Behavioral Interventions for the Classroom: Implications for Students with ADHD

A Digital Cognitive-Physical Intervention for Attention-Deficit/Hyperactivity Disorder: Randomized Controlled Trial

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Pharmacotherapy has been the primary treatment for ADHD, supplemented by behavioral interventions. Digital and exercise interventions are promising nonpharmacologic approaches for enhancing the physical and psychological health of children with ADHD. However, the combined impact of digital and exercise therapies remains unclear.

OBJECTIVE

The aim of this study was to determine whether BrainFit, a novel digital intervention combining gamified cognitive and exercise training, is efficacious in reducing ADHD symptoms and executive function (EF) among school-aged children with ADHD.

METHODS

This 4-week prospective randomized controlled trial included 90 children (6-12 years old) who visited the ADHD outpatient clinic and met the diagnostic criteria for ADHD. The participants were randomized (1:1) to the BrainFit intervention (n=44) or a waitlist control (n=46) between March and August 2022. The intervention consisted of 12 30-minute sessions delivered on an iPad over 4 weeks with 3 sessions per week (Monday, Wednesday, and Friday after school) under the supervision of trained staff. The primary outcomes were parent-rated symptoms of attention and hyperactivity assessed according to the Swanson, Nolan, and Pelham questionnaire (SNAP-IV) rating scale and EF skills assessed by the Behavior Rating Inventory of Executive Function (BRIEF) scale, evaluated pre and post intervention. Intention-to-treat analysis was performed on 80 children after attrition. A nonparametric resampling-based permutation test was used for hypothesis testing of intervention effects.

RESULTS

Among the 145 children who met the inclusion criteria, 90 consented and were randomized; ultimately, 80 (88.9%) children completed the study and were included in the analysis. The participants' average age was 8.4 (SD 1.3) years, including 63 (78.8%) male participants. The most common ADHD subtype was hyperactive/impulsive (54/80, 68%) and 23 (29%) children had severe symptoms. At the endpoint of the study, the BrainFit intervention group had a significantly larger improvement in total ADHD symptoms (SNAP-IV total score) as compared to those in the control group (β=-12.203, 95% CI -17.882 to -6.523; P<.001), owing to lower scores on the subscales Inattention (β=-3.966, 95% CI -6.285 to -1.647; P<.001), Hyperactivity/Impulsivity (β=-5.735, 95% CI -8.334 to -3.137; P<.001), and Oppositional Defiant Disorder (β=-2.995, 95% CI -4.857 to -1.132; P=.002). The intervention was associated with significant reduction in the Metacognition Index (β=-6.312, 95% CI -10.973 to -1.650; P=.006) and Global Executive Composite (β=-5.952, 95% CI -10.214 to -1.690; P=.003) on the BRIEF. No severe intervention-related adverse events were reported.

CONCLUSIONS

This novel digital cognitive-physical intervention was efficacious in school-age children with ADHD. A larger multicenter effectiveness trial with longer follow-up is warranted to confirm these findings and to assess the durability of treatment effects.

TRIAL REGISTRATION

Chinese Clinical Trial Register ChiCTR2300070521; https://www.chictr.org.cn/showproj.html?proj=177806.

A neuro-computational social learning framework to facilitate transdiagnostic classification and treatment across psychiatric disorders

Social deficits are among the core and most striking psychiatric symptoms, present in most psychiatric disorders. Here, we introduce a novel social learning framework, which consists of neuro-computational models that combine reinforcement learning with various types of social knowledge structures. We outline how this social learning framework can help specify and quantify social psychopathology across disorders and provide an overview of the brain regions that may be involved in this type of social learning. We highlight how this framework can specify commonalities and differences in the social psychopathology of individuals with autism spectrum disorder (ASD), personality disorders (PD), and major depressive disorder (MDD) and improve treatments on an individual basis. We conjecture that individuals with psychiatric disorders rely on rigid social knowledge representations when learning about others, albeit the nature of their rigidity and the behavioral consequences can greatly differ. While non-clinical cohorts tend to efficiently adapt social knowledge representations to relevant environmental constraints, psychiatric cohorts may rigidly stick to their preconceived notions or overly coarse knowledge representations during learning.

Pre-service teachers' perceptions of sluggish cognitive tempo

Sluggish cognitive tempo (SCT) is characterized by a passive form of inattention that may not overtly disrupt classroom goals. Due to the nature of these symptoms, children with SCT may be "falling through the cracks" in schools. The current study examined pre-service teachers' perceptions of SCT in the classroom. Undergraduate education majors (n = 161) read vignettes describing fictitious fourth-grade boys presenting with symptoms of SCT, attention-deficit/hyperactivity disorder (ADHD), or a non-ADHD-related control: social anxiety disorder (SA), and rated each of the vignettes in terms of their perceptions of the boy described. Results were analyzed using repeated measures ANOVAs and paired-sample t tests. Pre-service teachers viewed all three sets of symptoms as concerning, but viewed ADHD behaviors as the most problematic. These results are promising, as they suggest that pre-service teachers are concerned about both hyperactive (i.e., ADHD) and non-hyperactive behavioral problems (i.e., SCT and SA). Implications and future directions are discussed.

