. We identified six intervention categories: nonstimulant pharmacological (N = 3,576 participants), neurological (N = 1,935), psychological (N = 2,387), digital (N = 2,416), physiological (N = 680), and combination (N = 366). The bulk of the evidence supported pharmacological interventions as most effective in mitigating EF, followed by psychological and digital interventions.

CONCLUSION

A breadth of treatments exists for EF in youth with ADHD. Pharmacological, psychotherapeutic, and digital interventions had the most favorable, replicable outcomes. A lack of outcome standardization across studies limited treatment comparison. More data on the persistence of intervention effects are necessary.

Sustained improvements by behavioural parent training for children with attention-deficit/hyperactivity disorder: A meta-analytic review of longer-term child and parental outcomes

Background

Behavioural parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but little is known about the extent to which initial benefits are maintained.

Aims

This meta-analytic review investigated longer-term (i.e., more than 2 months post-intervention) child and parental outcomes of behavioural parent training for children with ADHD.

Materials & Methods

We searched for randomized controlled trials and examined ADHD symptoms, behavioural problems, positive parenting, negative parenting, parenting sense of competence, parent-child relationship quality, and parental mental health as outcomes. We included 27 studies (31 interventions; 217 effect sizes), used multilevel random-effects meta-analyses for between- and within-group comparisons (pre-intervention to follow-up and post-intervention to follow-up), and explored twelve predictors of change.

Results

Between pre-intervention and follow-up (M = 5.3 months), we found significant small-to-moderate between-group effects of the intervention on ADHD symptoms, behavioural problems, positive parenting, parenting sense of competence and parent-child relationship quality. Within-group findings show sustained improvements in the intervention conditions for all outcome domains. There were few significant changes from post-intervention to follow-up. Additionally, the large majority of the individual effect sizes indicated sustained outcomes from post-intervention to follow-up. There were seven significant predictors of change in child outcomes, including stronger reductions in ADHD symptoms of girls and behaviour problems of younger children. In contrast with some meta-analyses on short-term effects, we found no differences between masked and unmasked outcomes on ADHD symptoms at follow-up.

Discussion & Conclusion

We conclude that behavioural parent training has longer-term benefits for children's ADHD symptoms and behavioural problems, and for positive parenting behaviours, parenting sense of competence and quality of the parent-child relationship.

Transcranial random noise stimulation combined with cognitive training for treating ADHD: a randomized, sham-controlled clinical trial

Non-invasive brain stimulation has been suggested as a potential treatment for improving symptomology and cognitive deficits in Attention-Deficit/Hyperactivity Disorder (ADHD), the most common childhood neurodevelopmental disorder. Here, we examined whether a novel form of stimulation, high-frequency transcranial random noise stimulation (tRNS), applied with cognitive training (CT), may impact symptoms and neural oscillations in children with ADHD. We conducted a randomized, double-blind, sham-controlled trial in 23 unmedicated children with ADHD, who received either tRNS over the right inferior frontal gyrus (rIFG) and left dorsolateral prefrontal cortex (lDLPFC) or sham stimulation for 2 weeks, combined with CT. tRNS + CT yielded significant clinical improvements (reduced parent-reported ADHD rating-scale scores) following treatment, compared to the control intervention. These improvements did not change significantly at a 3-week follow-up. Moreover, resting state (RS)-EEG periodic beta bandwidth of the extracted peaks was reduced in the experimental compared to control group immediately following treatment, with further reduction at follow-up. A lower aperiodic exponent, which reflects a higher cortical excitation/inhibition (E/I) balance and has been related to cognitive improvement, was seen in the experimental compared to control group. This replicates previous tRNS findings in adults without ADHD but was significant only when using a directional hypothesis. The experimental group further exhibited longer sleep onset latencies and more wake-up times following treatment compared to the control group. No significant group differences were seen in executive functions, nor in reported adverse events. We conclude that tRNS + CT has a lasting clinical effect on ADHD symptoms and on beta activity. These results provide a preliminary direction towards a novel intervention in pediatric ADHD.

Psychosocial Interventions for Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis by the CADDRA Guidelines Work GROUP

Multiple psychosocial interventions to treat ADHD symptoms have been developed and empirically tested. However, no clear recommendations exist regarding the utilization of these interventions for treating core ADHD symptoms across different populations. The objective of this systematic review and meta-analysis by the CADDRA Guidelines work Group was to generate such recommendations, using recent evidence. Randomized controlled trials (RCT) and meta-analyses (MA) from 2010 to 13 February 2020 were searched in PubMed, PsycINFO, EMBASE, EBM Reviews and CINAHL. Studies of populations with significant levels of comorbidities were excluded. Thirty-one studies were included in the qualitative synthesis (22 RCT, 9 MA) and 24 studies (19 RCT, 5 MA) were included in the quantitative synthesis. Using three-level meta-analyses to pool results of multiple observations from each RCT, as well as four-level meta-analyses to pool results from multiples outcomes and multiple studies of each MA, we generated recommendations using the GRADE approach for: Cognitive Behavioral Therapy; Physical Exercise and Mind–Body intervention; Caregiver intervention; School-based and Executive intervention; and other interventions for core ADHD symptoms across Preschooler, Child, Adolescent and Adult populations. The evidence supports a recommendation for Cognitive Behavioral Therapy for adults and Caregiver intervention for Children, but not for preschoolers. There were not enough data to provide recommendations for the other types of psychosocial interventions. Our results are in line with previous meta-analytic assessments; however, they provide a more in-depth assessment of the effect of psychosocial intervention on core ADHD symptoms.

Co-Occurring Psychopathology Moderates Social Skills Improvement in a Randomized Controlled Trial of a Collaborative School-Home Intervention for Children with ADHD

OBJECTIVE

Children with ADHD often exhibit marked impairment in their social skills, but evidence-based psychosocial interventions for ADHD have shown limited efficacy in remediating these deficits. Co-occurring psychopathology exacerbates social deficits in children with ADHD and is a plausible moderator of treatment response. To identify factors contributing to variable social skills treatment response, we examined co-occurring externalizing, depression, and anxiety symptoms as moderators of social skills outcomes in a randomized controlled trial of the Collaborative Life Skills (CLS) program, an evidence-based collaborative school-home ADHD intervention.

METHOD

Participants were 159 children with ADHD (M age = 8.35 years, 28.3% female) at 27 schools in an urban public school district. Twenty-three schools were randomly assigned to CLS or usual services, with an additional four schools assigned to Spanish-adapted CLS or usual services. Multi-informant measures of co-occurring psychopathology and social skills were collected at baseline and post-treatment.

RESULTS

Parent-rated externalizing and depression symptoms moderated treatment effects on social skills, whereby higher symptomatology in each domain was unrelated to social skills improvement in the CLS group but predicted worsening social skills in response to usual services. In contrast, teacher-rated anxiety moderated treatment effects on social skills, whereby higher anxiety predicted greater social skills improvement in response to CLS but was unrelated to social skills outcomes following usual services.

CONCLUSIONS

Findings reflect novel evidence that child psychopathology domains exhibit unique moderating effects on social skills treatment response in children with ADHD. We discuss implications for optimizing evidence-based interventions to target social impairment in this population.

The Two-Factor Structure of the Parent Cognitive Error Questionnaire: A Measure of Parental Cognitive Errors in Relation to Child Problems

This study evaluated the factor structure of the scores from a parent rating scale, the Parent Cognitive Error Questionnaire (PCEQ), which measures parents' attributions of child misbehavior and problems. The factor structure of the scores of the PCEQ was examined among 199 children (ages 7-11; mean age: 8.64 years, 58.30% boys, 53.80% White) with Attention-Deficit/Hyperactivity Disorder (ADHD), Predominantly Inattentive Presentation. Reliability and validity of the factors were assessed. Two factors emerged from this sample: (1) parent-specific cognitive errors (self-blame for child problems), and (2) child-specific cognitive errors (child-blame for child problems). Both were related to parent-rated parental depression, parenting satisfaction, parenting self-efficacy, and child ADHD and Oppositional Defiant Disorder (ODD) symptoms. After adjusting for child-specific cognitive errors, parent-specific errors were related to parent-rated parent depressive symptoms, and after adjustment for parent-specific cognitive errors, child-specific cognitive errors were related to parent-rated child ADHD and ODD symptoms. A two-factor structure for the PCEQ scores from this sample was found with evidence of reliability and validity of factors, showing promise for measuring sources of parental attributions regarding child problems.

