Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder

Feasibility study of a telehealth school-based behavioral parent training group program for attention-deficit/hyperactivity disorder

OBJECTIVE

To evaluate the feasibility and preliminary efficacy of Telehealth Behavioral Parent Training (T-BPT), a school telehealth group intervention for attention-deficit/hyperactivity disorder (ADHD) with a companion training program for school clinicians.

METHODS

T-BPT was developed in an iterative three-phase design in partnership with community stakeholders during the COVID-19 pandemic. School clinicians (N = 4) delivered T-BPT over 8 weeks to parents (N = 21, groups of 5-6 per school) of children (Grades 2-5) with ADHD while simultaneously receiving training and consultation from PhD-level study trainers. A single-arm open trial was used to assess feasibility, engagement, and preliminary efficacy.

RESULTS

Parents and school clinicians endorsed high feasibility, acceptability, and usability of T-BPT. Parent attendance was high (M = 94.6%) and a majority of parents (66.7%) attended all eight sessions. Preliminary outcomes indicate moderate to large reductions in parent-reported ADHD symptoms (ω2 = .36), functional and clinical global impairment (ω2s= .21 and .19, respectively), and distance learning challenges (ω2 = .22).

CONCLUSIONS

Results were in line with in-person delivery, indicating promising feasibility of school telehealth BPT groups. This study also provided further support for the feasibility of the remote training model for school clinicians. Implications of the commonly endorsed barriers and benefits beyond COVID-19 and relevance to under resourced communities are also discussed.

Diversity and representation in ADHD psychosocial treatment research: A comprehensive synthesis with data from over 10,000 participants

Demographic data from nearly 50 years of treatment research for children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are synthesized. Comprehensive search identified ADHD treatment studies that were between-group designs, included a psychosocial, evidence-based treatment, and were conducted in the United States. One hundred and twenty-six studies that included 10,604 youth were examined. Reporting of demographics varied with 48% of studies (k = 61) reporting ethnicity, 73% (k = 92) reporting race, 80% (k = 101) reporting age (M age = 8.81, SD = 2.82), and 88% (k = 111) reporting gender. Most participants identified as non-Hispanic/Latine (15.99% Hispanic/Latine), White (62.54%), and boys (74.39%; 24.47% girls). Since the 1970s, zero youth in ADHD treatment studies identified as Middle Eastern/North African, 0.1% were American Indian/Alaskan Native or Native Hawaiian Pacific Islander, 1.77% were Asian, 15.10% were Black, and 3.14% were Multiracial. Based on publication year, the proportions of girls, racially minoritized youth, and Hispanic/Latine youth included in ADHD treatment research have increased over time. Girls, non-binary and non-cisgender youth, young children, adolescents, Hispanic/Latine youth, and youth from all racial groups other than White are underrepresented in ADHD treatment research. Research gaps are discussed, and recommendations for comprehensive demographic reporting in child and adolescent psychological research are provided.

Measuring Children's Reward and Punishment Sensitivity: An Initial Psychometric Evaluation of the Contingency Response Rating Scale

Existing research shows that children's responses to rewards and punishments are essential for understanding attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, and callous-unemotional traits. The present study developed the Contingency Response Rating Scale (CRRS) to fulfill the need for a reliable and valid measure of children's contingency response style that is brief, easy to use in applied settings, and provides additional information to existing clinical measures. We examined the psychometric properties of the CRRS in a sample of 196 children (ages 5-12), most of whom were referred to evaluate attention and behavior problems in an outpatient clinic. Using principal axis factoring, we identified five factors: (a) punishment ineffectiveness, (b) reward ineffectiveness, (c) punishment dysregulation, (d) reward dysregulation, and (e) contingency insensitivity. The subscales based on these factors showed acceptable test-retest and internal consistency reliability, and scale intercorrelations varied from low to moderate. The subscales also captured significant variance not explained by child or parent demographics and were associated with measures of psychopathology and impairment. The results provide preliminary evidence that the CRRS may be a helpful tool for assessing reward and punishment sensitivity in children with attention and behavior problems.

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

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

Could Nature Contribute to the Management of ADHD in Children? A Systematic Review

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder that is typically managed with pharmacological and psychotherapeutic interventions. In the general population, exposure to nature has been found to have robust beneficial effects on cognitive performance, including attention. With inattention being a factor of the symptomatology of individuals with ADHD, this provides a rationale to investigate the potential benefits of exposure to nature for this population. Four electronic databases (PubMED, PsycINFO, Embase, and Web of Science) were searched for empirical studies investigating the effects of nature on ADHD prevalence and/or symptom severity in populations of school-aged children. Key characteristics, methodologies, and outcomes of included studies were extracted and evaluated. Out of the 458 studies identified, 7 met the inclusion criteria. Despite the large heterogeneity in methodological approaches, the included articles consistently reported that exposure to nature is associated with reduced ADHD diagnoses and symptom severity. Furthermore, when several covariates, such as age, gender, annual household income, parental income, and education level, as well as several pre-natal factors, were controlled for, the relationship between nature and ADHD remained significant. The reviewed literature provides strong support for the benefits of exposure to nature on ADHD in school-aged children.

Reconceptualizing the approach to supporting students with attention-deficit/hyperactivity disorder in school settings

The long-term academic outcomes for many students with attention-deficit/hyperactivity disorder (ADHD) are strikingly poor. It has been decades since students with ADHD were specifically recognized as eligible for special education through the Other Health Impaired category under the Education for all Handicapped Children Act of 1975, and similarly, eligible for academic accommodations through Section 504 of the 1973 Rehabilitation Act. It is time to acknowledge that these school-policies have been insufficient for supporting the academic, social, and behavioral outcomes for students with ADHD. Numerous reasons for the unsuccessful outcomes include a lack of evidence-based interventions embedded into school approaches, minimizing the importance of the general education setting for promoting effective behavioral supports, and an over-reliance on assessment and classification at the expense of intervention. Contemporary behavioral support approaches in schools are situated in multi-tiered systems of support (MTSS); within this article we argue that forward-looking school policies should situate ADHD screening, intervention, and maintenance of interventions within MTSS in general education settings and reserve special education eligibility solely for students who require more intensive intervention. An initial model of intervention is presented for addressing ADHD within schools in a manner that should provide stronger interventions, more quickly, and therefore more effectively.

