Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder

Empowering Social Growth Through Virtual Reality-Based Intervention for Children With Attention-Deficit/Hyperactivity Disorder: 3-Arm Randomized Controlled Trial

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) usually begins in childhood and is often accompanied by impairments in social functioning. Virtual reality (VR) has emerged as an adjunctive tool to embed in social skills training to enhance the social skills of children with ADHD, but its effectiveness requires further investigation.

OBJECTIVE

This study aims to enhance the social skills of children with ADHD by examining the feasibility and effectiveness of VR-based training in comparison to traditional social skills training.

METHODS

A 3-arm randomized controlled trial was conducted with 90 children with ADHD aged 6-12 years. Participants were randomly assigned to 3 weeks of 12-session VR-based social skills training, traditional social skills training, or a waitlist control group of equivalent duration. Outcome measures included assessments by a clinical psychologist who was blinded to group assignments, the Social Skills Improvement System Rating Scale, the Behavior Rating Inventory of Executive Function, and the Simulator Sickness Questionnaire, conducted at baseline and after the intervention.

RESULTS

The preliminary results support the feasibility and acceptability of VR training for children with ADHD aged 6-12 years. Analysis showed that the VR and traditional social skills training groups experienced a statistically significant improvement in the clinical psychologist assessment of social skills and parent-rated self-control, initiative, and emotional control after the intervention compared with baseline. The VR group performed significantly better than the traditional social skills group on social skills assessed by clinical psychologists (F2,85=76.77; P<.001) and on parent-rated self-control (F2,85=18.77; P<.001), initiative (F2,85=11.93; P<.001), and emotional control (F2,85=17.27; P<.001). No significant between-group differences were found for parent-rated cooperation and inhibition (all P>.05).

CONCLUSIONS

The findings provide preliminary evidence supporting the feasibility and superior effectiveness of VR-based social skills training compared to traditional approaches for enhancing social skills and related executive functions in children with ADHD. These results suggest that VR may be a valuable tool to embed within social skills interventions for this population. Further research is warranted to explore the long-term impacts and generalizability of these benefits.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05778526; https://clinicaltrials.gov/study/NCT05778526.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/48208.

A Study of the Psychometric Properties of the Pediatric Symptom Checklist-17 for Children With Developmental Delays and Disorders

Primary care physicians (PCPs) frequently serve pediatric patients with developmental delays and disorders (DD/D). Although the most widely used primary care behavioral health screener, the Pediatric Symptom Checklist-17 (PSC-17), is validated for use with children without DD/D, it is unclear whether this measure accurately identifies behavioral health symptoms in youth with DD/D. Thus, the purpose of this study was to assess the psychometric properties of the PSC-17 for children with DD/D. Medical record data from 3596 pediatric patients at a primary care clinic were analyzed. Descriptive analyses, measurement invariance testing, and internal consistency evaluations were conducted to assess the psychometric properties of the PSC-17. The results of these analyses support the use of the PSC-17 for behavioral health screening for children with DD/D. Behavioral health screening in this population is critical, because the timely identification of behavioral health concerns can facilitate early intervention, which may enhance long-term functioning.

Compressed cerebro-cerebellar functional gradients in children and adolescents with attention-deficit/hyperactivity disorder

Both cortical and cerebellar developmental differences have been implicated in attention-deficit/hyperactivity disorder (ADHD). Recently accumulating neuroimaging studies have highlighted hierarchies as a fundamental principle of brain organization, suggesting the importance of assessing hierarchy abnormalities in ADHD. A novel gradient-based resting-state functional connectivity analysis was applied to investigate the cerebro-cerebellar disturbed hierarchy in children and adolescents with ADHD. We found that the interaction of functional gradient between diagnosis and age was concentrated in default mode network (DMN) and visual network (VN). At the same time, we also found that the opposite gradient changes of DMN and VN caused the compression of the cortical main gradient in ADHD patients, implicating the co-occurrence of both low- (visual processing) and high-order (self-related thought) cognitive dysfunction manifesting in abnormal cerebro-cerebellar organizational hierarchy in ADHD. Our study provides a neurobiological framework to better understand the co-occurrence and interaction of both low-level and high-level functional abnormalities in the cortex and cerebellum in ADHD.

A Family-Based Intervention for Early Elementary Students With Reading and Behavioral Difficulties: A Pilot Study

We created and tested a family-based intervention with families of children in Grades 1 and 2 with reading and behavioral difficulties to investigate its impact on text comprehension. Developed with input from parents, reading experts, and behavior specialists, Family-RISE (Reading Intervention with Supports for Engagement) integrates evidence-based practices for enhancing students' knowledge of narrative texts with effective behavioral supports to maximize student engagement and minimize disruptive behaviors to help parents engage successfully in shared storybook reading. We assessed the effects of Family-RISE on children's narrative text comprehension using a multiple-baseline design. A functional relation was established between Family-RISE and narrative text comprehension, indicating Family-RISE substantially improved narrative text comprehension. Furthermore, nonoverlap of all pairs, Tau-U, and standard mean difference effect sizes were all considered large in favor of the intervention. Family members reported that the intervention was highly usable, feasible to implement, and socially valid. These findings underscore the promise of the Family-RISE intervention and the value of developing interventions that simultaneously support reading and behavior for children with co-occurring difficulties in these areas.

A Comparison of Effectiveness of Attention Process Training (APT) with Parenting Management Training (PMT) in Reducing Symptoms of Attention Deficit Hyperactivity Disorder

Objective: Child-oriented psychotherapies, such as Attention Process Training (APT), target ADHD symptoms directly, whereas family-oriented interventions, like Parent Management Training (PMT), address its functional impairments. The aim of this study was to compare the effectiveness of APT and PMT in treating ADHD symptoms. Method : This research was a randomized controlled trial in which 45 children (26 females and 19 males, with a mean age of 8.47 ± 1.66 years) with ADHD were selected conveniently and assigned randomly to one of three groups (PMT = 15, APT = 15, and CTRL = 15). The groups had no significant differences in ADHD severity. The PMT children were managed with parenting techniques. Children in the APT group practiced attention techniques, while children in the control group did not receive any intervention. Ritalin was prescribed to all the children in the three groups. The score on the Conners Parenting Rating Scale-Revised: Short form was the outcome variable. Results: Both interventions decreased ADHD symptoms severity more than the control group. Howver, the reduction in the APT group was more than in the PMT group (P-value < 0.001). The scores of 40% of the APT group and 80% of the PMT group did not fall below the cut-off point. In the APT group after the intervention, the inattention subscale was significantly lower than the hyperactivity subscale, while in the PMT group, the hyperactivity subscale was lower. The effect sizes of APT and PMT were 2.18 and 2.09, respectively. Conclusion: For ADHD, psychological interventions are crucial in addition to medication. According to the results of this study, APT is more effective for inattention symptoms, while PMT is more effective for hyperactivity symptoms. When selecting psychotherapy, the subtype of ADHD should be taken into account. Treatment sessions must also be completed according to intervention protocols.

