NIMH collaborative multisite multimodal treatment study of children with ADHD: I. Background and rationale

Evaluating serdexmethylphenidate and dexmethylphenidate capsules as a once-daily treatment option for ADHD

INTRODUCTION

Attention deficit/hyperactivity disorder (ADHD) is a common behavioral disorder which is best treated through a combination of medication and behavioral therapy, with stimulant medications serving as a first-line treatment approach. Serdexmethylphenidate (SDX), a prodrug of dexmethylphenidate (d-MPH), a commonly utilized stimulant medication, has recently received approval and is marketed in the U.S.A.

AREAS COVERED

This review summarizes peer-reviewed literature on SDX published between 2021-2023 and a review of data available from ClinicalTrials.gov.

EXPERT OPINION

SDX represents a new option for treatment for ADHD. It is unique in its prodrug design and achieves a relatively extended duration of action in comparison to other stimulant formulations. Although the research is relatively limited thus far, early data suggests it to be a safe medication to consider with side effects being similar to other stimulant medications. Its prodrug design is useful in potentially serving as a deterrent to intentional parenteral abuse and its ability to be opened and sprinkled makes it an option for those individuals with ADHD who might be unable to swallow pills.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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 In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

PRIMARY OUTCOMES

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

SECONDARY OUTCOMES

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

AUTHORS' CONCLUSIONS

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

Effectiveness of Child-Focused Interventions for Externalizing Behavior: a Rapid Evidence Review

Parent behavior management training (BMT) is well established as an effective, evidence-based treatment for children with externalizing behavior. Despite the wealth of data supporting BMT, many community providers use a variety of child-focused and non-directive interventions to target behavior problems. There is lack of clarity as to whether the evidence supporting child-focused externalizing treatments is sufficiently compelling to support offering these treatments rather than or in addition to BMT. This rapid evidence review compares the effectiveness of BMT with several common child-focused interventions for externalizing behavior including cognitive behavioral (CBT), social skill (SS), and play/dynamic (PT) approaches. PubMed, PsychINFO, and Web of Science were searched for English-language articles from year 2000 onwards for each intervention type. Inclusion criteria were child age (12 and under), presence of a child-focused behavioral treatment condition, and externalizing behavior as an outcome variable. A total of 30 studies met inclusion criteria and were coded (13 CBT, 10 SS, 7 PT). Results supported social skills interventions with accompanying BMT as effective in improving externalizing problems, with generally moderate effect sizes. Individual social skills interventions were promising but needing further evaluation compared to treatment as usual. CBT treatments with and without accompanying BMT showed moderate effects over waitlist but produced less consistently significant effects compared to more robust controls. Play therapy approaches showed inconsistent effects and require further evaluation. This review supports social skills plus BMT treatments as a child-focused intervention with probable efficacy for child externalizing problems. Implications for policy and community practice are discussed.

Dopamine and norepinephrine transporter inhibition for long-term fear memory enhancement

Psychostimulants are highly effective cognitive-enhancing therapeutics yet have a significant potential for abuse and addiction. While psychostimulants likely exert their rewarding and addictive properties through dopamine transporter (DAT) inhibition, the mechanisms of their procognitive effects are less certain. By one prevalent view, psychostimulants exert their procognitive effects exclusively through norepinephrine transporter (NET) inhibition, however increasing evidence suggests that DAT also plays a critical role in their cognitive-enhancing properties, including long-term memory enhancement. The present experiments test the hypothesis that combined strong NET and weak DAT inhibition will mimic the fear memory-enhancing but not the addiction-related effects of psychostimulants in mice. We examined the effects of the high affinity NET inhibitors atomoxetine or nisoxetine and the low affinity DAT inhibitor bupropion, either alone or in combination, on short- and long-term memory of Pavlovian fear conditioning. We also examined the addiction-related effects of combined strong NET and weak DAT inhibition using conditioned place preference and a locomotor activity test. While atomoxetine or nisoxetine alone enhanced short-term fear memory, the addition of bupropion was required to significantly enhance long-term fear memory. Additionally, combined atomoxetine and bupropion did not produce substantial motor stimulation or place preference. These findings suggest that combining strong NET and weak DAT inhibition could lead to the development of a highly effective cognitive enhancer that lacks the potential for addiction.

Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents - assessment of adverse events in non-randomised studies

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in childhood. The psychostimulant methylphenidate is the most frequently used medication to treat it. Several studies have investigated the benefits of methylphenidate, showing possible favourable effects on ADHD symptoms, but the true magnitude of the effect is unknown. Concerning adverse events associated with the treatment, our systematic review of randomised clinical trials (RCTs) demonstrated no increase in serious adverse events, but a high proportion of participants suffered a range of non-serious adverse events.

OBJECTIVES

To assess the adverse events associated with methylphenidate treatment for children and adolescents with ADHD in non-randomised studies.

SEARCH METHODS

In January 2016, we searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, 12 other databases and two trials registers. We also checked reference lists and contacted authors and pharmaceutical companies to identify additional studies.