Reducing Driving Risk Factors in Adolescents with Attention Deficit Hyperactivity Disorder (ADHD): Insights from EEG and Eye-Tracking Analysis

Adolescents with attention deficit hyperactivity disorder (ADHD) face significant driving challenges due to deficits in attention and executive functioning, elevating their road risks. Previous interventions targeting driving safety among this cohort have typically addressed isolated aspects (e.g., cognitive or behavioral factors) or relied on uniform solutions. However, these approaches often overlook this population's diverse needs. This study introduces the "Drive-Fun" innovative intervention (DFI), aimed at enhancing driving skills among this vulnerable population. The intervention was tested in a pilot study including 30 adolescents aged 15-18, comparing three groups: DFI, an educational intervention, and a control group with no treatment. Assessments included a driving simulator, EEG, and Tobii Pro Glasses 2. Evaluation was conducted pre- and post-intervention and at a 3-month follow-up. Results indicated that the DFI group significantly improved in the simulated driving performance, attentional effort, and focused gaze time. The findings underscore that holistic strategies with personalized, comprehensive approaches for adolescents with ADHD are particularly effective in improving driving performance. These outcomes not only affirm the feasibility of the DFI but also highlight the critical role of sensor technologies in accurately measuring and enhancing simulator driving performance in adolescents with ADHD. Outcomes suggest a promising direction for future research and application.

Measuring quality-of-care in treatment of young children with attention-deficit/hyperactivity disorder using pre-trained language models

OBJECTIVE

To measure pediatrician adherence to evidence-based guidelines in the treatment of young children with attention-deficit/hyperactivity disorder (ADHD) in a diverse healthcare system using natural language processing (NLP) techniques.

MATERIALS AND METHODS

We extracted structured and free-text data from electronic health records (EHRs) of all office visits (2015-2019) of children aged 4-6 years in a community-based primary healthcare network in California, who had ≥1 visits with an ICD-10 diagnosis of ADHD. Two pediatricians annotated clinical notes of the first ADHD visit for 423 patients. Inter-annotator agreement (IAA) was assessed for the recommendation for the first-line behavioral treatment (F-measure = 0.89). Four pre-trained language models, including BioClinical Bidirectional Encoder Representations from Transformers (BioClinicalBERT), were used to identify behavioral treatment recommendations using a 70/30 train/test split. For temporal validation, we deployed BioClinicalBERT on 1,020 unannotated notes from other ADHD visits and well-care visits; all positively classified notes (n = 53) and 5% of negatively classified notes (n = 50) were manually reviewed.

RESULTS

Of 423 patients, 313 (74%) were male; 298 (70%) were privately insured; 138 (33%) were White; 61 (14%) were Hispanic. The BioClinicalBERT model trained on the first ADHD visits achieved F1 = 0.76, precision = 0.81, recall = 0.72, and AUC = 0.81 [0.72-0.89]. Temporal validation achieved F1 = 0.77, precision = 0.68, and recall = 0.88. Fairness analysis revealed low model performance in publicly insured patients (F1 = 0.53).

CONCLUSION

Deploying pre-trained language models on a variable set of clinical notes accurately captured pediatrician adherence to guidelines in the treatment of children with ADHD. Validating this approach in other patient populations is needed to achieve equitable measurement of quality of care at scale and improve clinical care for mental health conditions.

Incorporating emotion coaching into behavioral parent training program: evaluation of its effectiveness

Disruptive behaviors in childhood yield negative mental health outcomes. Both behavioral management and emotion coaching parenting programs were effective in reducing children's disruptive behaviors. This randomized control trial (RCT) study evaluated the effectiveness of a community clinic-based, parent training program that incorporated emotion coaching into behavioral training (BPEC) for 119 parents who expressed difficulty in handling their elementary school-aged children's disruptive behaviors. These parents were randomly assigned to the treatment group or waitlist control. Pre-tests, post-tests, and 3-month delayed post-tests were administered. Compared to those in the waitlist control group, participants in the BPEC group reported significantly (a) fewer child oppositional behaviors and ADHD symptoms and (b) more positive aspects of the parent-child relationship. Significant short-term effects were maintained after 3-month for parent-reported, child oppositional behaviors. Thus, BPEC effectively reduced the disruptive behaviors of children.

Use of School-Based Interventions for ADHD, Professional Support, and Burnout Symptoms among Teachers in Iceland

OBJECTIVE

Effective school-based interventions for youth with ADHD are critical to their success. We examined whether teacher application of such interventions and perceptions of professional support related to greater well-being, including fewer burnout symptoms.

METHOD

Teachers in primary schools in Iceland were invited to participate in an online survey, including questions about professional support and the Maslach Burnout Inventory (MBI). The sample comprised N = 592 (88.5% female) participants.

RESULTS

Regression analyses indicated that use of recommended ADHD interventions was positively associated with MBI-Personal Achievement (PA). Greater satisfaction with professional support related to lower MBI-Emotional Exhaustion and MBI-Depersonalization, and higher MBI-PA. Level of professional support was positively associated with use of recommended interventions.

CONCLUSION

Effective interventions and support for students with ADHD may enhance teacher well-being. Icelandic teachers require further training and professional support in best practices for ADHD, to help promote teacher and student success.

Comparison of brief group behavioural parent training with individual parent training for preschool children with attention deficit hyperactivity disorder: A randomized feasibility study

BACKGROUND

Behaviour parent training (BPT) is first-line treatment for preschool attention deficit hyperactivity disorder (ADHD). BPT in a group format can be a cost- and time-effective alternative in low and middle-income countries (LMIC) settings with limited resources. We conducted a randomized controlled trial to compare the feasibility and efficacy of group BPT with individual BPT in improving ADHD severity in the preschool age group over 12 weeks.

METHODS

After approval by the ethical committee, the study was conducted in the child guidance clinic, JIPMER. Fifty-six children aged 2.5 to 6 years diagnosed with ADHD according to DSM5 were recruited. Children with autism spectrum disorder and a social quotient less than 50 were excluded. Block randomization parallel design was done. Group interventions were delivered with 4-8 parents per group, focusing on psychoeducation, structuring of routine, attention enhancing tasks, behavioural parenting techniques, and TAU. ADHD severity was assessed using Conner's abbreviated behaviour rating scale at baseline, 4, 8, and 12 weeks. Parental stress was estimated by FISC-MR adapted for ADHD. Statistical analysis included repeated measures ANOVA.