Towards an Objective Measurement Tool for ADHD-like Traits in Family Dogs: A Comprehensive Test Battery

Family dogs exhibit neuropsychological deficits similar to attention-deficit/hyperactivity disorder (ADHD) symptoms in humans. Questionnaire methods have mostly been used to assess ADHD-like behaviours in dogs. In addition to our validated questionnaire (Dog ADHD and Functionality Rating Scale-DAFRS; 2024), we developed a simple behavioural test battery covering the ADHD symptom domains (i.e., inattention, hyperactivity, and impulsivity) in dogs. Our main aim was (i) to provide a final external validation step to the DAFRS by examining its associations with the test variables (N = 59); and (ii) to compare owner- and trainer-rated factor scores' associations with the test variables (n = 38). We developed four tests covering the ADHD symptom domains: the attention test (inattention), the plush dog test (impulsivity), the leash test, and the sit test (hyperactivity). All four behavioural variables correlated with their respective questionnaire scores, i.e., the strongest for hyperactivity, and the least strong for inattention. Both owner- and trainer-rated scores (n = 38) correlated with the relevant test variables in an expected direction. Dogs' training status was linked only to the sit test results. Test-retest analyses (n = 34) indicated moderate-to-excellent agreement across all behavioural variables. Our findings support the validity of our novel human-analogue questionnaire for dogs as the behavioural tests strongly correlate with the relevant questionnaire scores, indicating that the two constructs together can effectively assess inattention, hyperactivity, and impulsivity in dogs.

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.

Non-pharmacological treatment of Attention Deficit Disorder with or without Hyperactivity (ADHD). Overview and report of the first international symposium on the non-pharmacological management of ADHD

Attention Deficit Disorder with or without Hyperactivity (ADHD is a neurodevelopmental disorder which affects the day-to-day functioning of children and adults with this condition. Pharmacological treatment can reduce the symptoms associated with ADHD, but it has some limitations. The objective of this symposium is to determine the effects of non-pharmacological approaches on ADHD symptoms. Results indicate that the following intervention are promising approaches: cognitive behavioral therapy (CBT), mindfulness-based interventions (MBI), yoga, cognitive and metacognitive intervention, neurofeedback and parental training programs. Current research advocates multimodal approaches in conjunction with school or work accommodations integrating innovative technologies.

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.

Settling a distracted globe: An overview of psychosocial and psychotherapeutic treatment of attention-deficit/hyperactivity disorder

While the currently prevailing theory of ADHD postulates a neurobiological background and core deficits of behavioural inhibition and executive functioning as the basis of ADHD symptoms, our current conceptualisation also acknowledges the essential contributory role of psychosocial, ecological, and cognitive factors. Considering the multifactorial background of ADHD, its treatment equally needs to be multifactorial involving, besides pharmacotherapy, skill development and psychotherapy as well, especially if we postulate the increasing contribution of social factors in the background of the increasing burden of ADHD. Pharmacotherapies, including stimulants and non-stimulant ADHD medications applied as first-line treatments have a positive effect on core behavioural symptoms, however, they often do not sufficiently remediate several other symptoms and comorbid disorders, which are consequences of ADHD, especially considering that ADHD persists into adulthood and is present over the whole life span. Furthermore, pharmacological treatment is not sufficient to substitute for the skills needed to manage symptoms and adapt well to the environment. As part of a multimodal treatment approach, psychological therapies for ADHD target, besides core ADHD symptoms, other associated features including emotional dysregulation, personality development, neurocognitive dysfunction, depression, anxiety, and sleep problems. Insufficiently treated ADHD may contribute to psychological and personality developmental problems in children, as well as increased health costs and decreased productivity warranting multimodal treatment to address the areas not sufficiently targeted by ADHD-specific pharmacotherapy.

Facial expression recognition ability and its neuropsychological mechanisms in children with attention deficit and hyperactive disorder

Attention deficit and hyperactive disorder (ADHD) is a chronic neurodevelopmental disorder characterized by inattention, hyperactivity-impulsivity, and working memory deficits. Social dysfunction is one of the major challenges faced by children with ADHD. It has been found that children with ADHD can't perform as well as typically developing children on facial expression recognition (FER) tasks. Generally, children with ADHD have some difficulties in FER, while some studies suggest that they have no significant differences in accuracy of specific emotion recognition compared with typically developing children. The neuropsychological mechanisms underlying these difficulties are as follows. First, neuroanatomically. Compared to typically developing children, children with ADHD show smaller gray matter volume and surface area in the amygdala and medial prefrontal cortex regions, as well as reduced density and volume of axons/cells in certain frontal white matter fiber tracts. Second, neurophysiologically. Children with ADHD exhibit increased slow-wave activity in their electroencephalogram, and event-related potential studies reveal abnormalities in emotional regulation and responses to angry faces when facing facial stimuli. Third, psychologically. Psychosocial stressors may influence FER abilities in children with ADHD, and sleep deprivation in ADHD children may significantly increase their recognition threshold for negative expressions such as sadness and anger. This article reviews research progress over the past three years on FER abilities of children with ADHD, analyzing the FER deficit in children with ADHD from three dimensions: neuroanatomy, neurophysiology and psychology, aiming to provide new perspectives for further research and clinical treatment of ADHD.

The effectiveness of a dialogical family guidance intervention regarding child treatment response in families with a child with neurodevelopmental disorders

BACKGROUND

Children with neurodevelopmental disorders (NDD) can have emotional and behavioral symptoms affecting not only the child, but the whole family. Since family members have a strong impact on each other, studies highlight the need to offer effective family interventions to strengthen the wellbeing of the family. The aim of the current study is to clarify whether there is a difference between parents` opinions regarding their child`s emotional and behavioral condition immediately after Dialogical Family Guidance (DFG) has ended and after a three and six month follow-up.