SELECTION CRITERIA

We included non-randomised study designs. These comprised comparative and non-comparative cohort studies, patient-control studies, patient reports/series and cross-sectional studies of methylphenidate administered at any dosage or formulation. We also included methylphenidate groups from RCTs assessing methylphenidate versus other interventions for ADHD as well as data from follow-up periods in RCTs. Participants had to have an ADHD diagnosis (from the 3rd to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders or the 9th or 10th edition of theInternational Classification of Diseases, with or without comorbid diagnoses. We required that at least 75% of participants had a normal intellectual capacity (intelligence quotient of more than 70 points) and were aged below 20 years. We excluded studies that used another ADHD drug as a co-intervention.

DATA COLLECTION AND ANALYSIS

Fourteen review authors selected studies independently. Two review authors assessed risk of bias independently using the ROBINS-I tool for assessing risk of bias in non-randomised studies of interventions. All review authors extracted data. We defined serious adverse events according to the International Committee of Harmonization as any lethal, life-threatening or life-changing event. We considered all other adverse events to be non-serious adverse events and conducted meta-analyses of data from comparative studies. We calculated meta-analytic estimates of prevalence from non-comparative cohorts studies and synthesised data from patient reports/series qualitatively. We investigated heterogeneity by conducting subgroup analyses, and we also conducted sensitivity analyses.

MAIN RESULTS

We included a total of 260 studies: 7 comparative cohort studies, 6 of which compared 968 patients who were exposed to methylphenidate to 166 controls, and 1 which assessed 1224 patients that were exposed or not exposed to methylphenidate during different time periods; 4 patient-control studies (53,192 exposed to methylphenidate and 19,906 controls); 177 non-comparative cohort studies (2,207,751 participants); 2 cross-sectional studies (96 participants) and 70 patient reports/series (206 participants). Participants' ages ranged from 3 years to 20 years. Risk of bias in the included comparative studies ranged from moderate to critical, with most studies showing critical risk of bias. We evaluated all non-comparative studies at critical risk of bias. The GRADE quality rating of the evidence was very low.Primary outcomesIn the comparative studies, methylphenidate increased the risk ratio (RR) of serious adverse events (RR 1.36, 95% confidence interval (CI) 1.17 to 1.57; 2 studies, 72,005 participants); any psychotic disorder (RR 1.36, 95% CI 1.17 to 1.57; 1 study, 71,771 participants); and arrhythmia (RR 1.61, 95% CI 1.48 to 1.74; 1 study, 1224 participants) compared to no intervention.In the non-comparative cohort studies, the proportion of participants on methylphenidate experiencing any serious adverse event was 1.20% (95% CI 0.70% to 2.00%; 50 studies, 162,422 participants). Withdrawal from methylphenidate due to any serious adverse events occurred in 1.20% (95% CI 0.60% to 2.30%; 7 studies, 1173 participants) and adverse events of unknown severity led to withdrawal in 7.30% of participants (95% CI 5.30% to 10.0%; 22 studies, 3708 participants).Secondary outcomesIn the comparative studies, methylphenidate, compared to no intervention, increased the RR of insomnia and sleep problems (RR 2.58, 95% CI 1.24 to 5.34; 3 studies, 425 participants) and decreased appetite (RR 15.06, 95% CI 2.12 to 106.83; 1 study, 335 participants).With non-comparative cohort studies, the proportion of participants on methylphenidate with any non-serious adverse events was 51.2% (95% CI 41.2% to 61.1%; 49 studies, 13,978 participants). These included difficulty falling asleep, 17.9% (95% CI 14.7% to 21.6%; 82 studies, 11,507 participants); headache, 14.4% (95% CI 11.3% to 18.3%; 90 studies, 13,469 participants); abdominal pain, 10.7% (95% CI 8.60% to 13.3%; 79 studies, 11,750 participants); and decreased appetite, 31.1% (95% CI 26.5% to 36.2%; 84 studies, 11,594 participants). Withdrawal of methylphenidate due to non-serious adverse events occurred in 6.20% (95% CI 4.80% to 7.90%; 37 studies, 7142 participants), and 16.2% were withdrawn for unknown reasons (95% CI 13.0% to 19.9%; 57 studies, 8340 participants).

AUTHORS' CONCLUSIONS

Our findings suggest that methylphenidate may be associated with a number of serious adverse events as well as a large number of non-serious adverse events in children and adolescents, which often lead to withdrawal of methylphenidate. Our certainty in the evidence is very low, and accordingly, it is not possible to accurately estimate the actual risk of adverse events. It might be higher than reported here.Given the possible association between methylphenidate and the adverse events identified, it may be important to identify people who are most susceptible to adverse events. To do this we must undertake large-scale, high-quality RCTs, along with studies aimed at identifying responders and non-responders.

Predictors of Long-Term Risky Driving Behavior in the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

This study examines predictors of later risky driving behavior in children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Stepwise logistic regression and receiver operating characteristic (ROC) analysis were used to explore baseline predictors of risky driving behavior for adolescents who completed the 8-year follow-up assessment in the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA).

RESULTS

Stepwise logistic regression analysis explained 19% of the total variance in risky driving behavior. Increased likelihood of risky driving behavior was associated with parental history of conduct disorder, low parental monitoring and supervision, and increased age. ROC analysis identified discriminative predictors for adolescents older and younger than 16 years of age at follow-up. The most discriminative predictors of later risky driving behavior were parental stress at baseline (for children 16 years or older) and increased child-rated parental protectiveness (for children less than 16 years old).