RESULTS

Significant improvement was noticed for both groups (F = 20.261, p < .001, ES (η2 ) = 0.539). Group intervention was not inferior to individual BPT in reducing ADHD severity (F = 0.860, p = .468, ES (η2 ) = 0.047). There was a statistically significant difference from baseline to 12 weeks of intervention in the reduction of parental stress (F = 20.80, p < .001, ES (η2 ) = 0.278) and enhancement of the coping strategies (F = 64.4, (p < .001), ES (η2 ) = 0.78). The intervention had high attendance and fidelity rates.

CONCLUSION

Group BPT was promising in treating ADHD in low-resource settings.

Efficacy of the Fast Track Friendship Group Program for Peer-rejected Children: A Randomized-Controlled Trial

OBJECTIVE

To evaluate the benefits of the Fast Track Friendship Group program implemented as a stand-alone school-based intervention on the social cognitions, social behavior, peer and teacher relationships of peer-rejected students.

METHOD

Over four successive years, 224 peer-rejected elementary students (57% White, 17% Black, 20% Latinx, 5% multiracial; 68% male; grades 1-4; Mage = 8.1 years old) were identified using peer sociometric nominations and randomly assigned to the intervention (n = 110) or a treatment-as-usual control group (n = 114). Four school districts serving economically-disadvantaged urban and rural communities participated. Intervention involved weekly small group social skills training with classmate partners, with sessions tailored to address individual child needs. Consultation meetings held at the start and mid-point of intervention were designed to help teachers and parents support the generalization of targeted skills.

RESULTS

Multi-level linear models, with children nested within schools (controlling for demographics and baseline scores) documented improvements in social-cognitive skills (direct assessments of emotion recognition and competent social problem-solving), social behavior (teacher ratings of social skills and externalizing behavior), and interpersonal relationships (peer sociometric nominations of peer acceptance and friendships, teacher-rated student-teacher closeness). Significant effects were generally small (ds = .19-.36) but consistent across child sex, grade level, and behavioral characteristics.

CONCLUSIONS

The intervention proved feasible for high-fidelity implementation in school settings and produced significant improvements in the social adjustment of peer-rejected children, validating the approach as a school-based Tier 2 intervention.

Peer-Based Intervention for Socioemotional Concerns Among Children with ADHD

This study examined the potential benefits of peer-based dyadic interventions for improving the socioemotional functioning of children with ADHD. Participants included children ages 8-12 diagnosed with ADHD-combined type (n = 34) pooled from a larger randomized study comparing peer-based dyadic interventions. Self-concept and depressive symptoms were evaluated at pre- and post-treatment using single group design. Results showed significantly positive child responses to intervention for self-concept. Further, improvements in self-concept were not moderated by the type of dyadic intervention received or by treatment related changes in externalizing behaviors. The severity of reported depressive symptoms, however, did not significantly change. This suggests therapeutic interaction with peers, as demonstrated in peer-based dyadic intervention models, can improve self-concept in children with ADHD even when socioemotional concerns are not a primary target of treatment and independent of behavioral outcomes achieved. These preliminary findings support promoting prosocial peer behavior as a critical domain for ADHD intervention for children.

Single and Combined Effects of Multiple Intensities of Behavioral Modification and Methylphenidate for Children with ADHD in the Home Setting

Behavioral treatment, stimulants, and their combination are the recommended treatments for childhood attention-deficit/hyperactivity disorder (ADHD). The current study utilizes within-subjects manipulations of multiple doses of methylphenidate (placebo, 0.15, 0.30, and 0.60 mg/kg/dose t.i.d.) and intensities of behavioral modification (no, low, and high intensity) in the summer treatment program (STP) and home settings. Outcomes are evaluated in the home setting. Participants were 153 children (ages 5-12) diagnosed with ADHD. In alignment with experimental conditions implemented during the STP day, parents implemented behavioral modification levels in three-week intervals, child medication status varied daily, and the orders were randomized. Parents provided daily reports of child behavior, impairment, and symptoms and self-reported parenting stress and self-efficacy. At the end of the study, parents reported treatment preferences. Stimulant medication led to significant improvements across all outcome variables with higher doses resulting in greater improvement. Behavioral treatment significantly improved child individualized goal attainment, symptoms, and impairment in the home setting and parenting stress and self-efficacy. Effect sizes indicate that behavioral treatment combined with a low-medium dose (0.15 or 0.30 mg/kg/dose) of medication results in equivalent or superior outcomes compared to a higher dose (0.60 mg/kg/dose) of medication alone. This pattern was seen across outcomes. Parents overwhelmingly reported preferring treatment with a behavioral component as a first-choice treatment (99%). Results underscore the need to consider dosing as well as parent preference when utilizing combined treatment approaches. This study provides further evidence that combining behavioral treatment and stimulant medication may reduce the stimulant dose needed for beneficial effects.

Involving Parents in Child Mental Health Treatments: Survey of Clinician Practices and Variables in Decision Making

OBJECTIVE

Child therapy outcomes research has indicated that involving parents in child mental health treatments is generally beneficial. This study aimed to explore clinicians' decisions to involve parents in treatment for childhood disorders and child-, parent-, and clinician-related variables influencing these decisions.

METHODS

Data on decision making and reported use of parent involvement by 40 therapists with patients ages 6-12 were obtained from a self-report survey. Most clinicians were psychologists, White, and female and worked in community-based clinics. They reported using cognitive-behavioral and family system interventions considerably more than psychodynamic therapy.

RESULTS

Clinician-reported use of parent involvement was significantly greater for children with oppositional defiant or conduct disorder than for those with attention-deficit hyperactivity disorder, depression, anxiety, or posttraumatic stress disorder or trauma. A child's age and diagnosis (100% of clinicians), parental level of stress (85%), and parent interest in working with the clinician (60%) were frequently reported as being important to clinicians' decisions. Ninety percent of clinicians reported that they believed working with parents was effective, whereas only 25% reported their own training to be influential in decision making.