METHOD

Fifty families with a child with NDD were randomized into two groups. Group 1 received DFG with an immediate starting point, and Group 2 received DFG after a three-month waiting period. Parent experiences of treatment response regarding their children`s emotional and behavioral symptoms were estimated before and after DFG using the parent version of the Strengths and Difficulties Questionnaire (SDQ-p) at baseline, and after three and six months. Additionally, comparisons between boys and girls, and the age of the child were analyzed.

RESULTS

The total difficulties score between Group 1 and Group 2 showed no difference immediately after DFG, or after three months. Regarding subdomains boys had more peer problems than girls, and at baseline, children between 3 and 6 years appeared to have more conduct problems than children between 7 and 13 years. Subdomain prosocial behavior increased statistically significantly during the study period in Group 1. Other SDQ-p subdomains remained constant in both groups between baseline and three and six month follow-up.

CONCLUSIONS

The result does not show any differences between parents` opinions regarding their child immediately after or three months after DFG regarding SDQ-p total difficulties scores in either group. The difference between younger and older children regarding conduct problems at baseline, and the difference between boys and girls regarding peer problems is worth paying attention to in the clinical setting. Because of the small sample, it is not possible to draw relevant conclusions regarding the intervention`s effect regarding the child`s mental health dimensions, gender, or age. Nevertheless, Dialogical family Guidance represents one intervention that can be used.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04892992 (retrospectively registered May 18th 2021).

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

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

Parent training for disruptive behavior symptoms in attention deficit hyperactivity disorder: a randomized clinical trial

Background

Attention-Deficit/Hyperactivity Disorder (ADHD) affects 5% of children and 2.5% of adults worldwide. Comorbidities are frequent, and Oppositional Defiant Disorder (ODD) reaches 50%. Family environment is crucial for the severity of behaviors and for prognosis. In middle-income countries, access to treatment is challenging, with more untreated children than those under treatment. Face-to-face behavioral parent training (PT) is a well-established intervention to improve child behavior and parenting.

Method

A clinical trial was designed to compare PT-online and face-to-face effects to a waiting list group. Outcomes were the ADHD and ODD symptoms, parental stress and styles, and quality of life. Families were allocated into three groups: standard treatment (ST), ST + PT online, and ST + Face-to-Face PT. We used repeated measures ANOVA for pre × post treatment analysis corrected for multiple comparisons.

Results and discussion

Parent training was effective in reducing symptoms of ADHD (p = 0.030) and ODD (p = 0.026) irrespective of modality (p = 1.000). The combination of ST and PT was also associated with better quality of life in the physical domain for patients (p = 0.009) and their parents (p = 0.050). In addition to preliminary data, online intervention seems effective for parenting and improving social acceptance of children. The potential to reach many by an online strategy with a self-directed platform may imply effectiveness with a low cost for public health to support parents' symptoms management.

Development of a human-analogue, 3-symptom domain Dog ADHD and Functionality Rating Scale (DAFRS)

The family dog, in its natural environment, exhibits neuropsychological deficits redolent of human psychiatric disorders, including behaviours that are similar to human attention-deficit/hyperactivity disorder (ADHD) symptoms. Based on standard questionnaire methods in humans, we aimed to develop and validate a detailed, psychometrically improved tool to assess owner views on relevant dog behaviours. We modified available questionnaires by adding items that allow for separate analysis of impulsivity, and items on functional impairment. We collected data from 1168 owners for different validation steps of the new questionnaire and, similarly to assessment of humans where teachers also evaluate as an expert control, we collected data from dog trainers. Exploratory and confirmatory factor analysis revealed 3 factors: inattention (IA), hyperactivity (H) and impulsivity (I), corresponding to all three human symptom dimensions in dogs. Test-retest analyses showed excellent agreement between measurements for all factors. Similarly to findings with humans, trainer-owner rating comparisons showed fair (IA) to moderate (H, I) agreement. As in humans, greater ADHD scores were associated with greater functional impairment scores. We suggest that in dogs, similarly to humans, parallel examination of (extreme) ADHD and functional impairment scores could help distinguish diagnosable individuals, after further validation of the questionnaire using a relevant behaviour test.

"A bit lost"-Living with attention deficit hyperactivity disorder in the transition between adolescence and adulthood: an exploratory qualitative study

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) begins in childhood and in many cases persists into adulthood. The transition from adolescence to adulthood for young people with ADHD is a vulnerable time and can be associated with comorbid conditions and unfavorable outcomes. Thus, further studies are needed to explore the characteristics of the transition period in emerging adulthood. The overall aim of this study was to gain increased knowledge of emerging adults' experience of living with ADHD in the transition from adolescence to adulthood. This is a follow-up from a previous qualitative study that examined how young people experience receiving and living with a diagnosis of ADHD.

METHOD

The study has a qualitative retrospective design. Seven participants were included in this study using a purposive sampling method. We re-invited the same participants who were interviewed in 2015-2016 and conducted in-depth interviews. The data were subjected to Malterud's systematic text condensation (STC).

RESULTS

Four crosscutting themes were identified from our analysis: (1) low level of knowledge about ADHD and treatment options; (2) barriers to seeking and accessing help; (3) developing self-help strategies; and (4) a preference to discontinued medication use.

CONCLUSION

The participants emphasized a need for more information about ADHD in transition phases and support, both from professionals and peers, about finding ways to live meaningful lives. The treatment they had been offered was particularly linked to symptom reduction and medication use. A more appropriate focus would have been linked to how they, as citizens, could gain knowledge and skills to live meaningful lives with ADHD.

Patterns of Childhood Adversity among Women with and without Childhood ADHD: Links to Adult Psychopathology and Global Functioning

We examine the outcomes associated with childhood adversity for women with and without carefully diagnosed childhood ADHD, via an ethnically diverse sample of 140 participants with ADHD (Mage = 9.7) and 88 age- and ethnicity-matched comparisons (Mage = 9.4). At adult follow-up, we retained 211 of the original 228 participants (92.6%; Mage = 25.6). We used latent class analysis to identify patterns of childhood adversity and examine their association with adult global functioning and psychopathology. Key findings: (1) Four childhood adversity classes emerged (Low Exposure, Familial Dysfunction, Emotional Maltreatment, Pervasive Exposure); (2) Childhood ADHD predicted membership in the Emotional Maltreatment class; and (3) Childhood adversity classes were differently associated with adult outcomes, such that membership in both the Emotional Maltreatment and Pervasive Exposure classes predicted significantly higher internalizing and externalizing symptoms as well as significantly lower global functioning than women in the Low Exposure class. Furthermore, compared to the Emotional Maltreatment class, the Familial Dysfunction class had lower externalizing symptoms, whereas the Pervasive Exposure class had lower global functioning and higher internalizing symptoms by adulthood. Findings provide information about girls and women who could be targeted for intervention in terms of ADHD behavior patterns plus adverse experiences in childhood. Beyond limitations, we discuss the need to investigate the confluence of neurodevelopmental conditions and adverse child events with respect to maladaptive outcomes.