Annual Research Review: Attention-deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions

Attention-deficit/hyperactivity disorder (ADHD) - and its underlying behavioral dimensions of inattention and hyperactivity-impulsivity - have been understudied in females. We first cover the conceptual issues of prevalence, diagnostic practices, diversity, comorbidity, and causal factors, plus forces limiting awareness of ADHD in females. After a narrative review of cross-sectional and longitudinal findings, we conclude the following. (a) Girls meet diagnostic criteria for ADHD at just under half the rates of boys, a ratio that becomes much closer to equal by adulthood. (b) Girls and women with ADHD show a predominance of inattention and associated internalizing problems; boys and men display greater levels of hyperactive-impulsive symptoms and associated externalizing problems. (c) Sex differences in ADHD symptoms and related outcomes depend heavily on the clinical versus nonreferred nature of the samples under investigation. (d) Females with ADHD experience, on average, serious impairments, with a particularly heightened risk for problems in close relationships and engagement in self-harm. (e) Clinicians may overlook symptoms and impairments in females because of less overt (but still impairing) symptom manifestations in girls and women and their frequent adoption of compensatory strategies. Our review of predictors and mediators of adult outcomes highlights (a) the potential for heterotypically continuous pathways in females with childhood ADHD and (b) developmental progressions to self-harm, intimate partner violence, unplanned pregnancy, and comorbid psychopathology. Focusing on ADHD in females is necessary to characterize causal and maintaining mechanisms with accuracy and to foster responsive interventions, as highlighted in our closing list of clinical implications and research priorities.

A comparative study: quality of life, self-competence, and self-liking among the caregivers of children with attention deficit hyperactivity disorder and other non-ADHD children

Background

The presence of attention deficit hyperactive disorder (ADHD) causes great impairment in social and professional activities as well as in the quality of life (QOL) and increases level of parental stress.

Objective

This study aimed to compare the QOL, self-competence, and self-liking among the caregivers of ADHD and non-ADHD children.

Method

A descriptive cross-sectional study was conducted on 216 caregivers. They were divided into two groups: caregivers of children with ADHD and caregivers of children without ADHD.

Setting

This study was conducted in the Elsinbellawin City at Dakahlia Governorate in Egypt. Tools used were socio-demographic data sheet and WHO Quality of Life Scale-Brief (WHOQOL-Brief) and self-liking/self-competence scale.

Results

Our results showed that all QOL dimensions of the caregivers of ADHD children were markedly deteriorated, if compared to those of non-ADHD children, and two thirds of caregivers of ADHD children suffered from poor level quality of life (QOL). Caregivers of non-ADHD children had fair level of self-competence but a good level of self-liking. Caregiver of ADHD children who had no work or history of medical diseases has a fair level of QOL and self-competence but a good level of self-liking.

Conclusions

We found that caregivers of ADHD children have fair levels of QOL, self-liking, and self-competence, if compared to those of non-ADHD children. There are statistically significant correlations between QOL, self-competence, and self-liking among both caregivers of both non-ADHD children and ADHD children.

An Individual Participant Data Meta-analysis: Behavioral Treatments for Children and Adolescents With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Behavioral interventions are well established treatments for children with attention-deficit/hyperactivity disorder (ADHD). However, insight into moderators of treatment outcome is limited.

METHOD

We conducted an individual participant data meta-analysis (IPDMA), including data of randomized controlled behavioral intervention trials for individuals with ADHD <18 years of age. Outcomes were symptoms of ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) and impairment. Moderators investigated were symptoms and impairment severity, medication use, age, IQ, sex, socioeconomic status, and single parenthood.

RESULTS

For raters most proximal to treatment, small- to medium-sized effects of behavioral interventions were found for symptoms of ADHD, inattention, hyperactivity/impulsivity (HI), ODD and CD, and impairment. Blinded outcomes were available only for small preschool subsamples and limited measures. CD symptoms and/or diagnosis moderated outcome on ADHD, HI, ODD, and CD symptoms. Single parenthood moderated ODD outcome, and ADHD severity moderated impairment outcome. Higher baseline CD or ADHD symptoms, a CD diagnosis, and single parenthood were related to worsening of symptoms in the untreated but not in the treated group, indicating a protective rather than an ameliorative effect of behavioral interventions for these children.

CONCLUSION

Behavioral treatments are effective for reducing ADHD symptoms, behavioral problems, and impairment as reported by raters most proximal to treatment. Those who have severe CD or ADHD symptoms, a CD diagnosis, or are single parents should be prioritized for treatment, as they may evidence worsening of symptoms in the absence of intervention.

Psychoeducation Intervention Effectiveness to Improve Social Skills in Young People with ADHD: A Meta-Analysis

OBJECTIVE

Attention Deficit Hyperactivity Disorder (ADHD) can be associated with limited understanding of the condition and poor social skills. Some evidence favors a psychoeducational approach, but little is known about the effectiveness of psychoeducation.

METHODS

Systematic review and meta-analysis of studies assessing psychoeducational interventions that aim to improve social skills of young people with ADHD.

RESULTS

Ten studies, including 943 participants, reported across 13 papers met the inclusion criteria. Although effect sizes were small, findings suggest the included interventions significantly improved social skills in young people with ADHD.

CONCLUSIONS

Results show promise for psychoeducational behavioral interventions . However, the recommendations that can be developed from existing evidence are somewhat limited by the low quality of studies. Further rigorous trials are needed. In addition, future research should consider the long-term outcomes for these interventions, they should be iteratively co-designed and research should consider the context they intend to be delivered in.

The Efficacy of Visual Activity Schedule Intervention in Reducing Problem Behaviors in Children With Attention-Deficit/Hyperactivity Disorder Between the Age of 5 and 12 Years: A Systematic Review

Objectives

Children with attention-deficit/hyperactivity disorder (ADHD) tend to be noisy and violate rules with their disruptive behaviors, resulting in greater difficulties with off-task behaviors and being at risk for social refusal. The visual activity schedule (VAS) intervention program is a frequently used method to teach multiple skills involving on-task, use of schedules, transition behaviors, social initiation, independent play skills, classroom skills, and academic skills. The current systematic review aimed to examine the efficacy of using VAS intervention in reducing problem behaviors in children with ADHD between 5 and 12 years of age.

Methods

Systematic searches were conducted using two electronic databases (PubMed and Scopus) to identify relevant studies published in English between 2010 and 2020. Four studies met the inclusion criteria: two studies examined the effect of schedule-based tasks and the use of an iPad on classroom skills, while the other two examined randomized clinical trials (RCTs) of psychosocial treatment for ADHD inattentive type and a cross-sectional study examined the impact of the group size on task behavior and work productivity in children with ADHD.

Results

The findings indicate that the interventions used in all four studies could lead to increased satisfaction among participants and parents, as well as a reduction in problem behavior. In terms of the research indicators, the RCT had low quality, while the others were of high quality.

Conclusion

A larger number of studies and the ADHD clinical population would help to increase the generalizability of future reviews of treatments in this context.