CONCLUSIONS

Findings regarding use of parent involvement stratified by common childhood disorder were not surprising, given the behavioral and treatment complexities of oppositional defiant or conduct disorder. Clinicians often reported parents' stress level and interest in working with the clinician as influencing decision making, reflecting the importance of lesser researched decision variables. The relatively limited influence of training on decision making suggests the need for better parent involvement education for clinicians treating children.

Behavioral Parent Training Engagement Among Young Children With Autism Spectrum Disorder

The purpose of the current study was to examine engagement with Behavioral Parent Training (BPT) for families of children with Autism Spectrum Disorder (ASD) and assess openness to novel delivery formats for BPT (e.g., telehealth, group). Participants were caregivers of 501 children with ASD (ages 2-6) enrolled in the SPARK (Simons Foundation Powering Autism Research for Knowledge) online national registry. The study assessed: (1) rates of child disruptive behavior diagnoses, (2) engagement and satisfaction with BPT, (3) parent and child factors (e.g., diagnostic history), and (4) openness to novel delivery formats. Almost 25% of young children with ASD in this sample had disruptive behavior problems rising to the level of a diagnosis of ADHD or ODD and thus would benefit from BPT. However, only one third of these families had actually been referred to BPT. Families indicated high level of interest in participating in BPT, with a particular interest in Parent Child Interaction Therapy (PCIT) as well as novel delivery formats such as telehealth and group. Specific components of the therapy and delivery formats were indicative of parent satisfaction (e.g. groups, longer treatment sessions, longer treatment length). Specific parent and child characteristics were predictive of openness to novel formats (e.g. parental depression, more severe behavioral challenges, lower verbal skills). Results underscore the need for increased referrals and access to BPT programs the ASD population. Both parent and child characteristics are important for determining appropriate delivery formats.

Intervention and Implementation Characteristics to Enhance Father Engagement: A Systematic Review of Parenting Interventions

In recent years, the prevalence rates of children's mental health disorders have increased with current estimates identifying that as many as 15-20% of children meet criteria for a mental health disorder. Unfortunately, the same robust parenting interventions which have long targeted some of the most common and the most treatable child concerns (e.g., externalizing, disruptive behavior, and aggression) have also shown consistently low rates of father engagement. This persistent issue of engagement comes in the wake of an increasingly large body of literature which highlights the unique positive contributions fathers make to children and families when they are engaged in parenting interventions. As the role fathers play in families shifts to become more inclusive of childcare responsibilities and less narrowly defined by financial contributions, it becomes increasingly important to understand how best to engage fathers in interventions that aim to enhance parenting efficacy and family outcomes such as coparenting. The current review examined intervention (e.g., format and setting) and implementation characteristics (e.g., training and agency-level changes) associated with father engagement. Particular attention is paid to studies which described father-specific engagement strategies (e.g., inviting fathers directly, father-only groups, and adapting intervention to incorporate father preferences). A total of 26 articles met inclusion criteria after screening and full-text review. Results indicate that father engagement (i.e., initiating treatment) remains low with 58% of studies either not reporting father engagement or having engagement rates below 50%. More than two-thirds of studies did not include specific father engagement strategies. Those that did focused on changes to treatment format (e.g., including recreational activities), physical treatment setting (e.g., in-home and school), and reducing the number of sessions required for father participation as the most common father-specific engagement strategies. Some studies reported efforts to target racially and ethnically diverse fathers, but review results indicated most participants identified as Non-Hispanic White. Interventions were largely standard behavioral parent training programs (e.g., PCIT and PMT) with few exceptions (e.g., COACHES and cultural adaptations), and very few agencies or programs are systematically making adjustments (e.g., extended clinic hours and changes to treatment format) to engage fathers. Recommendations for future directions of research are discussed including the impact of differential motivation on initial father engagement in treatment, the importance of continuing to support diverse groups of fathers, and the potential for telehealth to address barriers to father engagement.

Conceptualizing the Role of Parent and Child Emotion Regulation in the Treatment of Early-Onset Behavior Disorders: Theory, Research, and Future Directions

Behavior disorders (BDs) are common and costly, making prevention and early-intervention a clinical and public health imperative. Behavioral Parent Training (BPT) is the standard of care for early-onset (3-8 years old) BDs, yet effect sizes vary and wane with time suggesting the role of underlying factors accounting for variability in outcomes. The literature on emotion regulation (ER), which has been proposed as one such underlying factor, is reviewed here, including a brief overview of ER, theory and research linking ER, externalizing symptoms, and/or BDs, and still largely preliminary work exploring the role of parent and child ER in BPT outcomes. Research to date provides clues regarding the interrelationship of ER, BDs, and BPT; yet, determining whether adaptations to BPT targeting ER are necessary or useful, for whom such adaptations would be most important, and how those adaptations would be implemented requires addressing mixed findings and methodological limitations. To guide such work, we propose a conceptual model elucidating how standard BPT may impact ER and processes linked to ER, which we believe will be useful in organizing and advancing both basic and applied research in future work.

Supporting Parents of Children with ADHD During COVID-19 School Closures: A Multiple-Baseline Trial of Behavioral Parent Training for Home Learning

During the COVID-19 pandemic, schools rapidly changed from in-class instruction to remote learning. Parent involvement and management of the home learning situation was greatly emphasized, and this presented challenges and opportunities for parents of children with attention-deficit/hyperactivity disorder (ADHD). There was an urgent need for effective parent support in the home learning situation, particularly for parents of youth with ADHD. The current study implemented a behavioral parent training (BPT) program, an evidence-based intervention for childhood ADHD, modified to target home learning and be delivered via telehealth. The intervention was evaluated in a multiple baseline trial across families of youth with ADHD (n = 3). The primary outcome was daily, parent-reported academic engagement during home learning. Parents also completed daily ratings of their child's respectful and disruptive behavior, and remote, home observations of academic tasks were recorded at baseline and post-treatment. Based on visual analysis of baseline, treatment and post-treatment daily ratings, two of the three participants had a positive response to treatment indicated by improved academic engagement. These findings provide preliminary support for the home-learning, telehealth-delivered BPT program in supporting families during the COVID pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12310-023-09569-y.