CONCLUSION

Risky driving behavior was significantly predicted by baseline characteristics for the MTA cohort. Aspects of parenting behavior (or the child's perception of them), including parental stress levels, parental protectiveness, and parental levels of monitoring and supervision, were most informative in predicting these outcomes. Our results suggest that interventions to reduce high-risk behaviors in these high-risk children with ADHD might involve targeted parenting interventions.

The Direct/Indirect Association of ADHD/ODD Symptoms with Self-esteem, Self-perception, and Depression in Early Adolescents

The present study aimed to reveal the influences of attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms on self-esteem and self-perception during early adolescence and to clarify the spillover effect of self-esteem on depressive symptoms. ADHD symptoms in 564 early adolescents were evaluated via teacher-rating scales. Self-esteem and depressive symptoms were assessed via self-reported scales. We analyzed the relationships among these symptoms using structural equation modeling. Severe inattentive symptoms decreased self-esteem and hyperactive-impulsive symptoms affected self-perception for non-academic domains. Although these ADHD symptoms did not directly affect depressive symptoms, low self-esteem led to severe depression. ODD symptoms had a direct impact on depression without the mediating effects of self-esteem. These results indicated that inattentive symptoms had a negative impact on self-esteem and an indirect negative effect on depressive symptoms in adolescents, even if ADHD symptoms were subthreshold. Severe ODD symptoms can be directly associated with depressive symptoms during early adolescence.

Predictors of Long-Term School-Based Behavioral Outcomes in the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To explore predictors of 8-year school-based behavioral outcomes in attention-deficit/hyperactivity disorder (ADHD).

METHODS

We examined potential baseline predictors of school-based behavioral outcomes in children who completed the 8-year follow-up in the multimodal treatment study of children with ADHD. Stepwise logistic regression and receiver operating characteristic (ROC) analysis identified baseline predictors that were associated with a higher risk of truancy, school discipline, and in-school fights.

RESULTS

Stepwise regression analysis explained between 8.1% (in-school fights) and 12.0% (school discipline) of the total variance in school-based behavioral outcomes. Logistic regression identified several baseline characteristics that were associated with school-based behavioral difficulties 8 years later, including being male (associated with truancy and school discipline), African American (school discipline, in-school fights), increased conduct disorder (CD) symptoms (truancy), decreased affection from parents (school discipline), ADHD severity (in-school fights), and study site (truancy and school discipline). ROC analyses identified the most discriminative predictors of truancy, school discipline, and in-school fights, which were Aggression and Conduct Problem Scale Total score, family income, and race, respectively.

CONCLUSIONS

A modest, but nontrivial portion of school-based behavioral outcomes, was predicted by baseline childhood characteristics. Exploratory analyses identified modifiable (lack of paternal involvement, lower parental knowledge of behavioral principles, and parental use of physical punishment), somewhat modifiable (income and having comorbid CD), and nonmodifiable (African American and male) factors that were associated with school-based behavioral difficulties. Future research should confirm that the associations between earlier specific parenting behaviors and poor subsequent school-based behavioral outcomes are, indeed, causally related and independent cooccurring childhood psychopathology. Future research might target increasing paternal involvement and parental knowledge of behavioral principles and reducing use of physical punishment to improve school-based behavioral outcomes in children with ADHD.

The Effects of Stimulant Medication and Training on Sports Competence Among Children With ADHD

The current study examined the relative efficacy of behavioral sports training, medication, and their combination in improving sports competence among youth with attention deficit/hyperactivity disorder (ADHD). Participants were 73 youth (74% male; 81% Hispanic) between the ages of 5 and 12 diagnosed with Diagnostic and Statistical Manual of Mental Disorders (4th ed.) ADHD enrolled in a Summer Treatment Program (STP). The study consisted of a 2 (medication: methylphenidate, placebo) × 2 (sports training: instruction and practice, recreational play) between-groups design and was conducted over a 3-week period during the STP. Sports training was conducted with a novel sport, badminton, to limit previous sport knowledge and to differentiate it from concurrent sports training that occurred within the STP. Objective and subjective measures of sports skills, knowledge, and behavior were collected. Results indicated that, relative to recreational play, brief sports training improved observed and counselor-rated measures of sports competence including sports skills, knowledge, game awareness, effort, frustration, and enjoyment. During sports training, medication incrementally improved children's observed rule following behavior and counselor-rated sportsmanship relative to placebo. In the absence of sports training, medication improved behavior, effort, and sport knowledge. Training in sports skills and rules produced the largest magnitude effects on sports-related outcomes. Therefore, skills training, rather than medication alone, should be used in conjunction with behavioral intervention to teach sports to youth with ADHD. It is recommended that medication be used only as an adjunct to highly structured sports skills training for youth who display high rates of negative behavior during sports activities.

Modeling ADHD Child and Family Relationships

Little information is available on how to help families manage common negative sequelae of attention deficit/hyperactivity disorder (ADHD). This article is a report of the extent to which a theoretical formulation of child behavior, maternal distress, and family conflict was explained by data obtained from a community sample of families with children and adolescents with ADHD. Structural equation modeling was used to test the theoretical model. The primary variables of interest were (a) child behavior problems, (b) maternal distress, and (c) family conflict. The results suggest that maternal distress may mediate the relationship between child behavior problems and family conflict, indicating the critical importance of mothers in ADHD families and the need to provide them with additional support.