Cost-Effectiveness and Cost Utility of Treatment of Attention-Deficit/Hyperactivity Disorder: A Systematic Review

Objectives: This systematic review provides an overview of full economic evaluations of attention-deficit/hyperactivity disorder (ADHD) treatments, evaluates their outcomes, and highlights gaps in the literature. Data Sources: Electronic databases were searched for full economic evaluations of ADHD treatments for children, adolescents, or adults published in English or Dutch. Results: Twenty-nine studies met the inclusion criteria. Almost all studies that compared medication or psychosocial treatment to no treatment, placebo, or care as usual indicated that medication and psychosocial treatment were cost-effective compared to the control group. Stimulant treatment appeared to be cost-effective for the treatment of ADHD in children and adolescents. Only few studies focus on treatments in adults and psychosocial treatments and the number of studies with long time horizons and without industry funding is limited. Conclusions: Despite the rising interest in cost-effectiveness, this systematic review shows that more cost-effectiveness research of higher quality is warranted to aid in the optimal use of available treatments and resources for individuals with ADHD. Specifically, more studies should focus on treatments in adults and psychosocial treatments, and more studies with long time horizons and without industry funding are warranted. Nevertheless, we can conclude that treating ADHD is generally cost-effective compared to no treatment. PROSPERO: CRD42017060074. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=60074.

Organizational skills training for children with ADHD: study protocol for a randomized, controlled trial

Background

Problems with sustained attention, impulsivity, and hyperactivity are the most prominent symptoms of attention-deficit hyperactivity disorder (ADHD), but many children with this diagnosis also present with poor organizational skills that are important in relation to school. These problems tend to increase from childhood to adolescence and are often not well managed by medication. Organizational skills training (OST) is a range of behavioral interventions that specifically target organizational skills deficits. Evidence supports the effect of OST on improving organizational skills, inattention, and academic performance in children with ADHD. Because previous clinical trials included mostly children above the age of 8 years, this trial includes children in the age range 6–13 years to expand the knowledge on the effects of OST in younger children. Previous OST research has also shown improvement on inattention in parent ratings; we will investigate if a change in inattention can be confirmed with neurocognitive tests. Finally, little is known about predictors of treatment response in OST.

Objectives

The primary objective is to investigate if OST has positive effects on organizational skills in children with ADHD. The primary outcome measurement is the parent-rated Children’s Organizational Skills Scale (COSS), collected before and at the end of the 10 week intervention. Secondary and exploratory outcomes include inattention ratings, family and school functioning, and cognitive functions measured before the intervention period, immediately after, and at a 6 month follow-up. Additional objectives are to investigate both neurocognitive outcomes and age as predictors of treatment response.

Methods

This is a randomized clinical superiority trial investigating the effect of OST vs a treatment-as-usual (TAU) control group for children with ADHD in the age range of 6–13 years. All participants (n = 142) receive TAU. OST is administered in a group format of 10 weekly sessions. Adverse events are monitored by study clinicians during weekly therapy sessions and all assessments. Data analyses will be conducted using mixed linear regression models with random intercepts for patients, adjusted for the stratification variables and the baseline value.

Perspectives

This study will provide important new knowledge and expand on existing research in the field of non-pharmacological treatment of children with ADHD. OST can potentially have a significant impact on the lives of children with ADHD by helping them learn how to cope with their present deficits and to become more independent and self-reliant. It is also important to investigate predictors of treatment response in order to optimize OST.

Trial registration

ClinicalTrials.gov NCT03160378. Registered on May 19, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05499-9.

Harnessing Home-School Partnerships and School Consultation to Support Youth With Anxiety

Youth with anxiety often experience significant impairment in the school setting. Despite the relevance and promise of addressing anxiety in schools, traditional treatment approaches to school-based anxiety often do not adequately address generalization to the school setting, or they require removing the student from the classroom to deliver time- and staff-intensive programs. Such programs often leave teachers and caregivers feeling ill-equipped to support the student with anxiety throughout the natural course of the school day. Given the heavy demands placed on teachers and documented burnout among school professionals, providing effective school supports requires collaborative partnerships among outpatient therapists/specialists, school personnel, and caregivers. Drawing from literature on collaborative models for externalizing problems, we offer recommendations for outpatient therapists and specialists working to implement evidence-based supports in school settings and promote home-school partnerships to benefit youth with anxiety in the school setting. Our recommendations touch upon several components of such school consultation, including (a) identification of key parties involved, (b) conducting a needs assessment, (c) collaborative goal setting and development of a fear hierarchy, (d) plan development and implementation (e.g., facilitating a school-based exposure mindset, promoting home-school communication, enhancing school relationships), and (e) progress monitoring and ongoing support. We conclude with a case example to bring these recommendations to life.

Effectiveness of Virtual Reality-Based Interventions for Children and Adolescents with ADHD: A Systematic Review and Meta-Analysis

This review aims to evaluate the effectiveness of virtual reality-based interventions (VR-based interventions) on cognitive deficits in children with attention deficit hyperactivity disorder (ADHD). A systematic review and meta-analysis were performed according to the PRISMA statement and the Cochrane Handbook guidelines for conducting meta-analyses. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the quality of the evidence. Clinical trials published up to 29 October 2020, were included. The meta-analysis included four studies, with a population of 125 participants with ADHD. The magnitude of the effect was large for omissions (SMD = −1.38; p = 0.009), correct hits (SMD = −1.50; p = 0.004), and perceptual sensitivity (SMD = −1.07; p = 0.01); and moderate for commissions (SMD = −0.62; p = 0.002) and reaction time (SMD = −0.67; p = 0.03). The use of VR-based interventions for cognitive rehabilitation in children with ADHD is limited. The results showed that VR-based interventions are more effective in improving sustained attention. Improvements were observed in attentional vigilance measures, increasing the number of correct responses and decreasing the number of errors of omission. No improvements were observed in impulsivity responses.

Do Parents' ADHD Symptoms Affect Treatment for their Children? The Impact of Parental ADHD on Adherence to Behavioral Parent Training for Childhood ADHD

Nearly half of all youth with Attention-Deficit Hyperactivity Disorder (ADHD) have at least one parent who also meets criteria for the disorder, and intergenerational ADHD is a significant risk factor for poor outcomes following evidence-based behavioral parent training (BPT) programs. Given that BPT is predicated on consistent parental involvement, symptoms of ADHD in parents may be a significant barrier to effective engagement with BPT treatment. In the present investigation, we examine the effect of parental ADHD symptoms on BPT treatment engagement for children with ADHD-predominantly inattentive presentation (N = 148, ages 7-11). We examine the following parent- and clinician-rated treatment engagement domains: between-session skill adherence, in-session participation, perceived skill understanding, treatment-engagement attitudes, and session attendance. Parent- and clinician-rated between-session adherence was the only treatment engagement domain related significantly to parental ADHD symptoms. This finding was robust and remained even after accounting for symptoms of parental anxiety and depression, child ADHD symptom severity, and various sociodemographic factors (parental education level, household income, employment status, and being a single parent). These findings suggest that targeting parental ADHD symptoms in the context of parenting interventions may be a promising approach for improving adherence and treatment outcomes for BPT interventions.

What explains the link between childhood ADHD and adolescent depression? Investigating the role of peer relationships and academic attainment

There is increasing evidence that childhood Attention-Deficit Hyperactivity Disorder (ADHD) elevates risk of later depression, but the mechanisms behind this association are unclear. We investigated the relationship between childhood ADHD symptoms and late-adolescent depressive symptoms in a population cohort, and examined whether academic attainment and peer problems mediated this association. ALSPAC (Avon Longitudinal Study of Parents and Children) is an ongoing prospective longitudinal population-based UK cohort that has collected data since September 1990. 2950 individuals with data on parent-reported ADHD symptoms in childhood (7.5 years) and self-reported depressive symptoms in late adolescence (17.5 years) were included in analyses. 2161 individuals with additional data at age 16 years on parent-reported peer problems as an indicator of peer relationships and formal examination results (General Certificate of Secondary Education; GCSE) as an indicator of academic attainment were included in mediation analyses. Childhood ADHD symptoms were associated with higher depressive symptoms (b = 0.49, SE = 0.11, p < 0.001) and an increased odds of clinically significant depressive symptoms in adolescence (OR = 1.27, 95% CI 1.15-1.41, p < 0.001). The association with depressive symptoms was mediated in part by peer problems and academic attainment which accounted for 14.68% and 20.13% of the total effect, respectively. Childhood ADHD is associated with increased risk of later depression. The relationship is mediated in part by peer relationships and academic attainment. This highlights peer relationships and academic attainment as potential targets of depression prevention and intervention in those with ADHD. Future research should investigate which aspects of peer relationships are important in conferring later risk for depression.