Understanding Problematic Social Media Use in Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD): A Narrative Review and Clinical Recommendations

Attention-Deficit/Hyperactivity Disorder (ADHD) is consistently associated with a host of social problems, such as victimization and difficulties in maintaining close friendships. These problems are not limited to offline relations but also manifest in the online social world, as previous research shows that ADHD is associated with problematic use of social media. Given the ubiquitous nature of social media, the goal of the current review is to understand why adolescents with ADHD demonstrate more problematic social media use than their typically developing peers. To this end, we provide a narrative review on the evidence for the link between ADHD and social media use, and consequently present an integrative framework, which encompasses neurobiological mechanisms (i.e., imbalance theory of brain development and dual pathway model of ADHD) and social mechanisms, including influences from peers and parents. We conclude that empirical work shows most consistent evidence for the link between problematic social media use and ADHD (symptoms), while intensity of social media use is also associated with several other behaviors and outcomes. Finally, we hypothesize how existing interventions for ADHD may work on the identified mechanisms and provide at-hand clinical recommendations for therapists working with adolescents with ADHD who exhibit problematic social media use.

Therapeutic Approaches for ADHD by Developmental Stage and Clinical Presentation

Attention Deficit Hyperactivity Disorder is a neurodevelopmental disorder with three presentations: inattentive, hyperactive/impulsive and combined. These may represent an independent disease entity. Therefore, the therapeutic approach must be focused on their neurobiological, psychological and social characteristics. To date, there is no comprehensive analysis of the efficacy of different treatments for each presentation of ADHD and each stage of development. This is as narrative overview of scientific papers that summarize the most recent findings and identify the most effective pharmacological and psychosocial treatments by ADHD presentation and age range. Evidence suggests that methylphenidate is the safest and most effective drug for the clinical management of children, adolescents and adults. Atomoxetine is effective in preschoolers and maintains similar efficacy to methylphenidate in adults, whereas guanfacine has proven to be an effective monotherapy for adults and is a worthy adjuvant for the management of cognitive symptoms. The psychosocial treatments with the best results in preschoolers are behavioral interventions that include training of primary caregivers. In adolescents, the combination of cognitive and cognitive-behavioral therapies has shown the best results, whereas cognitive-behavioral interventions are the most effective in adults. Pharmacological and psychosocial treatments must be adjusted to the ADHD presentation and its neurocognitive characteristics through the patient's development.

Behavioral Parent Training for Preschool ADHD: Family-Centered Profiles Predict Changes in Parenting and Child Outcomes

OBJECTIVE

Behavioral parent training (BPT) is the first line of treatment for preschool-aged children with attention-deficit hyperactivity disorder (ADHD); however, clinically significant improvements are not universal. In the current study, we employ a person-centered approach to create subgroups of families based on the intersection of multiple parent, child, and family pre-treatment factors. Further, we explore the utility of pre-treatment family profiles in predicting post-treatment differences in observed parenting behavior (i.e., behavioral control, parental warmth) and clinically significant change in child ADHD and oppositional symptoms.

METHOD

Longitudinal data were collected using observational and parent-, teacher- and clinician-reported assessments from 130 parent-child dyads (Mage= 3.57, range = 3.0- 4.11, 73.8% male, 69.2% White, 25.6% Hispanic) participating in BPT.

RESULTS

Findings from the current study suggest three distinct family profiles, which consisted of one profile with high family stress (HFS) as evidenced by elevated symptomatology across parent, child, and family-level domains, a second profile with elevated parental anxiety (PA), and a final profile with elevated parental depression (PD). These family-centered profiles were differentially associated with changes in observed parenting practices. Specifically, the PD profile (39%) demonstrated minimal improvements in behavioral control and warmth following treatment. In contrast, the HFS profile (30%) only improved in behavioral control and the PA profile (31%) improved in both parenting domains following treatment. In addition, marginally significant differences in child oppositional and ADHD symptoms were observed across profiles.

CONCLUSIONS

Family-centered approaches may be useful for selecting and implementing interventions.

Associations between Family Functioning and Symptoms of Attention-Deficit Hyperactivity Disorder (ADHD): A Cross-Sectional Study

Poor family functioning is linked with poor child ADHD symptoms. However, there are many dimensions of family functioning. Thus, this study aims to find the association between each dimension of family functioning and controlled ADHD symptoms in an Asian culture. This cross-sectional study involved caregivers of 113 Thai children with ADHD ages 4–16 years old who visited the Outpatient Department at Maharaj Nakorn Chiang Mai Hospital between October 2017 and March 2018. The caregivers completed the Chulalongkorn Family Inventory and the SNAP-IV Thai version. Logistic regression was used to examine each dimension of family functioning adjusting for potential confounders. In univariate analyses, six of the seven dimensions of family functioning were associated with controlled ADHD symptoms. In multivariate analyses, findings revealed that good family roles (aOR 7.48, 95% CI = 1.56 to 35.85, p = 0.01) and behavior control (aOR 2.56, 95% CI = 1.08 to 6.03, p = 0.03) were associated with controlled ADHD symptoms. In children with ADHD with poor symptom control, the assessment of family functioning could be helpful. Developing a more specific intervention for caregivers that promotes good family roles and behavioral control may be beneficial.

Classifying Young Children with Attention-Deficit/Hyperactivity Disorder Based on Child, Parent, and Family Characteristics: A Cross-Validation Study

We aimed to identify subgroups of young children with differential risks for ADHD, and cross-validate these subgroups with an independent sample of children. All children in Study 1 (N = 120) underwent psychological assessments and were diagnosed with ADHD before age 7. Latent class analysis (LCA) classified children into risk subgroups. Study 2 (N = 168) included an independent sample of children under age 7. A predictive model from Study 1 was applied to Study 2. The latent class analyses in Study 1 indicated preference of a 3-class solution (BIC = 3807.70, p < 0.001). Maternal education, income-to-needs ratio, and family history of psychopathology, defined class membership more strongly than child factors. An almost identical LCA structure from Study 1 was replicated in Study 2 (BIC = 5108.01, p < 0.001). Indices of sensitivity (0.913, 95% C.I. 0.814−0.964) and specificity (0.788, 95% C.I. 0.692−0.861) were high across studies. It is concluded that the classifications represent valid combinations of child, parent, and family characteristics that are predictive of ADHD in young children.