Evidence-Based Psychological Treatments of Pediatric Mental Disorders

With many youth presenting to primary care settings for mental health difficulties, knowledge of the respective evidence-based psychotherapies is imperative in ensuring that these youth receive the appropriate interventions in a timely manner. Most frequently, children present with internalizing and/or externalizing disorders, which cover a broad range of common pediatric mental disorders. Treatments of these disorders generally incorporate cognitive and/or behavioral components, which are derived from theoretical underpinnings and empirical support. Although the interventions share common components, they are distinctive in nature and are further tailored toward the idiosyncratic needs of children and their families. Careful consideration of the apposite intervention and individual needs of youth are pertinent to the effective amelioration of symptomology.

A systematic review of meta-analyses of psychosocial treatment for attention-deficit/hyperactivity disorder

The present report synthesizes outcomes across meta-analyses of psychosocial (i.e., non-pharmacological) treatments for ADHD. A total of 12 meta-analyses were identified that met search criteria. The meta-analyses were notable in that there was surprisingly little overlap in studies included across them (range of overlap was 2-46 %). Further, there was considerable diversity across the meta-analyses in terms of the inclusion/exclusion criteria, types of psychosocial treatments reviewed, methodological characteristics, and magnitude of reported effect sizes, making it difficult to aggregate findings across meta-analyses or to investigate moderators of outcome. Effect sizes varied across the outcomes assessed, with meta-analyses reporting positive and significant effect sizes for measures of some areas of child impairment (e.g., social impairment) and small and more variable effect sizes for distal and/or untargeted outcomes (e.g., academic achievement). Results are reviewed in light of the larger literature on psychosocial interventions for ADHD, and specific recommendations for future meta-analyses of psychosocial treatments for ADHD are offered.

A program for at-risk high school students informed by evolutionary science

Improving the academic performance of at-risk high school students has proven difficult, often calling for an extended day, extended school year, and other expensive measures. Here we report the results of a program for at-risk 9th and 10th graders in Binghamton, New York, called the Regents Academy that takes place during the normal school day and year. The design of the program is informed by the evolutionary dynamics of cooperation and learning, in general and for our species as a unique product of biocultural evolution. Not only did the Regents Academy students outperform their comparison group in a randomized control design, but they performed on a par with the average high school student in Binghamton on state-mandated exams. All students can benefit from the social environment provided for at-risk students at the Regents Academy, which is within the reach of most public school districts.

Behaviors that discriminate ADHD in children and adolescents: primary symptoms, symptoms of comorbid conditions, or indicators of functional impairment?

OBJECTIVE

The objectives of this study were to evaluate whether behaviors that differentiate children and adolescents with ADHD from those without are related to the primary diagnostic criteria (i.e., inattention and impulsivity-hyperactivity), symptoms of comorbid conditions, functional impairment, or a combination, and to determine whether behaviors that discriminate are consistent between the key developmental stages of childhood and adolescence.

METHOD

Parents and teachers rated children and adolescents with a formal diagnosis of ADHD and those without any mental, physical, or emotional disorders on the multidimensional Behavior Assessment System for Children (2nd ed., BASC-2).

RESULTS

Results indicated that behaviors that discriminate children and adolescents with ADHD from those without were associated with primary symptoms, symptoms of comorbid conditions, and indicators of functional impairment. Teachers rated atypicality as the strongest discriminator of children with ADHD from those without and learning problems as the strongest discriminator of adolescents. Parents rated hyperactivity as the strongest discriminator for children and attention problems for adolescents. Activities of daily living was the third strongest discriminator of adolescents as rated by parents.

CONCLUSIONS

Findings supported the need for a multidimensional view of ADHD that adds emphasis to issues of functional impairment in routine, daily activities important to success in school and interpersonally. Findings showed that conceptualizing and assessing behaviors demonstrated by children and adolescents with ADHD as a whole instead of only equating a diagnosis of ADHD to hyperactivity, inattention, and impulsivity will establish a foundation for understanding, interpreting, and addressing students' academic and behavioral needs across the home and school.

Developmental pathways to severe antisocial behavior: interventions for youth with callous-unemotional traits

There is an emerging body of research that has focused on understanding the different causal pathways through which children develop severe aggressive and antisocial behavior. In addition, there is a substantial body of research indicating that certain models of intervention have some demonstrated level of effectiveness for preventing and treating antisocial behavior, albeit with some significant limitations. The focus of this paper is to integrate these two bodies of research in an effort to improve the effectiveness of the next generation of interventions for antisocial youth, especially those designed to prevent and treat certain subgroups of antisocial youth who have largely been unresponsive to existing approaches to intervention. One such group consists of those antisocial youths who show a callous and unemotional interpersonal style and who seem to be at risk for showing a particularly severe and aggressive pattern of antisocial behavior.