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.

Psychological Treatments for Hyperactivity and Impulsivity in Children with ADHD: A Narrative Review

Treatment of the ADHD types (hyperactive-impulsive, inattentive, and combined) in children has rarely been studied separately, although their prognostic courses differ widely. In addition, data show that improvements in hyperactivity/impulsivity are hard to achieve. Thus, we focused on treatments tailored to hyperactivity/impulsivity. We examined meta-analyses and systematic reviews within the inter- and intra-individual treatments and found that psychoeducation and training for parents, school-based interventions, reinforcement strategies, and neurofeedback consistently showed small to moderate effect sizes in reducing hyperactivity/impulsivity in children. Conversely, emotional self-regulation, social skills, and cognitive trainings showed unsatisfactory results. In summary, we found that the quality of usual care can be surpassed when the designated interventions are purposefully combined into a multimodal treatment program.

Factors Influencing Long-Term Behavioral Intervention Outcomes in Preschool Children with Attention-Deficit Hyperactivity Disorder in Southeast China

Introduction

Previous studies have demonstrated the long-term effectiveness of behavioral interventions for attention-deficit hyperactivity disorder (ADHD) in preschool children. We continue to design a case‒control study to further investigate the factors influencing the long-term effect of behavioral intervention.

Methods

From May 2020 to August 2021, children who were newly diagnosed with ADHD and not receiving any treatment received a one-year behavioral intervention. A total of 86 children completed the behavioral intervention and assessment.

Results

50 children (58.140%) were in the effective group, and 36 children (41.860%) were in the ineffective group. Attention retention time (OR=0.559, 0.322-0.969), Swanson, Nolan, and Pelham total score (OR=1.186, 1.024-1.374) at baseline, performance score for parents (OR=0.631, 0.463-0.859), and teacher coordination (OR=0.032, 0.002-0.413) were the influencing factors of behavioral intervention effects. The area under the receiver operating curve was 0.979 (p<0.001). The comprehensive nomogram model showed that the discrimination and mean absolute error were 0.979 and 0.023, respectively.

Discussion

During behavioral intervention, the implementation skills of parents should be evaluated in a timely manner. The behavioral intervention effect can be predicted based on a child's attention retention time at baseline, teacher involvement, behavioral scale score, and performance score for parents, which can guide clinicians in adjusting personalized treatment plans and provide a basis for clinical decision-making. The treatment of ADHD in preschool children requires a systematic framework that integrates family, school, and society.

Child ViReal Support Program: A Randomized Controlled Trial Study for Effective Support of Parents Raising Children with Attention Deficits

Attention deficit hyperactivity disorder (ADHD) results in various functioning impairments in children's lives and families. Parents of children with ADHD report high levels of parenting stress, low levels of parental self-efficacy, and use of more authoritarian and/or permissive parenting practices than parents of typically developing children. Intervention programs need to address both children's and parents' needs and multimodal intervention programs could cover this demand. The aim of this study was to examine the efficacy of "Child ViReal Support Program"-a multi-level evidence-based comprehensive program-on parenting stress, parental self-efficacy, parenting practices, and the core symptoms of children's ADHD. Families with a child diagnosed with ADHD (n = 16) were randomly allocated to two groups (PC and CP; P = parent training, C = child training), and a cross-over design was utilized. Participating parents completed, in four different times during the study, the Parenting Stress Index-Short Form, the Parenting Sense of Competence Scale, the Parenting Styles and Dimensions Questionnaire-Short Version, and the parent form of the ADHD Rating Scale-IV. Parents from both groups, after their participation in the parent training, demonstrated reduced parenting stress, enhanced parental self-efficacy, and increased the employ of democratic parenting practices. More than that, they reported decreased levels of inattention and impulsivity/hyperactivity for their children. Evidence-based multi-level intervention programs could produce positive effects on parents and children by incorporating effective methods and tools in accordance with the needs and the demands of the family context.

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.

Effect of financial and non-financial reward and punishment for inhibitory control in boys with attention deficit hyperactivity disorder

BACKGROUND

The development of inhibitory processes is disturbed in children with attention deficit hyperactivity disorder (ADHD); however, little is known about the effect of negative punishment for inhibitory performance in this population.

AIMS

We investigated differences in the effects of reward and punishment, developmental changes, and response inhibition between children with and without ADHD, using financial (F-FB) and non-financial (NF-FB) feedback.

METHODS AND MATERIALS

We conducted financial and non-financial go/no-go tasks under reward and punishment conditions with 21 boys with ADHD and 21 healthy controls (HCs), in Japan.

OUTCOMES AND RESULTS

We found group-related significant interactions between group, feedback type, and punishment (p = .013), and group, feedback type, and age (p = .009). There were significant differences in inhibitory error under F-FB only in HCs between the punishment-absent and punishment-present conditions (p = .003). In the ADHD group, age-dependent effects were found for both feedback types (ps < .01), but only F-FB effects were found in HCs (p = .008).

CONCLUSIONS AND IMPLICATIONS

Punishment for inhibitory control had different effects on the ADHD and HC groups. Children with ADHD respond differently to external motivation than HCs, leading to difficulties with peers or confusion among teachers and caregivers.

Examining Influences on Problem Recognition and Help-Seeking for Child Externalizing Behaviors Among African American Mothers

Childhood behavior problems are one of the most common clinical referrals. If left untreated, these behaviors can result in detrimental consequences to the child's development (Wehmeier et al., 2010; Scholtens et al., 2012). Behavior parent training has been identified as first-line treatment for oppositional behavior; however, many racial minority families fail to enroll in behavior parent training. The current study examines maternal help-seeking for children displaying oppositional behavior in hopes to delineate variables that might influence parent training enrollment among African American families. Participants were 112 African American mothers who were provided child behavior vignettes and completed measures assessing factors related to problem recognition, parental attributions, child rearing values, mental health stigmatization, racial identity, and treatment utilization. Results found that when presented with a child displaying clinically significant externalizing child behaviors, slightly more than half of African American mothers recognized clinically significant child behavior problems. Mothers were more likely to engage in behavioral parent training if problematic behavior was recognized. Additionally, mothers' attributions of child behavior, cultural values, and mental health stigmatization were influential to help seeking. This study supports the importance of considering cultural variables that impact problem recognition and subsequent treatment utilization among African American families.