A Review of Clinical Practice Guidelines in the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder

Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. CPGs have evolved during the last 2 decades from general consensus statements by prominent practitioners in the field to highly structured instruments. The Institute of Medicine has laid out specific standards for selecting the experts who develop a CPG and the process by which CPGs are developed. Attention-deficit/hyperactivity disorder (ADHD) has been the focus of more than 20 CPGs created by governments and professional societies, both in the United States and internationally. There is a good deal of consensus across these CPGs regarding the principles of the diagnosis and treatment of ADHD. Drawing on the rich research base in ADHD, all CPGs emphasize the need for screening, a diagnosis based on history and standardized rating scales, as well as the use of evidence-based psychosocial and pharmacologic treatments. They vary in terms of their emphasis on the role of psychosocial treatment and the degree to which they address comorbid disorders in ADHD. Although limited research has shown ADHG CPGs do change provider practice, there is no research examining if the changes in practice brought about by CPGs impact patient outcomes.

Attention-Deficit/Hyperactivity Disorder Practice Patterns: A Survey of Kentucky Pediatric Providers

OBJECTIVE

Kentucky ranks among the highest in the nation for attention-deficit/hyperactivity disorder (ADHD) prevalence in children aged 4 to 17 years. In 2011, the American Academy of Pediatrics (AAP) released a clinical practice guideline based on the DSM-IV. A guideline revision based on the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) was released in October 2019. In this study, we assess and describe pediatric providers' ADHD practices using the 2011 guideline and DSM-5 diagnostic criteria.

METHODS

This was a cross-sectional, survey-based descriptive study. Kentucky Chapter of the AAP (KY AAP) members were anonymously surveyed. The results were examined for trends in routine practice.

RESULTS

Fifty-eight general pediatricians and pediatric residents responded to the survey, yielding a 38% (58/154) response rate. Among respondents performing routine diagnosis of ADHD (N = 51), 73% (37/51) used DSM-5 criteria. Most providers usually or always initially assessed for coexisting behavioral conditions (96%; 49/51), developmental conditions (78%; 39/51), and adverse childhood experiences (73%; 37/51). Among respondents performing routine management of ADHD (N = 55), only 11% (6/55) of respondents indicated that they titrated stimulant medications every 3 to 7 days. After initiation of medication, 78% of providers scheduled a follow-up visit within 2 to 4 weeks. During subsequent visits, only half indicated discussing behavioral interventions, screening for coexisting conditions, and reviewing follow-up teacher-rated ADHD scales.

CONCLUSION

Pediatricians in the KY AAP adhere to the DSM-5 criteria for diagnosing ADHD. Pediatric providers' practices would benefit from education in improvements in pharmacotherapy titration, surveillance of coexisting conditions associated with ADHD, discussion of psychosocial interventions, and school support strategies.

Identification and Characterization of Influential Factors in Susceptibility to Attention Deficit Hyperactivity Disorder Among Preschool-Aged Children

Attention deficit hyperactivity disorder (ADHD) is the most common childhood-onset neurodevelopmental disorder. Currently, increasing amounts of attention have been focused on the epidemiologic profiling of ADHD in children, viewed as a continuously distributed risk dimension throughout the whole lifespan. This study aimed to identify and characterize potential influential factors susceptible to ADHD-related symptoms among preschool-aged children. A comprehensive questionnaire was self-designed for both children and their parents or guardians and was distributed to 30 kindergartens from Beijing and Hebei, collecting potential influential factors in susceptibility to ADHD. ADHD was assessed by the Conner’s Abbreviated Symptom Questionnaire (C-ASQ), and 7,938 children were analyzed. Least absolute shrinkage and selection operator (LASSO) regression and hierarchical degree of adjustment were used to control possible covariates. Five factors, namely, children’s secondhand smoking exposure, breastfeeding duration, sleep mode, maternal pregnancy smoking exposure, and parental self-rating for patience, were identified to be independently and significantly associated with ADHD susceptibility. Meanwhile, dose–response relationships were observed between breastfeeding duration, parental self-rating for patience, and ADHD-related symptoms. Finally, a nomogram model was created for predicting ADHD susceptibility based on significant and conventional attributes under each criterion.

School-Based Interventions for Elementary School Students with Attention-Deficit/Hyperactivity Disorder

Children with attention-deficit/hyperactivity disorder experience significant academic, social, and behavioral impairments in elementary school settings. Although psychopharmacologic treatments can improve symptomatic behaviors, these rarely are sufficient for enhancing school performance. Thus, medication should be supplemented by one or more school interventions, including behavioral strategies, academic interventions, behavioral peer interventions, organizational skills training, and self-regulation strategies. Although all of these school interventions have been found effective, classroom behavioral strategies, organizational skills training, and self-regulation strategies have the strongest empirical support. Clinicians should collaborate with school mental health professionals to encourage implementation of effective school interventions across school years.

Family-based treatments for attention-deficit/hyperactivity disorder: A review of family functioning outcomes in randomized controlled trials from 2010 to 2019

This review details advances in randomized controlled trials of family-based treatments for attention-deficit/hyperactivity disorder (ADHD) conducted in the United States from 2010 to 2019, and the impact of these treatments on the domain of family functioning. Twenty-two studies were included in the review and three types of family treatments, integrated parent-child treatments, parent-directed treatments, and youth treatments with adjunctive parent involvement, were identified for children and adolescents. Studies point to considerable advancements in consideration of understudied and diverse populations, and results of the review show all three types of family interventions for ADHD should be considered well-established interventions addressing family functioning. Practical guidelines are offered, and future directions for research are discussed.