Diagnostic Classification of ADHD Versus Control: Support Vector Machine Classification Using Brief Neuropsychological Assessment

Objective: Common methods for clinical diagnosis include clinical interview, behavioral questionnaires, and neuropsychological assessment. These methods rely on clinical interpretation and have variable reliability, sensitivity, and specificity. The goal of this study was to evaluate the utility of machine learning in the prediction and classification of children with ADHD-Combined presentation (ADHD-C) using brief neuropsychological measures (d2 Test of Attention, Children with ADHD-C and typically developing control children completed semi-structured clinical interviews and measures of attention/concentration and parents completed symptom severity questionnaires. Method: We used a forward feature selection method to identify the most informative neuropsychological features for support vector machine (SVM) classification and a decision tree model to derive a rule-based model. Results: The SVM model yielded excellent classification accuracy (100%) of individual children with and without ADHD (1.0). Decision tree algorithms identified individuals with and without ADHD-C with 100% sensitivity and specificity. Conclusion:This study observed highly accurate statistical diagnostic classification, at the individual level, in a sample of children with ADHD-C. The findings suggest data-driven behavioral algorithms based on brief neuropsychological data may present an efficient and accurate diagnostic tool for clinicians.

Occupational Therapy Practice Guidelines for Children and Youth Ages 5-21 Years

IMPORTANCE

Demand is increasing for activity- and occupation-based interventions to address occupational performance and support maximal participation of children and youth.

OBJECTIVE

This Practice Guideline was developed to guide decision making and support best practices in service delivery for children and youth ages 5-21 yr at home, at school, and in the community.

METHOD

The results from three systematic reviews (SRs) of activity- and occupation-based interventions for children and youth ages 5-21 yr were reviewed, synthesized, and translated into recommendations for education, practice, and research.

RESULTS

One hundred eighty-five articles were included in the three SRs examining the evidence for interventions to promote activities of daily living, instrumental activities of daily living, play and leisure, and rest and sleep; to improve mental health, positive behavior, and social participation; and to enhance learning, academic achievement, and successful participation in school. The reviews provide evidence for interventions associated with typical concerns addressed by occupational therapy practitioners.

CONCLUSIONS AND RECOMMENDATIONS

On the basis of the evidence, this guideline recommends that occupational therapy practitioners consistently collaborate with families and caregivers and provide services in the natural context of the desired occupation. The evidence also supports group service models and models that include peer mediation; these models can promote participation across areas of occupation. Skills-based training and therapeutic practice in the context of valued occupations are recommended over isolated sensorimotor approaches. Technology, manualized programs, and sports activities can be effective but should be evaluated and matched to age, diagnosis, and outcomes as guided by the evidence.

WHAT THIS ARTICLE ADDS

When guided by evidence, activity- and occupation-based interventions are effective in promoting participation and enhancing performance in valued occupations of children and youth ages 5-21 yr.

Activity- and Occupation-Based Interventions to Support Mental Health, Positive Behavior, and Social Participation for Children and Youth: A Systematic Review

IMPORTANCE

Children and youth are often challenged to maintain well-being, positive behavior, and social participation.

OBJECTIVE

To identify evidence for occupational therapy interventions for children and youth with and at risk for mental health concerns.

DATA SOURCES

Articles published in English-language peer-reviewed journals between January 2010 and March 2017 identified through searches of MEDLINE, PsycINFO, CINAHL, ERIC, OTseeker, and Cochrane databases.

Study Selection and Data Collectio

: The methodology in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used to complete the review. Of 5,310 articles screened by title and abstract, 357 were retrieved for full-text review, and 62 met inclusion criteria. Articles describing interventions that were activity or occupation based were included. Conference proceedings, non-peer reviewed publications, dissertations, theses, and presentations were excluded.

FINDINGS

Of the 62 studies included in the review, 20 (32%) were Level I studies, 22 (36%) were Level II studies, and 20 (32%) were Level III studies. Articles were categorized by type: outdoor camps, video and computer games, productive occupations and life skills, meditation, animal-assisted interventions, creative arts, play, sports, and yoga. Moderate to strong evidence supports the use of yoga and sports. Moderate-strength evidence supports the use of play and creative arts. Evidence for the use of animal-assisted interventions, meditation, video and computer games, and productive occupations was of low strength.

CONCLUSION AND RELEVANCE

Substantial evidence exists to support the use of activity- and occupation-based interventions to address the mental health, behavioral, and social participation concerns of children and youth. Occupational therapy practitioners should match the desired outcome of therapy with the appropriate intervention to provide the best and most effective services to their clients.

WHAT THIS ARTICLE ADDS

This review provides additional support for the use of activity- and occupation-based interventions (i.e., those that involve active participation) to improve the behavior, social participation, and mental health of children and youth.

Randomized control study of the effects of executive function training on peer difficulties of children with attention-deficit/hyperactivity disorder C subtype

Objective: Attention-deficit/hyperactivity disorder C subtype (ADHD-C) is associated with social rejection and peer difficulties. The present study evaluates the comparative efficacy of group executive function training (GEFT) with social skills training (SST) in children with ADHD-C in China.Methods: A randomized, controlled treatment outcome study that comprised of 52 boys and 29 girls (age range: 9-12 years old) was conducted. The primary variable (peer relationship), secondary variables (executive functions [EFs] and social skills) and ADHD symptoms (inattention and hyperactive) were measured before and after the intervention and 3-month follow-up.Results: First, both GEFT and SST had instant effects on peer relationship. Second, GEFT mainly improved their EFs and self-control dimension of social skills. At the same time, ADHD symptoms were reduced. SST mainly improved their social skills, but had no effect on EFs and ADHD symptoms. Third, GEFT had better long-term effects than SST on peer relationship.Conclusion: Executive function training produced more effective and lasting changes on peer difficulties of ADHD children.

Patterns and Predictors of Service Utilization Among Youth With ADHD-Predominantly Inattentive Presentation

Objective: This study examined rates and predictors of educational and mental health service utilization among youth with ADHD-predominantly inattentive presentation (ADHD-I). Method: Participants were 199 children with ADHD-I in Grades 2 to 5. Parents reported past-year child service utilization. Parents and teachers rated child ADHD and oppositional defiant disorder (ODD) symptom severity and functional impairment. Children completed an academic achievement test. Results: All children had impairment at school and home. Most received some sort of school service (79%), but only 23% received community-based services. ADHD symptom severity was unrelated to service utilization. However, higher parent-rated functional impairment predicted community service utilization. Academic underachievement and higher teacher-rated functional impairment predicted school service utilization. Conclusion: Many youth with ADHD-I experience impairment across domains without receiving adequate services for these problems. Functional impairment appears to be a stronger predictor of service utilization than ADHD symptom severity, demonstrating the importance of impairment in understanding service needs for ADHD-I.

