The impact of a multimodal Summer Camp Training on neuropsychological functioning in children and adolescents with ADHD: An exploratory study

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.

Efficacy of non-pharmacological interventions on executive functions in children and adolescents with ADHD: A systematic review and meta-analysis

OBJECTIVE

Although front-line doctors recommend medications, this kind of treatment has limited efficacy in improving executive functions (EFs) in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). This study explored the effects of non-pharmacological intervention on EFs in children and adolescents with ADHD.

METHODS

In accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses guidelines, we searched seven electronic databases: APA PsycINFO, CINAHL Complete, EMBASE, ERIC, Medline, Pubmed, and Web of Science, from inception to March 2022. Two authors independently screened studies for eligibility, extracted data, and assessed bias risk using the Physiotherapy Evidence Database scale. Our analyses included randomized controlled trials and non-randomized comparison studies of non-pharmacological interventions and assessed EFs through neurocognitive tasks in children and adolescents between 5 and 18 years.

RESULTS

Sixty-seven studies with 3147 participants met the inclusion criteria. The final meta-analysis included 74 independent interventions categorized into six categories: cognitive training, EF-specific curriculum, game-based training, mindfulness practice, neurofeedback training, and physical exercise. Overall, non-pharmacological interventions (combined) produced significant moderate to large effects on overall EFs in children and adolescents with ADHD (g=0.673). Physical exercise had a large positive effect on domain-specific EFs, including inhibitory control (g=0.900) and cognitive flexibility (g=1.377). Cognitive training had a large training effect on working memory (g=0.907), and an EF-specific curriculum had a small to moderate beneficial effect on planning performance (g=0.532).

CONCLUSION

Non-pharmacological interventions, particularly physical exercise, cognitive training, and an EF-specific curriculum, appear to have beneficial effects on EFs in children and adolescents with ADHD.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

PRIMARY OUTCOMES

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

SECONDARY OUTCOMES

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

AUTHORS' CONCLUSIONS

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

Persistent Deficits in Self-Regulation as a Mediator between Childhood Attention-Deficit/Hyperactivity Disorder Symptoms and Substance Use Disorders

The link between attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs) has been largely demonstrated. Some scholars have hypothesized that self-regulation mechanisms might play a key role in explaining this association. Objective(s): The current study tested the hypothesis that retrospective childhood ADHD symptoms might lead to more severe SUDs and this association should be mediated by current self-ratings of behavioral disinhibition, inattention, and emotional dysregulation among 204 treatment-seeking adults (male: 67.3%; female: 32.7%) with a primary diagnosis of alcohol use disorder and other SUDs. Methods: The mediational model was estimated through self-report measures of childhood ADHD symptoms (independent variable; WURS), current self-regulation mechanisms (mediators)-behavioral disinhibition (BIS-11 motor subscale), difficulties with attention regulation (MAAS) and emotion regulation (DERS)-and severity of SUDs (dependent variable; SPQ alcohol, illicit and prescribed drugs). Results: The analysis showed that alterations in the self-regulation system fully mediated the association between the severity of childhood ADHD symptoms and SUDs in adulthood. Behavioral disinhibition and difficulties in attention regulation were the most representative alterations in self-regulation processes that explained this association. Conclusions: These findings suggest it is useful to implement several therapeutic approaches (e.g. behavioral, mindfulness-based, and pharmacological) to increase the self-regulation abilities of children and adolescents with ADHD in order to reduce the probability of SUD onset in adulthood. However, future longitudinal neuroimaging and neuropsychological studies are needed to further support the role of self-regulation mechanisms in explaining the prospective association between childhood ADHD symptoms and SUDs in adulthood.

Auch Du Hast Sommerferien

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

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

SECONDARY OUTCOMES

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

AUTHORS' CONCLUSIONS

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

Towards a functional model of mental disorders incorporating the laws of thermodynamics

The current paper presents the hypothesis that the understanding of mental disorders can be advanced by incorporating the laws of thermodynamics, specifically relating to energy conservation and energy transfer. These ideas, along with the introduction of the notion that entropic activities are symptomatic of inefficient energy transfer or disorder, were used to propose a model of understanding mental ill health as resulting from the interaction of entropy, capacity and work (environmental demands). The model was applied to Attention Deficit Hyperactivity Disorder, and was shown to be compatible with current thinking about this condition, as well as emerging models of mental disorders as complex networks. A key implication of the proposed model is that it argues that all mental disorders require a systemic functional approach, with the advantage that it offers a number of routes into the assessment, formulation and treatment for mental health problems.

Intensivtherapie

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

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

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