Enhancing neural markers of attention in children with ADHD using a digital therapeutic

Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental condition characterized by diminished attentional control. Critically, these difficulties are related to negative consequences in real-life functioning both during development and into adulthood. There is now growing evidence that modulating the underlying neural circuits related to attention can improve behavior and brain function in children with ADHD. We have previously shown that game-based digital therapeutics targeting a key neural marker of attention-midline frontal theta (MFT)-yield positive effects on attentional control in several populations. However, the effects of such digital therapeutics in children with ADHD and no other comorbidities has not been yet examined. To address this gap, we assessed a sample of 25 children with ADHD (8-12 years old) on neural, behavioral, and clinical metrics of attention before and after a 4-week at-home intervention on an iPad targeting MFT circuitry. We found that children showed enhancements on a neural measure of attention (MFT power), as well as on objective behavioral measures of attention and parent reports of clinical ADHD symptoms. Importantly, we observed relationships between the neural and behavioral cognitive improvements, demonstrating that those children who showed the largest intervention-related neural gains were also those that improved the most on the behavioral tasks indexing attention. These findings provide support for using targeted, digital therapeutics to enhance multiple features of attentional control in children with ADHD. Study registration: ClinicalTrials.gov registry (NCT03844269) https://clinicaltrials.gov/ct2/show/NCT03844269.

COVID-19 and the Acceleration of Behavioral Parent Training Telehealth: Current Status and Future Directions

The SARS-COV-2 (COVID-19) pandemic and associated social distancing guidelines have accelerated the telehealth transition in mental health. For those providing Behavioral Parent Training (BPT), this transition has called for moving sessions that are traditionally clinic-based, active, and directive to engaging, supporting, and treating families of children with behavior disorders remotely in their homes. Whereas many difficulties accompany this transition, the lessons learned during the current public health crisis have the potential to transform BPT service delivery on a large scale in ways that address many of its long-standing limitations. We describe both challenges and opportunities and consider the possibilities inherent in a large scale BPT service delivery model capable of increasing the reach and impact of evidence-based treatment for all families.

Combined Treatment for Children with Attention-Deficit/Hyperactivity Disorder: Brief History, the Multimodal Treatment for Attention-Deficit/Hyperactivity Disorder Study, and the Past 20 Years of Research

Decades of research support 3 interventions for youth with attention-deficit/hyperactivity disorder (ADHD): behavioral intervention, stimulant medication, and their combination. However, professional organizations have long disagreed regarding the best approach for implementing evidence-based interventions for ADHD in practice. The accompanying Society of Developmental and Behavioral Pediatrics guidelines for complex ADHD provide a framework for initiating treatment with behavioral intervention and adding stimulant medication as necessary, resulting in combined/multimodal treatment for many, if not most, children. In this special article, we review the extant literature on combined treatment, with special emphasis on the past 15 years of research that have led to the recommendation for this approach. Specifically, we review the literature on dosing and sequencing of multimodal treatment for youth with ADHD and the impact of multimodal interventions on areas of functional impairment. The extant research provides clear support for a psychosocial-first approach in treating youth with complex ADHD.

Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurodevelopmental disorder and is associated with an array of coexisting conditions that complicate diagnostic assessment and treatment. ADHD and its coexisting conditions may impact function across multiple settings (home, school, peers, community), placing the affected child or adolescent at risk for adverse health and psychosocial outcomes in adulthood. Current practice guidelines focus on the treatment of ADHD in the primary care setting. The Society for Developmental and Behavioral Pediatrics has developed this practice guideline to facilitate integrated, interprofessional assessment and treatment of children and adolescents with "complex ADHD" defined by age (<4 years or presentation at age >12 years), presence of coexisting conditions, moderate to severe functional impairment, diagnostic uncertainty, or inadequate response to treatment.

Outcomes of School-Home Intervention for Attention and Behavior Problems: Teacher Adherence Matters

This study evaluated the effects of teacher adherence to behavioral treatment on student outcomes. Eighty-four children (ages 7-11) completed a 12-week, collaborative school-home behavioral intervention designed for youth with significant attention-deficit/hyperactivity disorder symptoms and impairment. Teacher adherence was assessed via school mental health provider (SMHP) ratings and Daily Report Card (DRC) implementation. Pre- and post-treatment outcomes included parent and teacher ratings of organizational skills and problem behaviors, observational measures of classroom task engagement and off task behaviors and report card standard grades. Using multi-level models to account for clustering by school, teacher adherence rated by SMHPs predicted improvement across teacher- and parent-rated organizational skills, parent-rated problem behaviors, and classroom observations of task engagement and off-task behavior. Higher rates of DRC implementation only predicted improvements in parent-rated organizational skills; percentage of days parents signed the DRC only predicted teacher-rated improvement in organizational skills. Post-hoc analyses indicated that teacher adherence and child success with academic targets on the DRC during the first month predicted parent-rated improvement in organizational skills. These results suggest that teacher adherence, particularly when rated by SMHPs, is an important predictor of positive treatment outcomes across both school and home settings. Future research is needed to better understand methods for measuring and optimizing teacher adherence to classroom behavioral interventions.

A Review of Predictors of Psychosocial Service Utilization in Youth with Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood disorders. Professional practice guidelines recommend combined treatment, psychopharmacological and psychosocial, for youth with ADHD. There have been multiple reviews of pharmacological prescription practices and utilization, however, less is known about predictors of ADHD psychosocial service utilization. Given the importance of accessing psychosocial treatment in relation to improving functional impairment, this review synthesizes evidence on predictors of ADHD psychosocial intervention utilization in clinic, community, and school settings. Eighteen studies were identified and included in the review. Findings are summarized across informant profile factors, predisposing characteristics, and barriers and facilitators. The most robust findings were for the impact of symptom severity/impairment, the presence of comorbidities, and age on ADHD psychosocial service utilization. Race/ethnicity, sex, parental knowledge of the disorder and insurance coverage were also identified as key factors. Future avenues of research are provided, and clinical and policy implications targeted at reducing psychosocial treatment disparities in youth with ADHD are discussed.

Exploring the Efficacy of a Mindfulness Program for Boys With Attention-Deficit Hyperactivity Disorder and Oppositional Defiant Disorder

Objective: This study was the first attempt to explore the efficacy of a mindfulness protocol for children with attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), and their parents. Method: Fifty male children with ADHD and ODD diagnosis, aged 8 to 12, were randomly assigned to the mindfulness intervention (n = 25) or the wait-list (n = 25) group. Outcome measures included children, parents', and teachers' reports and objective measures of attention. Results: Children from the intervention group had a greater reduction in hyperactive behaviors in the school context (effect size [ES] = 0.59) and a greater improvement in visual sustained attention (ES = 0.77) and in Avoidance and Fusion Questionnaire scores (ES = 0.43) than those in the wait-list control group. No significant effect of the intervention on aggressive behaviors was revealed. Conclusion: A mindfulness intervention for children and their parents showed partial beneficial effects in children with ADHD + ODD.