Learning Disorder Confers Setting-Specific Treatment Resistance for Children with ADHD, Predominantly Inattentive Presentation

Attention deficit/hyperactivity disorder-predominantly inattentive presentation (ADHD-I) and specific learning disorder (SLD) are commonly co-occurring conditions. Despite the considerable diagnostic overlap, the effect of SLD comorbidity on outcomes of behavioral interventions for ADHD-I remains critically understudied. The current study examines the effect of reading or math SLD comorbidity in 35 children with comorbid ADHD-I+SLD and 39 children with ADHD-I only following a behavioral treatment integrated across home and school (Child Life and Attention Skills [CLAS]). Pre- and posttreatment outcome measures included teacher-rated inattention, organizational deficits, and study skills and parent-rated inattention, organizational deficits, and homework problems. A similar pattern emerged across all teacher-rated measures: Children with ADHD-I and comorbid ADHD-I+SLD did not differ significantly at baseline, but between-group differences were evident following the CLAS intervention. Specifically, children with ADHD-I and comorbid ADHD-I+SLD improved on teacher-rated measures following the CLAS intervention, but children with ADHD-I only experienced greater improvement relative to those with a comorbid SLD. No significant interactions were observed on parent-rated measures-all children improved following the CLAS intervention on parent-rated measures, regardless of SLD status. The current results reveal that children with ADHD-I+SLD comorbidity benefit significantly from multimodal behavioral interventions, although improvements in the school setting are attenuated significantly. A treatment-resistant fraction of inattention was identified only in the SLD group, implying that this fraction is related to SLD and becomes apparent only when behavioral intervention for ADHD is administered.

Social skills training for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) in children is associated with hyperactivity and impulsivity, attention problems, and difficulties with social interactions. Pharmacological treatment may alleviate the symptoms of ADHD but this rarely solves difficulties with social interactions. Children with ADHD may benefit from interventions designed to improve their social skills. We examined the benefits and harms of social skills training on social skills, emotional competencies, general behaviour, ADHD symptoms, performance in school of children with ADHD, and adverse events.

OBJECTIVES

To assess the beneficial and harmful effects of social skills training in children and adolescents with ADHD.

SEARCH METHODS

In July 2018, we searched CENTRAL, MEDLINE, Embase, PsycINFO, 4 other databases and two trials registers.We also searched online conference abstracts, and contacted experts in the field for information about unpublished or ongoing randomised clinical trials. We did not limit our searches by language, year of publication, or type or status of publication, and we sought translation of the relevant sections of non-English language articles.

SELECTION CRITERIA

Randomised clinical trials investigating social skills training versus either no intervention or waiting-list control, with or without pharmacological treatment of both comparison groups of children and adolescents with ADHD.

DATA COLLECTION AND ANALYSIS

We conducted the review in accordance with the Cochrane Handbook for Systematic Reviews of Intervention. We performed the analyses using Review Manager 5 software and Trial Sequential Analysis. We assessed bias according to domains for systematic errors. We assessed the certainty of the evidence with the GRADE approach.

MAIN RESULTS

We included 25 randomised clinical trials described in 45 reports. The trials included a total of 2690 participants aged between five and 17 years. In 17 trials, participants were also diagnosed with various comorbidities.The social skills interventions were described as: 1) social skills training, 2) cognitive behavioural therapy, 3) multimodal behavioural/psychosocial therapy, 4) child life and attention skills treatment, 5) life skills training, 6) the "challenging horizon programme", 7) verbal self-instruction, 8) meta-cognitive training, 9) behavioural therapy, 10) behavioural and social skills treatment, and 11) psychosocial treatment. The control interventions were no intervention or waiting list.The duration of the interventions ranged from five weeks to two years. We considered the content of the social skills interventions to be comparable and based on a cognitive-behavioural model. Most of the trials compared child social skills training or parent training combined with medication versus medication alone. Some of the experimental interventions also included teacher consultations.More than half of the trials were at high risk of bias for generation of the allocation sequence and allocation concealment. No trial reported on blinding of participants and personnel. Most of the trials did not report on differences between groups in medication for comorbid disorders. We used all eligible trials in the meta-analyses, but downgraded the certainty of the evidence to low or very low.We found no clinically relevant treatment effect of social skills interventions on the primary outcome measures: teacher-rated social skills at end of treatment (standardised mean difference (SMD) 0.11, 95% confidence interval (CI) 0.00 to 0.22; 11 trials, 1271 participants; I2 = 0%; P = 0.05); teacher-rated emotional competencies at end of treatment (SMD -0.02, 95% CI -0.72 to 0.68; two trials, 129 participants; I2 = 74%; P = 0.96); or on teacher-rated general behaviour (SMD -0.06 (negative value better), 95% CI -0.19 to 0.06; eight trials, 1002 participants; I2 = 0%; P = 0.33). The effect on the primary outcome, teacher-rated social skills at end of treatment, corresponds to a MD of 1.22 points on the social skills rating system (SSRS) scale (95% CI 0.09 to 2.36). The minimal clinical relevant difference (10%) on the SSRS is 10.0 points (range 0 to 102 points on SSRS).We found evidence in favour of social skills training on teacher-rated core ADHD symptoms at end of treatment for all eligible trials (SMD -0.26, 95% CI -0.47 to -0.05; 14 trials, 1379 participants; I2= 69%; P = 0.02), but the finding is questionable due to lack of support from sensitivity analyses, high risk of bias, lack of clinical significance, high heterogeneity, and low certainty.The studies did not report any serious or non-serious adverse events.

AUTHORS' CONCLUSIONS

The review suggests that there is little evidence to support or refute social skills training for children and adolescents with ADHD. We may need more trials that are at low risk of bias and a sufficient number of participants to determine the efficacy of social skills training versus no training for ADHD. The evidence base regarding adolescents is especially weak.

Processing Speed Predicts Behavioral Treatment Outcomes in Children with Attention-Deficit/Hyperactivity Disorder Predominantly Inattentive Type

Neuropsychological functioning underlies behavioral symptoms of attention-deficit/hyperactivity disorder (ADHD). Children with all forms of ADHD are vulnerable to working memory deficits and children presenting with the inattentive form of ADHD (ADHD-I) appear particularly vulnerable to processing speed deficits. As ADHD-I is the most common form of ADHD presented by children in community settings, it is important to consider how treatment interventions for children with ADHD-I may be affected by deficits in processing speed and working memory. We utilize data collected from 199 children with ADHD-I, aged 7 to 11 years, who participated in a randomized clinical trial of a psychosocial-behavioral intervention. Our aims are first to determine whether processing speed or working memory predict treatment outcomes in ADHD-I symptom severity, and second whether they moderate treatment effects on ADHD-I symptom severity. Results of linear regression analyses reveal that baseline processing speed significantly predicts posttreatment ADHD-I symptom severity when controlling for baseline ADHD-I symptom severity, such that better processing speed is associated with greater symptom improvement. However, predictive effects of working memory and moderation effects of both working memory and processing speed are not supported in the present study. We discuss study limitations and implications of the relation between processing speed and treatment benefits from psychosocial treatments for children with ADHD-I.

Social functioning in youth with attention-deficit/hyperactivity disorder and autism spectrum disorder: transdiagnostic commonalities and differences

Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are both neurodevelopmental disorders originating in childhood with high associated impairments and public health significance. There has been growing recognition of the frequent co-occurrence, and potential interrelatedness, between ADHD and ASD without intellectual disability. In fact, the most recent (5th) edition of the DSM is the first to allow ADHD and ASD to be diagnosed in the same individual. The study of transdiagnostic features in ADHD and ASD is important for understanding, and treating, these commonly co-occurring disorders. Social impairment is central to the description and prognosis of both disorders, and many youth with some combination of ADHD and ASD present to clinics for social skills training interventions. However, the aspects of social functioning that are impaired may have both shared and distinct features between the two disorders, relating to some overlapping and some diverse etiologies of social problems in ADHD compared to ASD. These findings have implications for interventions to address social problems in youth with these conditions. We conclude with a discussion about areas for future research and novel intervention targets in youth with ADHD, ASD, and their comorbidity.

Web-Based Intervention for Teachers of Elementary Students With ADHD: Randomized Controlled Trial

OBJECTIVE

To test the acceptability, satisfaction, and effectiveness of a web-based intervention for teachers of elementary school-aged children with ADHD.