A group contingency program to improve the behavior of elementary school students in a cafeteria

Studies of behavior modification interventions for disruptive behavior in schools have generally focused on classroom behavior with less research directed toward child behavior in other school settings (e.g., cafeterias). The present report documents the effect of a group contingency intervention with a random reward component, targeting disruptive cafeteria behavior. An uncontrolled study of the effect of the group contingency program across the school year suggested substantial behavior improvement after the program started. Two natural treatment discontinuations during the same school year provide further support for the intervention. Both sources of information suggest behavioral improvement in rule-following behavior when the program was actively implemented.

ADHD and stuttering: a tutorial

The purpose of this tutorial is twofold. The first is to provide a brief description of some of the key diagnostic features of attention deficit hyperactivity disorder (ADHD) for speech-language pathologists who might not be knowledgeable about this disorder. The second purpose is to provide information and suggestions about treating children who stutter and who have been diagnosed with ADHD. Specific information is provided regarding medication used to treat ADHD symptoms as well as the minimal documented evidence of its impact on stuttering. Suggestions for educational, behavioral, and cognitive management of children who stutter and have ADHD also are discussed.

EDUCATIONAL OBJECTIVES

The reader will learn about and be able to: (1) identify diagnostic criteria for children with ADHD; (2) differentiate pharmacological, environmental, and behavioral interventions for children with ADHD; and (3) examine effective instructional techniques for children who stutter and have ADHD.

Effective interventions for children and adolescents with conduct disorder

Many different types of interventions have been used to treat children and adolescents with conduct disorder (CD). Unfortunately, most have had very limited effectiveness and, in some cases, have even shown iatrogenic effects. A primary reason for this limited effectiveness has been the failure of most treatments to directly address the causal mechanisms implicated in the development of CD. A few exceptions that have based interventions on the available research and that have proven to have some efficacy in reducing the conduct problems in youths with CD are reviewed. More important, a model for intervention is presented. This model emphasizes that interventions for youths with CD need to be comprehensive. That is, they need to take into account the myriad factors both within the child and within his or her social context that can cause and maintain CD symptoms. Further, interventions need to be individualized; they need to take into account the different pathways along which children may develop CD. Two intervention approaches that are consistent with these principles are reviewed, as are important directions for advancing treatment technology for youths with this disorder.

An intervention approach for children with teacher- and parent-identified attentional difficulties

Using a multimodal and multi-informant method for diagnosis, we selected 33 children by teacher and parent nomination for attention and work completion problems that met DSM-IV criteria for attention-deficit/hyperactivity disorder (ADHD). Of the 33 children in this group, 21 participated in the initial intervention, and 12 were placed in an ADHD control group and received the intervention after pre- and posttesting. A similarly selected group of 21 children without difficulties in attention and work completion served as a control group. Each child was assessed on pre- and posttest measures of visual and auditory attention. After an 18-week intervention period that included attention and problem-solving training, all children in the intervention and control groups were retested on visual and auditory tasks. Children in both ADHD groups showed significantly poorer initial performance on the visual attention task. Whereas the ADHD intervention group showed commensurate performance to the nondisabled control group after training, the ADHD control group did not show significant improvement over the same period. Auditory attention was poorer compared to the control group for both ADHD groups initially and improved only for the ADHD intervention group. These findings are discussed as a possible intervention for children with difficulties in strategy selection in a classroom setting.

Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children, adolescents, and adults with attention-deficit/hyperactivity disorder (ADHD). There are three types of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and combined. Together, they occur in as many as 10% of boys and 5% of girls of elementary school age. Prevalence declines with age, although up to 65% of hyperactive children are still symptomatic as adults. Frequency in adults is estimated to be 2% to 7%. Assessment includes clinical interviews and standardized rating scales from parents and teachers. Testing of intelligence and academic achievement usually are required. Comorbidity is common. The cornerstones of treatment are support and education of parents, appropriate school placement, and pharmacology. The primary medications are psychostimulants, but antidepressants and alpha-adrenergic agonists are used in special circumstances. Other treatments such as behavior modification, school consultation, family therapy, and group therapy address remaining symptoms.

ADHD children's responses to stimulant medication and two intensities of a behavioral intervention

Multimodal interventions involving pharmacotherapy and behavior therapy are increasingly viewed as the treatment of choice for Attention-Deficit Hyperactivity Disorder (ADHD). Virtually all investigations of combined treatments have involved powerful behaviortherapy packages including token economies. Such interventions are costly and labor intensive and not accessible to most youngsters with the disorder. This study examined the effects of a relatively simple behavioral intervention alone and in combination with stimulant medication. Subjects were three boys, ages 10 and 11, attending a summer day treatment program. Rates of off-task behavior in the classroom were examined in relation to all six possible conbinations of two doses of methylphenidate plus placebo and two "intensities" of teacher reprimands, immediate and delayed. Results suggest that for some children with ADHD, a simple behavioral intervention implemented in its most intense form can achieve results comparable to those achieved with medication. Additionally, for some children medication can obviate the need forthe most intense form of a behavioral intervention. A case-by-case assessment is necessary and feasible.