Patterns of Sensory Processing in Children with Attention Deficit Hyperactivity Disorder

The researchers conducted this study to compare the sensory responses of children whose primary diagnosis was Attention Deficit Hyperactivity Disorder (ADHD) and children without disabilities on the Sensory Profile, a parent-reporting measure of children's sensory responses in daily life (Dunn, 1999). Parents of 70 children 3 to 15 years old with a primary diagnosis of ADHD and parents of children without disabilities matched by age and gender completed the Sensory Profile. Researchers completed a series of Multivariate Analyses of Variance (MANOVA) with post hoc testing to compare the performance of the two groups of children. Children with ADHD differed significantly from children without disabilities in their sensory responsiveness based on Sensory Profile results. The Sensory Profile can contribute to diagnostic and program planning processes and increase understanding of the nature of the disorder of ADHD.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

SECONDARY OUTCOMES

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

AUTHORS' CONCLUSIONS

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

Overview of Attention Deficit Hyperactivity Disorder in Young Children

Attention deficit hyperactivity disorder (ADHD) is a complex disorder, which can be seen as a disorder of life time, developing in preschool years and manifesting symptoms (full and/or partial) throughout the adulthood; therefore, it is not surprising that there are no simple solutions. The aim of this paper is to provide a short and concise review which can be used to inform affected children and adults; family members of affected children and adults, and other medical, paramedical, non-medical, and educational professionals about the disorder. This paper has also tried to look into the process of how ADHD develops; what are the associated problems; and how many other children and adults are affected by such problems all over the world basically to understand ADHD more precisely in order to develop a better medical and or non-medical multimodal intervention plan. If preschool teachers and clinicians are aware of what the research tells us about ADHD, the varying theories of its cause, and which areas need further research, the knowledge will assist them in supporting the families of children with ADHD. By including information in this review about the connection between biological behavior, it is hoped that preschool teachers and clinicians at all levels will feel more confident about explaining to parents of ADHD children, and older ADHD children themselves about the probable causes of ADHD.

Psychometric properties of Japanese version of the Swanson, Nolan, and Pelham, version-IV Scale-Teacher Form: a study of school children in community samples

BACKGROUND

Psychometric properties of The Japanese version of Swanson, Nolan, and Pelham IV scale (SNAP-IV)-Teacher Form were examined in this study.

METHOD

Community samples of 1296 children (Grade 1-9, boys 52.9%) were collected from public elementary/middle schools in suburban areas. Teachers rated their children's behavior using Japanese version of SNAP-IV-Teacher Form and Strength and Difficulties Questionnaire (SDQ).

RESULTS

A three-factor structure model, which was equivalent with AD/HD symptoms subscales (inattention, hyperactivity/impulsivity) and oppositional-defiant disorder symptoms subscale was obtained and confirmed in an explorative/confirmative factorial analysis (Goodness-of-Fit Index=0.913, Comparative Fit Index=0.959, root mean square error of approximation=0.056). The current version of the SNAP-IV-Teacher Form demonstrated good test-retest reliability (intra-class correlation=0.752-0.822), high internal consistency (Cronbach's α=0.933-0.952), significant correlations with relevant subscales of Japanese version of SDQ, and typical effects of age and gender on those subscales.

CONCLUSION

The current study indicates that the Japanese version of SNAP-IV-Teacher Form is a reliable and valid instrument for rating symptoms related to AD/HD and ODD.

Shooting the Messenger: The Case of ADHD

Medicating ADHD is a controversial subject that was acutely inflamed in 1995 when high rates of ADHD diagnosis and treatment were documented in southeastern Virginia. Psychologists in southeastern Virginia formed a regional school health coalition to implement and evaluate interventions to address the problem. Other professionals with strong ties to the pharmaceutical industry launched ad hominem attacks on the coalition's research and work. These attacks contributed to the work being terminated in 2005. In the ensuing years, ADHD drug treatment continued to escalate. Today, the national rate of ADHD diagnosis exceeds all reasonable estimates of the disorder's true prevalence, with 14 % of American children being diagnosed before reaching young adulthood. Notable key opinion leaders continue to claim that there is no cause for concern, but with a message shift from "the prevalence is not too high" to "high prevalence is not too concerning." This paper provides an object lesson about how innovative research can be derailed to the detriment of sound medical and mental health care of children when industry interests are threatened. Tenure may be the only option for protecting innovative research from specious attacks. The authors offer a summary of the data on ADHD drug treatments, suggest judicious use of such treatments, and add their voices to others who are once again sounding a cautionary alarm.

Pilot physical activity intervention reduces severity of ADHD symptoms in young children

OBJECTIVE

Physical activity associates with mental health and neurocognitive function, showing potential for addressing ADHD symptoms. As a preliminary assessment of this potential, the authors piloted a before-school physical activity intervention for young children.

METHOD

Seventeen children (Grades K-3) exhibiting four or more hyperactivity/impulsivity symptoms on the Disruptive Behavior Disorders Rating Scale (Pelham, 2002) completed about 26 min of continuous moderate-to-vigorous physical activity daily over eight school weeks. The authors administered cognitive, motor, social, and behavioral functioning measures at pre- and postprogram, assessed response inhibition weekly, and coded negative behaviors daily.

RESULTS

Several measures showed significant or marginally significant change over time (effect size = 0.35-0.96) with additional measures showing meaningful effect size values (≥ 0.20). Response inhibition effects were most consistent. Most participants (64% to 71%) exhibited overall improvement according to postprogram parent, teacher, and program staff ratings.