METHOD

Elementary classroom teachers (N = 58), along with their students with ADHD, participated in a randomized controlled trial. The program consisted of six sessions that included evidence-based intervention strategies for reducing ADHD symptoms and impairment in the classroom setting. Teachers also had access to a moderated Discussion Board and an online ADHD coach. Questionnaire data were electronically collected from teachers and parents pre-intervention, post-intervention (6 weeks), and after an additional 6-week follow-up.

RESULTS

Intent-to-treat analyses found significant improvements based on teacher (but not parent) reports of core ADHD symptoms and impairment for the Teacher Help for ADHD treatment group. Teachers reported a high level of acceptability and satisfaction.

CONCLUSION

Web-based ADHD interventions have the potential to reduce the barriers to treatment utilization and implementation that are common problems for school-based ADHD interventions.

How are behavioural interventions delivered to children (5-11 years old): a systematic mapping review

CONTEXT

Behavioural interventions are used to prevent, manage and treat a wide variety of conditions including obesity, diabetes, chronic pain, asthma and emotional difficulties. There has been inadequate attention to the delivery of behavioural interventions to younger children (5-11 years old).

OBJECTIVE

Our objectives were to describe the characteristics of behavioural interventions for children aged 5-11 years.

DATA SOURCES

We searched five databases: CINAHL, EMBASE, PsycINFO, MEDLINE and Cochrane Library, from January 2005 to August 2019.

STUDY SELECTION

The inclusion criteria were (1) children aged 5-11, (2) cognitive and/or behavioural interventions, (3) randomised controlled trials and (4) 2005 onward. Two researchers independently identified studies for inclusion.

DATA EXTRACTION

Two researchers independently extracted data from eligible papers.

RESULTS

The search identified 10 541 papers. We extracted information on 117 interventions (from 152 papers). Many of the interventions were categorised as complex. This was particularly true for clinical populations; 78.7% were delivered to both the child and parent, and 33.9% took place across multiple settings, typically health and school settings. Most (70.9%) were 'First Wave' (behavioural) interventions, and few (4.3%) were 'Third Wave' (characterised by metacognition, acceptance and mindfulness). Thirty-nine per cent used interactive techniques (play, arts, story and/or games). Purely digital and paper-based interventions were rare, but around a third used these tools as supplements to face-face delivery. There were differences in interventions for younger (5-7 years) and older (8-11 years) children.

CONCLUSIONS

Interventions designed and delivered to children should be developmentally sensitive. This review highlights characteristics of interventions delivered to children 5-11 years old: the involvement of the child's parent, using behavioural (rather than cognitive) modalities, using interactive techniques and some interventions were delivered across multiple settings.

Practitioner Review: Current best practice in the use of parent training and other behavioural interventions in the treatment of children and adolescents with attention deficit hyperactivity disorder

BACKGROUND

Behavioural interventions are recommended for use with children and young people with attention deficit hyperactivity disorder (ADHD); however, specific guidance for their implementation based on the best available evidence is currently lacking.

METHODS

This review used an explicit question and answer format to address issues of clinical concern, based on expert interpretation of the evidence with precedence given to meta-analyses of randomised controlled trials.

RESULTS

On the basis of current evidence that takes into account whether outcomes are blinded, behavioural intervention cannot be supported as a front-line treatment for core ADHD symptoms. There is, however, evidence from measures that are probably blinded that these interventions benefit parenting practices and improve conduct problems which commonly co-occur with ADHD, and are often the main reason for referral. Initial positive results have also been found in relation to parental knowledge, children's emotional, social and academic functioning - although most studies have not used blinded outcomes. Generic and specialised ADHD parent training approaches - delivered either individually or in groups - have reported beneficial effects. High-quality training, supervision of therapists and practice with the child, may improve outcomes but further evidence is required. Evidence for who benefits the most from behavioural interventions is scant. There is no evidence to limit behavioural treatments to parents with parenting difficulties or children with conduct problems. There are positive effects of additive school-based intervention for the inattentive subtype. Targeting parental depression may enhance the effects of behavioural interventions.

CONCLUSIONS

Parent training is an important part of the multimodal treatment of children with ADHD, which improves parenting, reduces levels of oppositional and noncompliant behaviours and may improve other aspects of functioning. However, blinded evidence does not support it as a specific treatment for core ADHD symptoms. More research is required to understand how to optimise treatment effectiveness either in general or for individual patients and explore potential barriers to treatment uptake and engagement. In terms of selecting which intervention formats to use, it seems important to acknowledge and respond to parental treatment preferences.

Improved Parent Cognitions Relate to Immediate and Follow-Up Treatment Outcomes for Children With ADHD-Predominantly Inattentive Presentation

We investigated treatment effects on parenting self-efficacy and parent cognitive errors, and whether these parent cognitions are related to short- and long-term outcomes in parenting behaviors in psychosocial treatment for youth with attention-deficit/hyperactivity disorder, predominantly inattentive presentation (ADHD-I). In a randomized controlled trial across two sites (University of California, San Francisco, and University of California, Berkeley), 199 children between the ages of 7 and 11 were randomized to the Child Life and Attention Skills (CLAS; n = 74) program, parent-focused treatment (PFT; n = 74), or treatment as usual (TAU; n = 51). Parents reported on self-efficacy, cognitive errors, positive parenting, and negative parenting prior to treatment, immediately after treatment, and in the next school year at follow-up. Compared to TAU, CLAS and PFT had higher posttreatment parenting self-efficacy, and CLAS alone had lower posttreatment parent cognitive errors. At follow-up, only CLAS had improved parent cognitive errors compared to TAU. No other between-group differences were found in parenting self-efficacy or cognitive errors. Improved parenting self-efficacy was associated with improved posttreatment negative parenting outcomes for PFT and CLAS, and improved parent cognitive errors were also related to improvements in positive and negative posttreatment parenting outcomes for CLAS. Posttreatment parenting self-efficacy mediated follow-up negative parenting outcomes for CLAS and posttreatment parent cognitive errors mediated improved follow-up positive and negative parenting outcomes for CLAS. PFT and CLAS led to enhanced parenting self-efficacy, and CLAS appears especially robust in improving parent cognitive errors both in the short and long term. Pathways provide support for the possibility of parent cognitions as mediators of treatment effects on parenting; clinical focus on such cognitions may be useful.

Nonpharmacologic Treatments for Attention-Deficit/Hyperactivity Disorder: A Systematic Review

CONTEXT

Nonpharmacologic treatments for attention-deficit/hyperactivity disorder (ADHD) encompass a range of care approaches from structured behavioral interventions to complementary medicines.

OBJECTIVES

To assess the comparative effectiveness of nonpharmacologic treatments for ADHD among individuals 17 years of age and younger.

DATA SOURCES

PubMed, Embase, PsycINFO, and Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2009 through November 7, 2016.

STUDY SELECTION

We included studies that compared any ADHD nonpharmacologic treatment strategy with placebo, pharmacologic, or another nonpharmacologic treatment.

DATA EXTRACTION

Study design, patient characteristics, intervention approaches, follow-up times, and outcomes were abstracted. For comparisons with at least 3 similar studies, random-effects meta-analysis was used to generate pooled estimates.

RESULTS

We identified 54 studies of nonpharmacologic treatments, including neurofeedback, cognitive training, cognitive behavioral therapy, child or parent training, dietary omega fatty acid supplementation, and herbal and/or dietary approaches. No new guidance was identified regarding the comparative effectiveness of nonpharmacologic treatments. Pooled results for omega fatty acids found no significant effects for parent rating of ADHD total symptoms (n = 411; standardized mean difference -0.32; 95% confidence interval -0.80 to 0.15; I² = 52.4%; P = .10) or teacher-rated total ADHD symptoms (n = 287; standardized mean difference -0.08; 95% confidence interval -0.47 to 0.32; I² = 0.0%; P = .56).

LIMITATIONS

Studies often did not reflect the primary care setting and had short follow-up periods, small sample sizes, variations in outcomes, and inconsistent reporting of comparative statistical analyses.