Owner-rated hyperactivity/impulsivity is associated with sleep efficiency in family dogs: a non-invasive EEG study

Subjective sleep disturbances are reported by humans with attention-deficit/hyperactivity disorder (ADHD). However, no consistent objective findings related to sleep disturbances led to the removal of sleep problems from ADHD diagnostic criteria. Dogs have been used as a model for human ADHD with questionnaires validated for this purpose. Also, their sleep physiology can be measured by non-invasive methods similarly to humans. In the current study, we recorded spontaneous sleep EEG in family dogs during a laboratory session. We analyzed the association of sleep macrostructure and deep sleep (NREM) slow-wave activity (SWA) with a validated owner-rated ADHD questionnaire, assessing inattention (IA), hyperactivity/impulsivity (H/I) and total (T) scores. Higher H/I and T were associated with lower sleep efficiency and longer time awake after initial drowsiness and NREM. IA showed no associations with sleep variables. Further, no association was found between ADHD scores and SWA. Our results are in line with human studies in which poor sleep quality reported by ADHD subjects is associated with some objective EEG macrostructural parameters. This suggests that natural variation in dogs' H/I is useful to gain a deeper insight of ADHD neural mechanisms.

Behavioral Sleep Interventions for Children With ADHD: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate intervention characteristics and components within behavioral sleep interventions in school-aged children with ADHD and examine evidence related to effectiveness.

METHOD

A systematic review was conducted using PsycINFO, Embase, MEDLINE, PubMed, and OpenGray. The subsequent meta-analysis used sleep outcomes to produce comparable effect sizes (Hedges' g) and compare intervention effects between randomized controlled trials and pre-post studies.

RESULTS

Eleven articles satisfied the inclusion criteria (562 children, across all groups, aged 5-14 years, M = 8.71). Studies reported improvements in sleep although there was marked heterogeneity between studies and limited use of objective sleep measures within them. On average, intervention groups improved more than control groups in the five randomized controlled trials (-0.46, 95% CI = [-0.58, -0.35], k = 4).

CONCLUSION

The findings support the use of behavioral sleep interventions for school-aged children with ADHD. Findings suggest that brief, individualized intervention may be more effective than standardized.

Cerebro-cerebellar Dysconnectivity in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Abnormal cerebellar development has been implicated in attention-deficit/hyperactivity disorder (ADHD), although cerebro-cerebellar functional connectivity (FC) has yet to be examined in ADHD. Our objective is to investigate the disturbed cerebro-cerebellar FC in children and adolescents with ADHD.

METHOD

We analyzed a dataset of 106 individuals with ADHD (68 children, 38 adolescents) and 62 healthy comparison individuals (34 children, 28 adolescents) from the publicly available ADHD-200 dataset. We identified 7 cerebellar subregions based on cerebro-cerebellar FC and subsequently obtained the FC maps of cerebro-cerebellar networks. The main effects of ADHD and age and their interaction were examined using 2-way analysis of variance.

RESULTS

Compared to comparisons, ADHD showed higher cerebro-cerebellar FC in the superior temporal gyrus within the somatomotor network. Interactions of diagnosis and age were identified in the supplementary motor area and postcentral gyrus within the somatomotor network and middle temporal gyrus within the ventral attention network. Follow-up Pearson correlation analysis revealed decreased cerebro-cerebellar FC in these regions with increasing age in comparisons, whereas the opposite pattern of increased cerebro-cerebellar FC occurred in ADHD.

CONCLUSION

Increased cerebro-cerebellar FC in the superior temporal gyrus within the somatomotor network could underlie impairments in cognitive control and somatic motor function in ADHD. In addition, increasing cerebro-cerebellar FC in older participants with ADHD suggests that enhanced cerebellar involvement may compensate for dysfunctions of the cerebral cortex in ADHD.

Multiple needs and multiple treatments. What's a clinician to do? Update on the psychosocial treatment of disruptive behaviours in childhood

PURPOSE OF REVIEW

There are a wide range of psychosocial treatment options, delivered in different modalities, for children with disruptive behaviour. However, clinicians face many challenges in ensuring the empirically supported treatments (ESTs) they select will be effective for their patient. This has prompted studies to generate knowledge on how to improve treatment outcomes for children with disruptive behaviour. This review identifies the major challenges in treatment selection as well as emerging research seeking to improve outcomes.

RECENT FINDINGS

This review emphasizes the salience of the research-practice gap associated with establishing ESTs using narrow definitions of clinical problems. Recent research is reviewed considering the complex determinants of disruptive behaviours, including parent and family factors that influence outcomes. The review subsequently outlines recent advances in research and clinical practice guidelines aiming to surmount these challenges. Key advances discussed include examining the most impactful components of ESTs, personalizing interventions by targeting core dysfunction underlying behaviour, and addressing parent factors including mental health and cultural relevance to improve outcomes.

SUMMARY

Thorough assessment of patients' needs, combined with knowledge of treatment response predictors, are recommended to determine the most suitable treatment plan. Recent advances have focused on developing and designing interventions that meet needs in a way that is flexible and tailored.

Anger and Attention Problems as Mechanisms Linking Maltreatment Subtypes and Witnessed Violence to Social Functioning Among Children in Out-of-Home Care

Research has consistently shown that child maltreatment and witnessed violence lead to disrupted patterns of social functioning, yet the mechanisms underlying these pathways remain unclear. This cross-sectional study evaluated whether anger and/or attention problems mediated the links from abuse, neglect, and witnessed violence to peer problems and aggressive behavior. Participants included a diverse sample of 470 children (ages 8-11; 52.1% boys) living in out-of-home care. Subtype and severity of maltreatment exposure were coded using Child Protection Services' intake reports and court records. Witnessed violence and anger were assessed using child-reports, and caregivers provided ratings of attention problems and social functioning. Indirect effects were tested using a series of structural equation path analysis models. Results indicated that anger fully mediated the links from witnessed violence to both peer problems and aggressive behavior. Further, attention problems fully mediated the links from physical abuse and physical neglect to both peer problems and aggressive behavior. These findings highlight the need for interventions to target anger regulation and attentional control among children in out-of-home care in order to mitigate their risk for social maladjustment.

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.