CONCLUSION

Physical activity shows promise for addressing ADHD symptoms in young children.

Prevalence of ADHD symptoms in patients with congenital heart disease

OBJECTIVE

The presence of attention-deficit-hyperactivity disorder (ADHD) symptoms in children with congenital heart disease (CHD) was investigated.

METHODS

Swanson, Nolan and Pelham teacher and parent rating scales, version 4 (SNAP-IV), commonly used for assessing symptoms of ADHD, were completed by parents and counselors of children who attended a CHD summer camp. Mean scores (n = 51) were compared with two comparison groups without CHD: patients with ADHD (n = 75) and patients without ADHD (n = 41). Parent scores were also compared to previously published parent normative data.

RESULTS

Patients with CHD were reported to have elevated SNAP-IV scores by parents and counselors (11.8%). Parent ratings of inattention were significantly greater in CHD subjects when compared to the comparison group without ADHD (P < 0.001), and similar to the ADHD-positive comparison group. Regarding parent ratings of hyperactivity and impulsivity, the CHD group was significantly lower than the ADHD-positive controls (P = 0.024) but greater than the ADHD-negative controls (P < 0.001).

CONCLUSION

ADHD symptoms are more prevalent in children with CHD. Parent ratings of inattention and hyperactivity symptoms in CHD patients are similar to ratings in children diagnosed with ADHD. There is a trend towards a greater prevalence of inattention symptoms in patients with cyanosis or single ventricle physiology.

TDAH - Investigação dos critérios para diagnóstico do subtipo predominantemente desatento

O objetivo desta pesquisa foi identificar, através da literatura científica e entrevistas realizadas com três neuropediatras, os procedimentos médicos necessários para o diagnóstico seguro do TDAH - subtipo desatento e verificar se esses procedimentos foram aplicados ao diagnóstico de uma amostra de 10 crianças, alunos de um colégio particular na cidade de São José de Rio Preto. Os procedimentos foram relatados em entrevistas presenciais e questionários. A análise dos dados apontou para o amplo uso dos critérios do DSM-IV na maioria dos casos, porém o encaminhamento para avaliações multiprofissionais depende dos critérios seguidos por cada médico e não segue uma diretriz. Os resultados demonstraram que nenhum dos diagnósticos da amostra seguiu todos os procedimentos apontados, mostrando a necessidade de estabelecer um protocolo amplo, que agregue a participação de outros profissionais (fonoaudiólogos, psicopedagogos, psicólogos etc.), que garanta a precisão diagnóstica, descarte possibilidades e investigue fatores concorrentes para dificuldades apresentadas pela criança desatenta.

Long-term treatment of ADHD with stimulants: a large observational study of real-life patients

OBJECTIVE

To evaluate 410 real-life patients treated with stimulants and assessed systematically over several years.

METHOD

Naturalistic observational study. A database was compiled on the basis of a review of the medical charts of patients attending a specialized ADHD clinic.

RESULTS

The diversity of ADHD patients was evident from the comorbidity, age at start, comedication, and treatment needs over time. Dosages corresponded to guidelines in most patients, but some needed higher dosages or got along on lower dosages for long periods. Age at start and comorbidity influenced dosage, and dosage was associated to differential outcome groups.

CONCLUSION

The study findings underscored the diversity of ADHD patients and that individual factors should be taken into account when tailoring individual treatment schedules. Findings further showed that stimulant dosages are dynamic over time and depend on individual factors, that individual factors influence outcome, and that patients with ADHD should be individually monitored and stimulant dosages adjusted continuously.

School-based health centers: cost-benefit analysis and impact on health care disparities

OBJECTIVES

We evaluated the impact of school-based health centers-which provide essential health care for students by aiming to eliminate many access barriers-on health care access disparities and conducted a cost-benefit analysis.

METHODS

We employed a longitudinal quasi-experimental repeated-measures design. Primary data sources included the Ohio Medicaid claims, enrollment file with race/ethnicity, and survey reports from parents. We used hierarchical linear modeling to control unbalanced data because of student attrition. We assessed quarterly total Medicaid reimbursement costs for 5056 students in the SBHC and non-SBHC groups from 1997 to 2003. We calculated net social benefit to compare the cost of the SBHC programs with the value that SBHCs might save or create.

RESULTS

With SBHCs, the gap of lower health care cost for African Americans was closed. The net social benefits of the SBHC program in 4 school districts were estimated as $1,352,087 over 3 years. We estimated that the SBHCs could have saved Medicaid about $35 per student per year.

CONCLUSIONS

SBHCs are cost beneficial to both the Medicaid system and society, and may close health care disparity gaps.

The moderating role of sensory Overresponsivity in HPA activity: a pilot study with children diagnosed with ADHD

OBJECTIVE

To determine if sensory overresponsivity (SOR) is a moderating condition impacting the activity of the Hypothalamic Pituitary Adrenal (HPA) Axis in children with ADHD.

METHOD

Participants were children with (n = 24) and without ADHD (n = 24). Children in the ADHD group were divided into SOR (ADHDs) and non-SOR (ADHDt) groups using the Sensory Over-Responsivity Inventory. All children participated in the Sensory Challenge Protocol. Salivary cortisol was used as a measure of HPA activity. Two prechallenge and seven postchallenge samples of saliva were taken. Cortisol patterns between groups were examined using a mixed-effects ANOVA.