CONCLUSIONS

Despite wide use, there are significant gaps in knowledge regarding the effectiveness of ADHD nonpharmacologic treatments.

Sustained Effects of Collaborative School-Home Intervention for Attention-Deficit/Hyperactivity Disorder Symptoms and Impairment

OBJECTIVES

The Collaborative Life Skills (CLS) program is a school-home intervention for students with attention-deficit/hyperactivity disorder (ADHD) symptoms and impairment. CLS integrates school, parent, and student treatments followed by booster sessions during a maintenance period into the subsequent school year. The program is delivered by school-based mental health providers. Beneficial post-treatment effects have been documented. This study evaluated the effects of CLS after the maintenance period in the subsequent school year.

METHOD

Using a cluster randomized design, schools within a large urban public school district were randomly assigned to CLS (12 schools) or usual services (11 schools). Approximately 6 students participated at each school (N = 135, grade range = 2-5). Measures were completed at baseline, after treatment, and follow-up during the next school year.

RESULTS

Students from schools assigned to CLS compared with those assigned to usual services showed significantly greater improvement at follow-up on parent, but not teacher, ratings of ADHD and oppositional defiant disorder symptom severity, organizational skills, and global impairment. Within-group analyses indicated that parent- and teacher-reported post-treatment gains for CLS in ADHD and oppositional defiant disorder symptoms, organizational skills, and academic competence were maintained into the next school year.

CONCLUSIONS

These results extend support for CLS to the following school year by demonstrating sustained benefits on parent-reported ADHD and oppositional defiant disorder symptoms and functional impairment. The lack of significant teacher-reported differences between CLS and usual services highlights the need for further study of booster treatments for improving outcomes with new teachers across school years.

CLINICAL TRIAL REGISTRATION INFORMATION

Study of the Collaborative Life Skills Program; http://clinicaltrials.gov; NCT01686724.

Parenting as a Mechanism of Change in Psychosocial Treatment for Youth with ADHD, Predominantly Inattentive Presentation

We investigated whether parenting and child behavior improve following psychosocial treatment for Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Presentation (ADHD-I) and whether parenting improvements mediate child outcomes. We analyzed data from a randomized clinical trial investigating the efficacy of a multicomponent psychosocial intervention (Child Life and Attention Skills, CLAS, n = 74) in comparison to Parent-Focused Treatment (PFT, n = 74) and treatment as usual (TAU, n = 51) for youth with ADHD-I (average child age = 8.6 years, range 7-11 years, 58 % boys). Child and parent/family functioning were assessed prior to treatment, immediately following treatment, and at follow-up into the subsequent school year using parent and teacher reports of inattention, organization, social skills, academic competency (teachers only), parenting daily hassles, and positive and negative parenting behaviors (parents only). Both treatment groups improved on negative parenting and home impairment, but only CLAS families also improved on positive parenting as well as academic impairment. Improvements in positive and negative parenting mediated treatment effects on child impairment independent of improvements in child inattention, implicating parenting as an important mechanism of change in psychosocial treatment for ADHD-I. Further, whereas parent-focused training produces improvements in negative parenting and impairment at home for children with ADHD-I, a multicomponent approach (incorporating child skills training and teacher consultation) more consistently produces improvements at school and in positive parenting, which may contribute to improvements in social skills into the next school year.

Cost-Effectiveness of a Behavioral Psychosocial Treatment Integrated Across Home and School for Pediatric ADHD-Inattentive Type

We conducted a cost-effectiveness analysis (CEA) of two behavioral psychosocial interventions for children with ADHD-inattentive type: Child Life and Attention Skills (CLAS) program and parent-focused treatment (PFT) compared to community-based treatment as usual (TAU). The CEA evaluated cost per ADHD case resolved measured by parent and teacher reports of ADHD inattentive symptoms. Total cost per patient for CLAS, PFT, and TAU were $1559, $710, and $0. CLAS, the costliest treatment, was more effective than PFT and TAU. The incremental cost-effectiveness ratios (ICER) per disordered case resolved are: $3997 for CLAS versus TAU, $3227 for PFT versus TAU, and $4994 for CLAS versus PFT. PFT is the more cost-effective option based on initial CEA. However, CLAS may be comparably cost-effective by streamlining the model, which resulted in an ICER of $29 compared to PFT. Notably, cost for CLAS is substantially below the annual cost for unresolved ADHD.

Engagement in Behavioral Parent Training: Review of the Literature and Implications for Practice

Engagement in behavioral parent training (BPT), including enrollment, attrition, attendance, within-session engagement, and homework completion, has long been a critical issue in the literature. Several estimates of various aspects of engagement have been suggested in the literature, but a systematic review of the available literature has never been accomplished. This review examines engagement data across 262 studies of BPT. Recruitment attrition, program attrition, attendance, and within-session engagement are examined across studies, with particular emphasis on the impact that SES, study purpose (efficacy vs. effectiveness), treatment format (individual vs. group), and age of child may have on those rates. Results of this review suggest that the significant amount of attrition occurs prior to enrollment in BPT, with at least 25 % of those identified as appropriate for BPT not enrolling in such programs. An additional 26 % begin, but drop out before completing treatment. Still the combined dropout rate of at least 51 % leaves at best half of identified parents completing treatment. While SES status had a small effect on attrition, other variables were not found to meaningfully impact engagement. Information on within-session engagement (homework and ratings of participation) was not often reported in studies. Key issues in this literature (e.g., varying definitions of engagement, limited attention to reporting key aspects of engagement) are discussed, and recommendations are made to further improve this important area of research and clinical practice.

Social Skills Training and ADHD-What Works?

PURPOSE OF REVIEW

Many children and adolescents with attention-deficit/hyperactivity disorder (ADHD) have difficulties in their social skills and peer relationships. Because social problems exacerbate later maladjustment in ADHD populations, it is important to address this serious impairment. Although social skills training (SST) is a common intervention approach, evidence to date suggests that SST has limited efficacy, at least when provided in traditional, clinic-based settings. The current review summarizes recent advances to traditional SST approaches that may potentially enhance their efficacy.

RECENT FINDINGS

We identify two promising directions in which SST may be modified to make it more efficacious for ADHD populations. The first direction involves providing increased reinforcement and reminders of appropriate social behavior at the point of performance to youth with ADHD (e.g., in vivo, in real life peer situations as opposed to in the clinic). We note the importance of ensuring that youth with ADHD are receptive to such reminders. The second direction involves encouraging peers to be more socially accepting and inclusive of youth with ADHD. This avenue has been understudied in the literature to date. SST for children and adolescents with ADHD may be enhanced by providing more in vivo reminders and feedback at the point of performance and by making efforts to alter peers' impressions about youth with ADHD.

Parental Cognitive Errors Mediate Parental Psychopathology and Ratings of Child Inattention

We investigate the Depression-Distortion Hypothesis in a sample of 199 school-aged children with ADHD-Predominantly Inattentive presentation (ADHD-I) by examining relations and cross-sectional mediational pathways between parental characteristics (i.e., levels of parental depressive and ADHD symptoms) and parental ratings of child problem behavior (inattention, sluggish cognitive tempo, and functional impairment) via parental cognitive errors. Results demonstrated a positive association between parental factors and parental ratings of inattention, as well as a mediational pathway between parental depressive and ADHD symptoms and parental ratings of inattention via parental cognitive errors. Specifically, higher levels of parental depressive and ADHD symptoms predicted higher levels of cognitive errors, which in turn predicted higher parental ratings of inattention. Findings provide evidence for core tenets of the Depression-Distortion Hypothesis, which state that parents with high rates of psychopathology hold negative schemas for their child's behavior and subsequently, report their child's behavior as more severe.

Meta-analysis of organizational skills interventions for children and adolescents with Attention-Deficit/Hyperactivity Disorder

BACKGROUND

In addition to problems with attention and hyperactivity, children with ADHD present with poor organizational skills required for managing time and materials in academic projects. Organizational skills training (OST) has been increasingly used to address these deficits. We conducted a systematic review and meta-analysis of OST in children with ADHD.