Interventions for ADHD in children & adolescents with epilepsy: A review and decision tree to guide clinicians

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common pediatric epilepsy comorbidities. Treating ADHD in the context of epilepsy can be overwhelming for parents and clinicians. Current frontline treatment for ADHD is stimulant medication. However, some parents of pediatric patients with epilepsy have concerns about adding additional medication to their child's epilepsy regimen and/or about adverse effects of stimulant medication. Non-medication ADHD treatments including psychosocial interventions and ketogenic diet have also shown success in improving ADHD symptoms. Our focused review provides an easy-to-use guide for clinicians on ADHD interventions and combinations of interventions for pediatric patients with epilepsy and ADHD. Our guide includes information from 8 electronic databases for peer-reviewed, English language studies of psychosocial treatments for youth with epilepsy and ADHD. One hundred eight studies were selected based on inclusion criteria (21 systematic reviews, 12 meta-analyses, 8 literature reviews, 6 population surveys, 31 clinical trials, 20 cross-sectional studies, and 10 retrospective reviews). Results indicated that stimulant medication is a frontline treatment for ADHD symptoms in youth with epilepsy, with important caveats and alternatives.

Factors Associated With Bullying Victimization and Bullying Perpetration in Children and Adolescents With ADHD: 2016 to 2017 National Survey of Children's Health

OBJECTIVE

To identify characteristics associated with bullying involvement in pediatric ADHD.

METHODS

Data from the 2016 to 2017 National Survey of Children's Health for children aged 6 to 17 years with ADHD were evaluated to assess the association between parent-reported bullying victimization or perpetration and the following potential predictors: demographic characteristics, family factors, school factors, and child conditions/behaviors.

RESULTS

Among children with ADHD, 46.9% were bullying victims and 16.2% were perpetrators. Factors associated with victimization included having family financial strain, developmental delay or intellectual disability, friendship difficulties, and school reports about problems. Factors linked to perpetration included being male, receiving government assistance, lack of school engagement, school reports about problems, and having difficulties with friendships, staying calm, and arguing.

CONCLUSIONS

Children with ADHD frequently were bullying victims and sometimes bullying perpetrators. Factors related to family financial strain, developmental disabilities, emotional regulation, peer relationships, and school functioning may help to identify risk for bullying and opportunities for anti-bullying interventions.

Effectiveness of neurofeedback training, behaviour management including attention enhancement training and medication in children with attention-deficit/hyperactivity disorder - A comparative follow up study

BACKGROUND

Attention Deficit/ Hyperactivity Disorder (ADHD) is one of the most common neurodevelopmental psychiatric disorders of childhood. Treatment of ADHD includes medications and Behavioural interventions. Neurofeedback, a type of biofeedback, has been found to be useful in ADHD. It helps patients to control their brain waves consciously. However, it is not yet conclusive if it is efficacious in comparison to behavioural management training and medication.

AIM

To compare the efficacy of neurofeedback training, behaviour management including attention enhancement training and medication in children with ADHD.

METHOD

Ninety children between 6 and 12 years with ADHD were taken and randomly divided into 3 treatment groups equally- neurofeedback, behaviour management and medication (methylphenidate). Conners 3-P Short Scale was applied for baseline assessment. The respective interventions were given and follow up was done at the end of 3 months by using Conners 3-P Short scale to assess the improvement in the symptoms. There were 6 dropouts, the final sample size was 84.

RESULTS

The medication group showed the greatest reduction of symptoms in inattention, hyperactivity, executive functioning domain (core symptoms of ADHD). No statistically significant difference was observed between Neurofeedback and Behaviour Management in these domains. Learning problems improved in all three groups, neurofeedback being the most effective followed by medication. Both Neurofeedback and Medication groups showed similar effect which was higher than the Behavioural Management group in Peer Relation.

CONCLUSION

Improvement in core ADHD symptoms have been observed with all 3 interventions with medication showing the greatest improvement Neurofeedback has been superior for learning problems. Thus, Neurofeedback can be an independent or combined intervention tool for children with ADHD in outpatient department of Psychiatry.

Bayes factor benefits for clinical psychology: review of child and adolescent evidence base

Background: Statistical methods are a cornerstone of research in clinical psychology and are used in clinical trials and reviews to determine the best available evidence. The most widespread statistical framework, frequentist statistics, is often misunderstood and misused. Even when properly applied, this framework can lead to erroneous conclusions and unnecessarily prolonged trials. The implications for clinical psychology are difficulties in interpreting best available evidence and unnecessarily costly and burdensome research. An alternative framework, Bayesian statistics, is proposed as a solution to several issues with current practice. Methods: Statistical tests of primary outcome measures were extracted from 272 studies, which were cited in 11 recent reviews in the Evidence-based updates series in the Journal of Clinical Child and Adolescent Psychology. The extracted tests were examined regarding relevant features and re-analyzed using Bayes Factors. Results: When statistical tests were significant, the majority (98%) of re-analyzed tests agreed with such claims. When statistical tests were nonsignificant almost half (43%) of re-analyzed tests disagreed with such claims. Equally important for clinical research, an average of 13% fewer participants per study would have been required if the studies had used Bayes Factors. Conclusions: Bayes Factors offer benefits for research in clinical psychology through intuitive interpretations, and less costly trials.

Bayes factor benefits for clinical psychology: review of child and adolescent evidence base

Background: Statistical methods are a cornerstone of research in clinical psychology and are used in clinical trials and reviews to determine the best available evidence. The most widespread statistical framework, frequentist statistics, is often misunderstood and misused. Even when properly applied, this framework can lead to erroneous conclusions and unnecessarily prolonged trials. The implications for clinical psychology are difficulties in interpreting best available evidence and unnecessarily costly and burdensome research. An alternative framework, Bayesian statistics, is proposed as a solution to several issues with current practice. Methods: Statistical tests of primary outcome measures were extracted from 272 studies, which were cited in 11 recent reviews in the Evidence-based updates series in the Journal of Clinical Child and Adolescent Psychology. The extracted tests were examined regarding relevant features and re-analyzed using Bayes Factors. Results: When statistical tests were significant, the majority (98%) of re-analyzed tests agreed with such claims. When statistical tests were nonsignificant almost half (43%) of re-analyzed tests disagreed with such claims. Equally important for clinical research, an average of 13% fewer participants per study would have been required if the studies had used Bayes Factors. Conclusions: Bayes Factors offer benefits for research in clinical psychology through intuitive interpretations, and less costly trials.

School-based group intervention in attention and executive functions: Intervention response and moderators

Objective

This study investigated the effects of a school-based skill-training intervention in attention control and executive functions for pupils with hyperactivity-impulsivity (H-I) and cognitive control (CC) deficits. The main aim was to examine whether the intervention differently influenced H-I and CC, and whether cognitive abilities or conduct problems moderated response to the intervention.