RESULTS

There was a borderline significant difference found between the ADHDt and ADHDs group (p = .056) and a significant difference between ADHDt and the typical group (p = .014).

CONCLUSION

Preliminary results support the premise that SOR may be a moderating variable used to create subgroups in diagnostic populations such as ADHD. (J. of Att. Dis. 2010; 13(5) 468-478).

Impact of school-based health centers on students with mental health problems

OBJECTIVES

School-based health centers (SBHCs) play an increasingly major role in providing mental health services for students. This study evaluated the impact of SBHCs on mental health-care services and psychosocial health-related quality of life (HRQOL).

METHODS

Four SBHC intervention and two matched non-SBHC school districts were examined from 1997 to 2003. The SBHC intervention began in 2000. Data included child and parent pediatric HRQOL and Ohio Medicaid claims. A longitudinal quasi-experimental time-series repeated measures design was used for this study, involving analysis of covariance to assess health costs and regression analyses for HRQOL scores.

RESULTS

After the SBHC program, proportions of students accessing mental health-care services for urban and rural SBHC intervention schools increased 5.6% (chi2 = 39.361, p < 0.0001) and 5.9% (chi2 = 5.545, p < 0.0001), respectively, compared with increases of 2.6% (chi2 = 2.670, p = 0.1023) and 0.2% (chi2 = 0.006, p = 0.9361) for urban and rural non-SBHC schools, respectively. Using data from 109 students with mental health problems based on Medicaid claims, the study found SBHC students had significantly lower total health-care costs (F = 5.524, p = 0.005) and lower costs of mental health services (F = 4.820, p = 0.010) compared with non-SBHC students. While improvements over time in HRQOL for SBHC students compared with non-SBHC students and students from non-SBHC schools were observed, only some were statistically significant.

CONCLUSIONS

SBHC programs increase the proportion of students who receive mental health services and may improve pediatric HRQOL. SBHC students with mental health problems had lower total Medicaid reimbursements compared with non-SBHC students.

The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study

OBJECTIVES

To determine any long-term effects, 6 and 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA; N = 436); to test whether attention-deficit/hyperactivity disorder (ADHD) symptom trajectory through 3 years predicts outcome in subsequent years; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers (local normative comparison group; N = 261).

METHOD

Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by parent, teacher, and youth report.

RESULTS

In nearly every analysis, the originally randomized treatment groups did not differ significantly on repeated measures or newly analyzed variables (e.g., grades earned in school, arrests, psychiatric hospitalizations, other clinically relevant outcomes). Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results. ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes. The MTA participants fared worse than the local normative comparison group on 91% of the variables tested.

CONCLUSIONS

Type or intensity of 14 months of treatment for ADHD in childhood (at age 7.0-9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. Innovative treatment approaches targeting specific areas of adolescent impairment are needed.

Psychopharmacological treatment of oppositional defiant disorder

Oppositional defiant disorder (ODD) consists of an enduring pattern of uncooperative, defiant and hostile behaviour toward authority figures that does not involve major antisocial violations and is not accounted for by the developmental stage of the child. The rate of ODD in children and adolescents in the general population has been reported to be between 2% and 16%. The International Classification of Diseases 10th Revision (ICD-10) classifies ODD as a mild form of conduct disorder (CD), and it has been estimated that up to 60% of patients with ODD will develop CD. Therefore, ODD should be identified and treated as early and effectively as possible.In more than one-half of patients with attention-deficit hyperactivity disorder (ADHD), ODD is also part of the clinical picture. There is strong evidence in the literature to suggest that ODD and ADHD overlap; many medications that are used to treat ADHD may also be efficacious in the treatment of ODD. A few studies have reported the positive effects of psychostimulants or atomoxetine in the treatment of ODD associated with ADHD. Patients with ODD and CD with severe aggression may respond well to risperidone, with or without psychostimulants. Mood regulators, alpha(2)-agonists and antidepressants may also have a role as second-line agents in the treatment of ODD and its co-morbidities.

Peer relationships in boys with attention-deficit hyperactivity disorder with and without comorbid aggression

Peer relationship difficulties and peer rejection are common in youngsters with attention-deficit hyperactivity disorder (ADHD), mandating focus on assessment issues, underlying reasons for peer approval and disapproval, links with comorbid aggression, and the mediating role of sociocognitive mechanisms as well as emotion regulation strategies. With previously unfamiliar ADHD and comparison boys who attended naturalistic summer research programs, we found the following: (a) parent and teacher estimates (but not self-reports) showed moderate correspondence with peer-nominated social preference; (b) ADHD boys were more likely than their comparison peers to accept other ADHD agemates; (c) aggression and noncompliance Predominated as self-reported reasons for rejecting agemates in both ADHD and comparison groups, with Perceived similarity the chief mediator of peer acceptance; (d) the high-aggressive subgroup of ADHD boys showed markedly worse peer sociometric status than did ADHD boys without aggression, for whom social isolation was also a predictor of peer reputation; and (e) self-reported social goals of a sensation-seeking nature and observed emotional reactivity characterized high-aggressive boys with ADHD and predicted end-of-program peer disapproval. We discuss implications for normal developmental processes and for intervention efforts.