OBJECTIVES

The objective of this study was to systematically review the evidence of the effects of OST for children with ADHD for organizational skills, attention, and academic performance.

METHODS

We searched 3 electronic databases to locate randomized controlled trials published in English in peer-reviewed journals comparing OST with parent education, treatment-as-usual, or waitlist control conditions. Standardized mean difference effect sizes from the studies were statistically combined using a random-effects meta-analyses across six outcomes: teacher- and parent-rated organizational skills, teacher- and parent-rated inattention, teacher-rated academic performance, and Grade Point Average (GPA). Risk of bias was assessed for randomization, allocation concealment, blinding of participants and treatment personnel, blinding of outcome assessors, incomplete outcome data, and selective outcome reporting.

RESULTS

Twelve studies involving 1054 children (576 treatment, 478 control) were included in the meta-analyses. Weighted mean effect sizes for teacher- and parent-rated outcome measures of organizational skills were g=0.54 (95% CI 0.17 to 0.91) and g=0.83 (95% CI 0.32 to 1.34), respectively. Weighted mean effect sizes of teacher- and parent-rated symptoms of inattention were g=0.26 (95% CI 0.01 to 0.52) and g=0.56 (95% CI 0.38 to 0.74), respectively. Weighted standardized mean effect size for teacher-rated academic performance and GPA were g=0.33 (95% CI 0.14 to 0.51) and g=0.29 (95% CI 0.07 to 0.51), respectively.

CONCLUSIONS

OST leads to moderate improvements in organizational skills of children with ADHD as rated by teachers and large improvements as rated by parents. More modest improvements were observed on the ratings of symptoms of inattention and academic performance.

PROTOCOL REGISTRATION

PROSPERO (CRD42015019261).

Parent Adherence in Two Behavioral Treatment Strategies for the Predominantly Inattentive Presentation of ADHD

We examined the effects of parent adherence on child outcomes in two treatment strategies for the Predominantly Inattentive Presentation of attention deficit/hyperactivity disorder (ADHD-I): behavioral parent training adapted for ADHD-I (Parent-Focused Therapy [PFT]) and a multicomponent intervention that combined PFT, a child life skills group, and a classroom intervention (Child Life and Attention Skills Program [CLAS]). In a 2-site randomized controlled trial, 199 children (7-11 years of age) were randomized to PFT (n = 74), CLAS (n = 74), or treatment as usual (n = 51). Parent adherence was rated separately by parents and clinicians. Child outcomes included ADHD-I symptoms and parent- and teacher- rated impairment social, organizational, and home impairment. Results from multiple regression analyses utilizing a composite of parent and clinician ratings showed that parent adherence predicted improvement in all 3 parent-rated child impairment outcomes and no teacher-rated outcomes in the PFT treatment group. Adherence ratings did not predict any parent- or teacher-rated outcomes in the CLAS treatment group and did not predict ADHD symptom change in either treatment condition. These findings suggest that when parents are solely responsible for teaching and reinforcing new child skills and behaviors (as in PFT), their adherence to the assigned intervention may be especially important for improvement at home. It may be less critical in multicomponent interventions, like CLAS, where the responsibility for teaching new child skills is shared among parents, teachers, and child group clinicians. Parent adherence does not appear to impact child improvement in the school setting.

Predictors of Response to Behavioral Treatments Among Children With ADHD-Inattentive Type

The goal of the study was to examine baseline characteristics-child gender, IQ, age, internalizing problems, symptoms of hyperactivity/impulsivity (HI), oppositional defiant disorder, and sluggish cognitive tempo, and parent income, education, attention deficit/hyperactivity disorder (ADHD) severity, and anxiety/depression (A/D)-associated with response to behavioral treatments for ADHD, predominantly inattentive type. We employed data from 148 children (M = 8.7 years), 58% male, and 57% Caucasian in a randomized clinical trial. Positive treatment response was defined as (a) 5 or fewer inattentive symptoms and (b) a decrease of at least 3 inattentive symptoms from baseline to posttreatment. Child HI, parental A/D, and child IQ were associated with positive response, as follows: Child HI had a main effect in which it was negatively associated with treatment response (36% with 2 or more HI symptoms were positive responders vs. 59% of those with 1 or no symptoms) that was qualified by parental A/D and child IQ. When children had 2 or more symptoms of HI and higher parental A/D, positive response rate was low at 25%; when children had 2 or more symptoms of HI, low parental A/D, and an IQ of 105 or higher, positive response rate was 85%. Furthermore, the group with the poorest response rate (25%) had parents who self-reported greater ADHD severity, and the group with a relatively good rate of positive response (59%) had the lowest number of oppositional defiant disorder symptoms. Likelihood of positive response to our behavioral treatment for ADHD-I is dependent on child and parent factors.

A Randomized Controlled Trial of a School-Implemented School-Home Intervention for Attention-Deficit/Hyperactivity Disorder Symptoms and Impairment

OBJECTIVE

This study evaluated the efficacy of a novel psychosocial intervention (Collaborative Life Skills [CLS]) for primary-school students with attention-deficit/hyperactivity disorder (ADHD) symptoms. CLS is a 12-week program consisting of integrated school, parent, and student treatments delivered by school-based mental health providers. Using a cluster randomized design, CLS was compared with usual school/community services on psychopathology and functional outcomes.

METHOD

Schools within a large urban public school district were randomly assigned to CLS (12 schools) or usual services (11 schools). Approximately 6 students participated at each school (N = 135, mean age 8.4 years, grade range 2-5, 71% boys). Using PROC GENMOD (SAS 9.4), the difference between the means of CLS and usual services for each outcome at posttreatment was tested. To account for clustering effects by school, the generalized estimating equation method was used.

RESULTS

Students from schools assigned to CLS compared with those assigned to usual services had significantly greater improvement on parent and teacher ratings of ADHD symptom severity and organizational functioning, teacher-rated academic performance, and parent ratings of oppositional defiant disorder symptoms and social/interpersonal skills.

CONCLUSION

These results support the efficacy of CLS compared with typical school and community practices for decreasing ADHD and oppositional defiant disorder symptoms and improving key areas of functional impairment. They further suggest that existing school-based mental health resources can be redeployed from non-empirically supported practices to those with documented efficacy. This model holds promise for improving access to efficient evidence-based treatment for inattentive and disruptive behavior beyond the clinic setting. Clinical Trial Registration Information-Study of the Collaborative Life Skills Program; http://clinicaltrials.gov/; NCT01686724.

Trajectories and Predictors of Response to the Challenging Horizons Program for Adolescents With ADHD

The Challenging Horizons After School Program is one of the only psychosocial interventions developed specifically for adolescents with attention-deficit/hyperactivity disorder (ADHD) that has demonstrated efficacy in multiple randomized controlled trials. To date, however, all research with the intervention has evaluated outcomes at the group level, and it is unclear whether all adolescents respond similarly, or if the intervention is particularly well suited for certain adolescents with ADHD. This type of information is needed to guide stakeholders in making informed choices as part of dissemination and implementation efforts. The purpose of this study was to evaluate trajectories of response to intervention for a large sample of middle-school age adolescents with ADHD (grades 6-8) who received the after-school intervention (N=112). An additional goal of the study was to evaluate potential predictors of response trajectories, focusing on determining what factors best distinguished between intervention responders and nonresponders. Latent trajectory analyses consistently revealed four or five distinct classes. Depending on the outcome, between 16% and 46% of participants made large improvements, moving into the normal range of functioning, and between 26% and 65% of participants made small or negligible improvements. Multivariate predictor analyses revealed that a strong counselor/adolescent working alliance rated from the adolescent perspective and lower levels of parenting stress and parent-adolescent conflict consistently predicted an increased likelihood of intervention response. Implications of these findings for disseminating the after school intervention and for further intervention development are discussed.