Method

Elementary school pupils from 41 schools participated the study and were divided into an intervention group (n = 71) and a waitlist control group (n = 77). Intervention outcomes were assessed with an inventory assessing executive function difficulties (including H-I and CC) completed by classroom teachers.

Results

Significant intervention effects and positive changes were detected in CC but not in H-I. Significant intervention effects were found mainly among pupils with low levels of conduct problems.

Conclusions

The results suggest that a skill-training intervention has specific positive effects on CC, but conduct problems may diminish response to intervention.

Comparison of Four Classroom-Based Strategies for Middle School Students With ADHD: A Pilot Randomized Controlled Trial

Middle school students with ADHD often experience negative academic outcomes. To intervene, schools frequently provide services through special education or section 504. These services include strategies, such as breaks, prompting, and sensory proprioception to remove the impact of construct-irrelevant variance. Student plans rarely include strategies, such as selfmanagement, designed to teach students skills to increase independent functioning. The purpose of this study was to compare the effectiveness of four strategies on engagement, disruptive behavior, and time to initiate tasks. Fifteen sixth and seventh grade students were randomized daily to one of four conditions. Results indicated large statistically significant differences. Social validity data indicated that students found prompting and self-management helpful, but preferred breaks and sensory proprioception. This study builds on a growing empirical base that supports the prioritization of strategies to teach skills over strategies to remove the impact of ADHD on performance.

Indicators of suicidal outcomes among 6- to 12-year-old treatment seeking youth

Suicide among elementary school-age youth is vastly understudied despite being a major health concern. This study utilized mediation and moderation models to elucidate the nature of risk factors for suicide by examining the effect emotion dysregulation (of anger, sadness, and worry) has on the relation between ADHD symptoms (hyperactivity/impulsivity and inattention) and suicidal outcomes (suicidal behavior and risk for suicide) in children ages 6 to 12. When accounting for sex, age, depressive symptoms, and emotion dysregulation, hyperactivity/impulsivity was positively associated with suicidal behavior; however, inattention was negatively associated with suicidal behavior. After accounting for the variance associated with sex, age, and depressive symptoms, two interaction effects were evident. At low levels of sadness and worry dysregulation, hyperactivity was positively associated with suicide risk. However, at high levels of sadness and worry dysregulation, hyperactivity was not related to suicide risk. Findings support moderation over mediation.

Adult-Onset ADHD: A Critical Analysis and Alternative Explanations

Attention deficit/hyperactivity disorder (ADHD) is characterized as a neurodevelopmental disorder. However, data from several recent studies suggest that there may be adults who meet current criteria for ADHD, yet did not experience symptoms until adulthood (i.e., "adult-onset ADHD"). This systematic review evaluated and synthesized the empirical evidence on adult-onset ADHD to answer the question: Is the extant literature strong enough to evaluate adult-onset ADHD? Nine studies met strict inclusion/exclusion criteria. Results suggest that the methodologies of the extant studies were not strong enough to evaluate adult-onset ADHD. Insufficient methodologies provide presently unclear information about the nature of late-onset symptoms. These symptoms seem to exist but their source could be (1) adult-emergent symptoms that were previously surpassed due to lower environmental demands/supportive facilitators, (2) mimics that were not properly assessed, or (3) childhood-onset symptoms that were not detected earlier due to failure to come to clinical attention. Future directions, clinical recommendations, and limitations of the literature and the current review are discussed.

Parents' school-related concerns and perceived strengths in youth with spina bifida

BACKGROUND

Although the academic difficulties of children with spina bifida (SB) are well-documented, there is limited literature on parents' views of their children's school experiences and school-related supportive services. Thus, the current study examined parents' school-related concerns, as well as perceived areas of strength, among children with SB.

METHODS

Using a mixed-methods approach, 30 families (29 mothers and 19 fathers) of children with SB (ages 8-15 years) completed questionnaires and interviews. Content analysis was used to generate themes from interview data about parents' school-related concerns and perceptions of their child's strengths.

RESULTS

Overall, six themes emerged when assessing both parents' concerns and perceived strengths. Some parents did not endorse school concerns or strengths for their child. However, other parents described concerns related to academic performance, cognitive abilities, lack of school support, missed school and/or class time and disengagement, as well as strengths such as academic skills, cognitive abilities, persistence, self-advocacy and agreeableness. Despite parents' concerns about their children's academic performance, quantitative data revealed that less than 50% of children had received a neuropsychological evaluation and/or academic accommodations; additional quantitative data supported the qualitative findings.

CONCLUSIONS

The mixed-methods approach used in this study provides a richer understanding of parents' experiences in the school setting when they have a child with SB. Results can inform clinical practice, identifying a need to improve academic support for children with SB and help parents manage education-related stressors.

Cognitive behavioural group therapy as addition to psychoeducation and pharmacological treatment for adolescents with ADHD symptoms and related impairments: a randomised controlled trial

BACKGROUND

Cognitive behavioural therapy (CBT) is recommended for attention-deficit/hyperactivity-disorder (ADHD) in adolescents. However, all CBTs are not created equal, and the guidelines do not specify which CBT interventions are the most effective for this patient group. This study examines the efficacy of a group CBT without parent involvement as follow-up treatment compared to no additional CBT in adolescents with persistent and impairing ADHD symptoms after a short psychoeducational intervention and medical treatment.

METHODS

The authors conducted a two-arm parallel randomized controlled trial in two child and adolescent mental health outpatient clinics in Norway. One hundred patients aged 14-18 years with a diagnosis of ADHD (66%) or subthreshold ADHD (34%) were randomized to either a 12-week group CBT program (N = 50) or a non-CBT control condition (N = 50). Assessments were made at admission to the clinic, two weeks before and two weeks after treatment. The primary outcomes were parent-, teacher- and self-ratings of ADHD symptoms (ADHD Rating Scale-IV), and the secondary outcomes were ratings of ADHD symptom severity, executive function, functional impairment, and emotional problems. Evaluators blinded to group allocation rated ADHD symptom severity with the Clinical Global Impression Scale for Severity (CGI-S) at baseline and post-treatment.

RESULTS

Analyses using mixed-effects models showed no difference between the treatment arms from baseline to post treatment in primary and secondary outcomes.