Personal reflections on observational and experimental research approaches to childhood psychopathology

The past 50 years have seen dramatic changes in childhood psychopathology research. The goal of this overview is to contrast observational and experimental research approaches; both have grown more complex such that the boundary between these approaches may be blurred. Both are essential. Landmark observational studies with long-term follow-up (Robins, 1966; Yarrow, Campbell, & Burton, 1970) have had - and continue to have - unique impact on clinical research and practice. Epidemiological studies showed high rates of psychological disorder and their close tie to neurological impairment (Rutter, Tizard, & Whitemore, 1970). These studies have current impact with respect to brain imaging correlates of clinical outcome. Pharmacological studies, particularly those on stimulants and on treatment of pediatric obsessive compulsive disorder (OCD), have propelled experimental methodology and inspired translational approaches. Predicted future trends are: more informed subgrouping of our heterogeneous phenotypes, reliance on multicenter trials, and documentation of non-conventional methods of care delivery.

Attention deficit/hyperactivity disorder: a review and update

Attention deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and pervasive childhood disorder characterized by developmentally inappropriate activity level, impulsivity, and inability to sustain attention and concentration. Core symptoms of the disorder are associated with impairment in multiple domains of functioning and often coexist with other psychiatric disorders, the most prevalent being oppositional defiant disorder, conduct disorder, depression, and anxiety disorders. Concerns have been expressed about the overdiagnosis of ADHD, an upsurge in prescription of stimulant medication, and wide variations in practice patterns related to diagnosis and treatment of children with ADHD among primary care providers. Clinical research and expert consensus guidelines over the past decade have increasingly clarified the most effective approaches to diagnosis and treatment of the disorder. Hence, the purpose of this article was to provide primary care providers with the most current, evidence-based information on the assessment and treatment of children with ADHD.

Evidence, interpretation, and qualification from multiple reports of long-term outcomes in the Multimodal Treatment Study of children with ADHD (MTA): Part II: supporting details

OBJECTIVE

To review and provide details about the primary and secondary findings from the Multimodal Treatment study of ADHD (MTA) published during the past decade as three sets of articles.

METHOD

In the second of a two part article, we provide additional background and detail required by the complexity of the MTA to address confusion and controversy about the findings outlined in part I (the Executive Summary).

RESULTS

We present details about the gold standard used to produce scientific evidence, the randomized clinical trial (RCT), which we applied to evaluate the long-term effects of two well-established unimodal treatments, Medication Management (MedMGT) and behavior therapy (Beh), the multimodal combination (Comb), and treatment "as usual" in the community (CC). For each of the first three assessment points defined by RCT methods and included in intent-to-treat analyses, we discuss our definition of evidence from the MTA, interpretation of the serial presentations of findings at each assessment point with a different definition of long-term varying from weeks to years, and qualification of the interim conclusions about long-term effects of treatments for ADHD based on many exploratory analyses described in additional published articles.

CONCLUSIONS

Using a question and answer format, we discuss the possible clinical relevance of the MTA and present some practical suggestions based on current knowledge and uncertainties facing families, clinicians, and investigators regarding the long-term use of stimulant medication and behavioral therapy in the treatment of children with ADHD.

Attention deficit hyperactivity disorder in preschool children

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with a childhood onset of symptoms and impairment. Although it is most frequently identified during elementary school years, epidemiologic data suggest that the onset of ADHD frequently occurs earlier, with presentation as young as 3 years of age. Early identification, however, allows consideration of appropriate interventions. Many data are available on safe and efficacious treatment options for school-aged children who have ADHD; however, little is known about the use of these modalities in preschoolers and, ultimately, the long-term effects of early treatment. Recognition of the preschool presentation of ADHD, appropriate differential diagnosis, and identification of comorbid conditions, and a developmental perspective on the course and potential outcomes of the disorder may guide treatment planning. Newly available data on the safety and efficacy of pharmacotherapy and psychosocial intervention for preschoolers who have ADHD may help clinicians make treatment decisions for these young children and their families.

Efficacy of methylphenidate, psychosocial treatments and their combination in school-aged children with ADHD: a meta-analysis

INTRODUCTION

This meta-analysis compares effect-sizes of methylphenidate and psychosocial treatments and their combination on ADHD, concurrent oppositional, conduct symptoms, social behaviors and academic functioning.

METHOD

Several databases (PubMed, PsycInfo, ISI Web of Science) were searched for articles published between 1985 and September 2006. Inclusion criteria were: a diagnosis of ADHD; age from 6-12 years; a randomized controlled treatment design; efficacy established with parent and teacher rating scales; psychosocial treatments used were described as behavioral or cognitive-behavioral; the methylphenidate treatment was short-acting; and finally, treatment was conducted in a clinical setting.

RESULTS

ADHD outcomes showed large mean weighted effect-sizes for both methylphenidate and combined treatments, psychosocial treatments had a moderate mean weighted effect-size; a similar pattern emerged for oppositional and conducted behavior symptoms. Social behavior outcomes showed comparable moderate mean weighted effect-sizes for all treatments, while on academic functioning, all treatments had low mean weighted effect-sizes. There was no correlation between duration of psychosocial treatment and effect-size.

CONCLUSIONS

Both methylphenidate and psychosocial treatments are effective in reducing ADHD symptoms. However, psychosocial treatment yields smaller effects than both other treatment conditions. Psychosocial treatment has no additional value to methylphenidate for the reduction of ADHD and teacher rated ODD symptoms. However, for social behavior and parent rated ODD the three treatments were equally effective. For improvement of academic functioning no treatment was effective.