Study protocol of a randomised trial of Summer STRIPES: a peer-delivered high school preparatory intervention for students with ADHD

INTRODUCTION

High schoolers with attention-deficit/hyperactivity disorder (ADHD) experience substantial impairments, particularly in the school setting. However, very few high school students with ADHD receive evidence-based interventions for their difficulties. We aim to improve access to care by adapting evidence-based psychosocial intervention components to a low-resource and novel school-based intervention model, Summer STRIPES (Students Taking Responsibility and Initiative through Peer Enhanced Support). Summer STRIPES is a brief peer-delivered summer orientation to high school with continued peer-delivered sessions during ninth grade.

METHODS AND ANALYSIS

Participants will be 72 rising ninth grade students with ADHD who are randomised to receive either Summer STRIPES or school services as usual. Summer STRIPES will be delivered by 12 peer interventionists in a school setting. Outcomes will be measured at baseline, start of ninth grade, mid-ninth grade and end-of-ninth grade. At each assessment, self, parent and teacher measures will be obtained. We will test the effect of Summer STRIPES (compared with school services as usual) on ADHD symptoms and key mechanisms (intrinsic motivation, extrinsic motivation, executive functions) as well as key academic outcomes during the ninth-grade year (Grade Point Average (GPA), class attendance).

ETHICS AND DISSEMINATION

Findings will contribute to our understanding of how to improve access and utilisation of care for adolescents with ADHD. The protocol is approved by the institutional review board at Seattle Children's Research Institute. The study results will be disseminated through publications in peer-reviewed journals and presentations at scientific conferences.

TRIALS REGISTRATION NUMBER

NCT04571320; pre-results.

Do mothers and fathers agree? Examining interparental ratings of youth externalizing behaviors among ethnically diverse families

OBJECTIVE

This study examined the association between youth, parent, and family characteristics in mother-father agreement of youth externalizing behaviors among ethnically diverse families.

METHOD

Eighty-eight mother-father dyads of youth (44% Latino, 38% European-American, 17% African American) 6-16 years participated.

RESULTS

Overall associations between parent's reports of youth behavior problems were positively correlated. Significant predictors of parent difference scores in regression analyses included mother's depression scores (negatively), mother and father parenting stress scores (positively and negatively, respectively), and child's symptom severity (positively in the Inattention and Learning Problems models; negatively in the Defiance/Aggression model).

CONCLUSIONS

Results highlight the need for psychosocial screening of youth's parents during child psychological assessment to identify situations in which both parent reports are needed for youth assessment. Further, it contributes to the small literature base of discrepancies in parent reports in minority youth and expands upon the minimal research involving paternal caregivers.

A school-based parenting program for children with attention-deficit/hyperactivity disorder: Impact on paternal caregivers

Engaging male caregivers within school settings is a major need within the educational field. Paternal engagement may be particularly important for children with attention-deficit/hyperactivity disorder (ADHD). Children with ADHD have increased risk for a number of poor educational outcomes, which may be attenuated by the benefits of positive male caregiver involvement. The Coaching Our Acting Out Children: Heightening Essential Skills (COACHES) program has been illustrated to be an effective approach for engaging, retaining, and improving the parenting of male caregivers of children with ADHD in clinical settings. The present study reports on the efficacy of the COACHES in Schools program, an adaptation intended for deployment in elementary school settings. Sixty-one male caregivers were randomly assigned to COACHES in Schools or a waitlist control. Results indicated that male caregivers in COACHES in Schools used significantly more praise and less negative talk in a parent-child activity relative to male caregivers in the waitlist control at post-treatment and one-month follow-up. Distal outcomes related to child behavior at home and at school were not significantly different. Implications of the results for future studies and continued efforts to engage male caregivers within school settings are discussed.

Impact of the School Environment on Medical Treatment of Attention Deficit Hyperactivity Disorder: A Population-Wide Register Data Study of School-Wide Positive Behavioral Interventions and Supports

Although attention deficit hyperactivity disorder (ADHD) is among the most heritable psychiatric childhood disorders, social and gene-environment interactions seemingly play an important role in the etiology of ADHD. Consistent with this, this study finds that School-Wide Positive Behavioral Interventions and Supports (SWPBIS) reduced the likelihood of pharmacotherapeutic treatment for ADHD at age 14-16 by 12%, using population-wide Norwegian register data and a difference-in-difference design (N = 698,364, birth cohorts 1990-2002, 48.7% girls, 5.7% immigrant background). At-risk students in schools with high fidelity of implementation are driving these intervention effects. Overall, the findings indicate that children with a genetic disposition for ADHD are more likely to avoid medical treatment in an organized and predictable school setting with a focus on positive reinforcement.

Equine-Assisted Services for Children with Attention-Deficit/Hyperactivity Disorder: A Systematic Review

Objective: This systematic review evaluated equine-assisted activities and therapies (EAATs), formerly referred to as equine-assisted services (EAS), in children and youth (ages 6-18 years) with attention-deficit/hyperactivity disorder (ADHD), according to the International Classification of Functioning, Disability, and Health. Methods: Electronic database searches were conducted of studies from inception through December 2020. Results: A total of 12 articles were included: 8 noncontrolled prospective studies and 4 randomized-controlled trials (RCTs). Furthermore, seven of moderate methodological quality studies and five of moderate high methodological quality studies were included. Evidence was found for the effectiveness of various forms of EAS, including equine-assisted physical therapy (EAPT) and therapeutic riding (TR). Improvements in body functions and structures (n = 10) were found in the domains of mental and neuromusculoskeletal functions, as well as functions of the cardiovascular system using EAPT (n = 6). Limited evidence was found regarding the positive effect on activity and participation (n = 4) following TR interventions. Quality of life (QoL) was improved in both TR and EAPT (n = 4). Conclusion: There seems to be preliminary evidence that EAS may be beneficial in promoting the physiological functions of body systems for children with ADHD. The influence on participation and QoL still requires further evidence. More generally, further controlled studies, including bigger sample sizes, are needed to understand the specific effects of different EAS on the core symptoms and consequence of ADHD.

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.