CONCLUSIONS

Contrary to our hypothesis, we found no incremental treatment effect on the part of a group CBT as follow-up to psychoeducation and pharmacological treatment on ADHD symptoms and accompanying impairments. Limitations with the CBT was the large number and low dosage of treatment components, causing restricted time for practice. Unlike evidence-based, individualized targeted CBTs with parent involvement, a group CBT directed solely at the adolescents with no parent involvement does not appear effective for treating ADHD.

TRIAL REGISTRATION

NCT02937142 , 18/10/2016.

Perspectives of Rural Primary Care Clinicians on Pediatric Attention-Deficit/Hyperactivity Disorder Care

OBJECTIVE

Despite efficacious treatments, evidence-based guidelines, and increased availability of integrated behavioral health care, youth coping with attention-deficit/hyperactivity disorder (ADHD) receive suboptimal care. More research is needed to understand and address care gaps, particularly within rural health systems that face unique challenges. We conducted a qualitative study within a predominantly rural health system with a pediatric-integrated behavioral health care program to address research gaps and prepare for quality improvement initiatives, including primary care clinician (PCC) trainings and clinical decision support tools in the electronic health record (EHR).

METHOD

Semistructured interviews were conducted with 26 PCCs representing clinics within the health system. Interview guides were based on the Practical Robust Implementation and Sustainability Model to elicit PCC views regarding determinants of current practices and suggestions to guide quality improvement efforts. We used thematic analysis to identify patterns of responding that were common across participants.

RESULTS

PCCs identified several internal and external contextual factors as determinants of current practices. Of note, PCCs recommended increased access to continuing education trainings held in clinic over lunch and delivered in less than 30 minutes. Suggested improvements to the EHR included incorporating parent and teacher versions of the Vanderbilt Rating Scale into the EHR, documentation templates aligned with evidence-based guidelines, and alerts and suggestions to aid medication management during appointments.

CONCLUSION

Future research to identify implementation strategies to help rural PCCs adopt innovations are needed given the increased responsibility for managing ADHD care and intractable gaps in access to behavioral health care in rural regions.

School-Based Cognitive-Behavioral Therapy in an Inclusion Model for an Adolescent with Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Attention Deficit Hyperactivity Disorder : A Case Study

The goal of the current case study was to illustrate evidence-based cognitive-behavioral treatment (CBT) for an adolescent female with comorbid major depressive disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, suicidal ideations, and a history of multiple involuntary hospitalizations. Multimodal assessment of the child’s symptoms was conducted, including parent, teacher, and child self-report, academic data, and hospital records to inform case conceptualization. Treatment included a combination of psychoeducation, cognitive restructuring, positive self-talk, relaxation skills, and the support of a school-based personal aide. Significant improvements with inattentive, anxiety, and depressive symptoms were reported, with gains being maintained at 1 year follow-up. In addition to a reduction of reported psychosocial problems, treatment benefits also included a decrease in classroom disruptions, improvement in academic performance, and withdrawal of paraprofessional support at school. This study illustrates the use of school-based CBT strategies coupled with additional focused Tier 4 behavior supports as an efficacious treatment for youth with significant comorbidity.

Review: Which components of behavioral parent and teacher training work for children with ADHD? - a metaregression analysis on child behavioral outcomes

BACKGROUND

This metaregression analysis examined which behavioral techniques that are commonly used in behavioral parent and teacher training programs for children with attention-deficit/hyperactivity disorder (ADHD) were related to program effectiveness on children's behavioral outcomes.

METHODS

We included 32 randomized controlled trials (N = 2594 children) investigating behavioral parent training, teacher training, or a combination, in children with ADHD under 18 years. Outcomes were symptom counts of total ADHD, inattention, and hyperactivity-impulsivity and behavioral problems. The dosage of techniques was extracted from the intervention manuals. Metaregression was used to assess which techniques and intervention characteristics (setting, delivery method, duration, and home-school collaboration) were associated with intervention effectiveness.

RESULTS

Higher dosage of psycho-education for parents was associated with smaller effects on behavioral problems and, only in case of parent training, also with smaller effects on ADHD symptoms. Higher dosage of teaching parents/teachers to use negative consequences was associated with larger effects on behavioral problems. Individual training compared with group training was associated with larger effects on ADHD and hyperactivity-impulsivity symptoms.

CONCLUSIONS

This study provides first insights into the specific techniques that are essential in behavioral parent and teacher training programs for children with ADHD. This knowledge can eventually be used to improve and tailor interventions.

Evaluating ADHD Assessment for Dogs: A Replication Study

The family dog, in its natural environment, exhibits neuropsychological deficits redolent of human psychiatric disorders, including behaviours similar to human Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms. For dogs, Vas and colleagues developed a 13-item questionnaire to measure inattention and hyperactivity/impulsivity (Dog ARS; 2007). We re-assessed, in a large sample of dogs (N = 319), psychometric properties of the Dog ARS, to identify possible limitations as a basis for further development. We examined the cross-study stability of factor structure and 40-day temporal stability of item and subscale scores and compared owner-report with expert (dog trainer)-report (n = 86), paralleling human parent/teacher assessments. To identify ambiguous items, we administered a modified version (including “I don’t know” options, N = 520) to a different sample. We could replicate the factor structure with evidence of good internal consistency and test–retest reliability of both subscales. Agreement between owner and trainer ratings was fair (inattention) and moderate (hyperactivity/impulsivity). Three ambiguous items were identified. Overall, we claim that the Dog ARS is a reliable tool to assess ADHD-like behaviour in dogs, but in its current form, it is not suitable to detect diagnosable individuals, as it does not comprise items assessing functional impairment, and also, the inclusion of owner-expert ratings in the evaluation process would be necessary.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Parental Barriers in Seeking Mental Health Services for Attention Deficit Hyperactivity Disorder in Children: Systematic Review

OBJECTIVE

Many children at risk for negative outcomes related to untreated attention deficit hyperactivity disorder (ADHD) do not receive necessary mental healthcare. Parents' mental health-seeking behavior is important in the early identification of ADHD and preventing comorbidities with ADHD. Parents may experience some barriers that may delay or stop parents from seeking mental healthcare for their children.

METHOD

This systematic review summarized existing evidence of parents' barriers to seeking mental healthcare for their children at risk of ADHD.

RESULTS

This review included 21 studies that address different parental barriers under the three levels of the social-ecological model, including individual, interpersonal, and community levels.

CONCLUSION

Raising parents' awareness of the process of seeking mental healthcare has the potential to help identify children at risk for ADHD earlier. Developing psychoeducational intervention that improves parents' seeking behavior and reduces barriers toward seeking mental healthcare is needed.