Multimodal Treatments for Childhood Attention-deficit/Hyperactivity Disorder: Interpreting Outcomes in the Context of Study Designs

The goal of this article was to outline issues critical to evaluating the literature on incremental benefit of multiple effective treatments used together, vs. a single effective treatment, for childhood ADHD. These issues include: (1) sequencing and dosage of treatments being combined and compared; (2) difficulty drawing valid conclusions about individual components of treatment when treatment packages are employed; (3) differing results emerging from measurement tools that purportedly measure the same domain; and (4) the resultant difficulty in reaching a summary conclusion when multiple outcome measures yielding conflicting results are used. The implications of these issues for the design and conduct of future studies are discussed, and recommendations are made for future research.

Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder

This practice parameter describes the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) based on the current scientific evidence and clinical consensus of experts in the field. This parameter discusses the clinical evaluation for ADHD, comorbid conditions associated with ADHD, research on the etiology of the disorder, and psychopharmacological and psychosocial interventions for ADHD.

Moderators and Mediators of Treatment Outcome for Youth With ADHD: Understanding for Whom and How Interventions Work

OBJECTIVE

To present data on moderators and mediators of treatment response from the Multimodal Treatment Study of Children With ADHD (MTA).

METHODS

Moderator variables (baseline factors that define subgroups with greater vs lesser intervention response) and mediator variables (factors occurring during treatment that explain how interventions "work") are described with specific application to the outcomes of the MTA Study.

RESULTS

Key moderator variables (comorbid anxiety disorder, public assistance, severity of attention-deficit/hyperactivity disorder, parental depressive symptomatology, IQ) and mediator processes (negative/ineffective parental discipline) are reviewed.

CONCLUSIONS

Treatment research in the future should explicitly consider the exploration of moderator and mediator variables, which can greatly aid the explanatory power of clinical trials and specify the critical next steps for intervention research.

Working memory deficits in adults with ADHD: is there evidence for subtype differences?

BACKGROUND

Working memory performance is important for maintaining functioning in cognitive, academic and social activities. Previous research suggests there are prevalent working memory deficits in children with attention deficit hyperactivity disorder (ADHD). There is now a growing body of literature characterizing working memory functioning according to ADHD subtypes in children. The expression of working memory deficits in adults with ADHD and how they vary according to subtype, however, remains to be more fully documented.

METHODS

This study assessed differences in working memory functioning between Normal Control (NC) adults (N = 18); patients with ADHD, Combined (ADHD-CT) Type ADHD (N = 17); and ADHD, Inattentive (ADHD-IA) Type (N = 16) using subtests from the Wechsler Adult Intelligence Scale-III and Wechsler Memory Scale-III and the Paced Auditory Serial Addition Task (PASAT).

RESULTS

The ADHD groups displayed significant weaknesses in contrast to the NC group on working memory tests requiring rapid processing and active stimulus manipulation. This included the Letter-Number-Sequencing test of the Wechsler scales, PASAT omission errors and the longest sequence of consecutive correct answers on the PASAT. No overall ADHD group subtype differences emerged; however differences between the ADHD groups and the NC group varied depending on the measure and the gender of the participants. Gender differences in performance were evident on some measures of working memory, regardless of group, with males performing better than females.

CONCLUSION

In general, the data support a dimensional interpretation of working memory deficits experienced by the ADHD-CT and ADHD-IA subtypes, rather than an absolute difference between subtypes. Future studies should test the effects of processing speed and load on subtype performance and how those variables interact with gender in adults with ADHD.

Hyperactivity and attention problems in a Swiss sample of school-aged children: effects of school achievement, child gender, and informants

OBJECTIVE

The sensitivity and tolerance regarding ADHD symptoms obviously differ from one culture to another and according to the informants (parents, teachers, or children). This stimulates the comparison of data across informants and countries.

METHOD

Parents and teachers of more than 1,000 school-aged Swiss children (5 to 17 years old) fill in Conners's questionnaires on ADHD. Children who are older than 10 years old also fill in a self-report questionnaire. Results are compared to data from a North American sample.

RESULTS

Swiss parents and teachers tend to report more ADHD symptoms than American parents and teachers as far as the oldest groups of children are concerned. Interactions are evidenced between school achievement, child gender, and informants. A relatively low rate of agreement between informants is found.

CONCLUSION

These results strengthen the importance to take into account all informants in the pediatric and the child psychiatry clinic, as well as in the epidemiological studies.

School-based mental health programming for children with inattentive and disruptive behavior problems: first-year treatment outcome

This article examines the effectiveness of an evidence-based behavioral treatment package for children with inattentive and disruptive behavior problems when delivered in the context of a school-based mental health program. Child symptomatology and functioning are assessed in a treatment group (n = 30) and a waitlist control group (n = 12) across multiple time points (fall, winter, and spring). Treatment includes a daily report card procedure, year-long teacher consultation, and parenting sessions. According to the parent report, treated children show marked reductions in hyperactive and impulsive, oppositional or defiant and aggressive behavior, and marked improvement in peer relationships. Teachers observe treatment-related group differences in inattention, academic functioning, and the student-teacher relationship. Feasibility and acceptability data have implications for transporting evidence-based treatments to community settings and for integrating mental health services into the culture of the school community.