Methylphenidate and behavior modification in children with ADHD and comorbid ODD or CD: main and incremental effects across settings

Psychopharmacological treatment of disruptive behavior in youths: systematic review and network meta-analysis

To conduct a systematic review of the comparative efficacy of various psychotropic medications for the treatment of disruptive behavior (DBs) in youths. To this aim, we systematically reviewed randomized clinical trials (RCTs) of various psychotropic medications targeting symptoms of DBs and applied network meta-analysis to investigate their relative efficacy. Fifty-five RCTs meeting the inclusion criteria were selected. To predict and interpret relative treatment efficacy, we compared the efficacy of various psychotropic medications prescribed for DB symptoms based on their mechanism of action. Network meta-analysis revealed that for reducing DBs, second-generation antipsychotics, stimulants, and non-stimulant ADHD medications were more efficacious than placebo, and second-generation antipsychotics were the most efficacious. The dopaminergic modulation of top-down inhibitory process by these medications is discussed in this review. This study offers information on the relative efficacy of various psychotropic medications for the treatment of DB, and insight into a potential neurobiological underpinning for those symptoms. It also illustrates the potential utility of these neurobiological mechanisms as a target for future treatment studies.

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 In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate.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.

Efficacy and Safety of Medication for Attention-Deficit Hyperactivity Disorder in Children and Adolescents with Common Comorbidities: A Systematic Review

Introduction

Comorbid psychiatric conditions in children and adolescents with attention-deficit hyperactivity disorder (ADHD) occur frequently, complicate management, and are associated with substantial burden on patients and caregivers. Very few systematic reviews have assessed the efficacy and safety of medications for ADHD in children and adolescents with comorbidities. Of those that were conducted, most focused on a particular comorbidity or medication. In this systematic literature review, we summarize the efficacy and safety of treatments for children and adolescents with ADHD and comorbid autism spectrum disorders, oppositional defiant disorder, Tourette’s disorder and other tic disorders, generalized anxiety disorder, and major depressive disorder.

Methods

We searched MEDLINE, Embase, and ClinicalTrials.gov (to October 2019) for studies of patients (aged < 18 years) with an ADHD diagnosis and the specified comorbidities treated with amphetamines, methylphenidate and derivatives, atomoxetine (ATX), and guanfacine extended-release (GXR). For efficacy, placebo-controlled randomized controlled trials (RCTs) or meta-analyses of RCTs were eligible for inclusion; for safety, all study types were eligible. The primary efficacy outcome measure was ADHD Rating Scale IV (ADHD-RS-IV) total score.

Results

Of 2177 publications/trials retrieved, 69 were included in this systematic literature review (5 meta-analyses, 37 placebo-controlled RCTs, 16 cohort studies, 11 case reports). A systematic narrative synthesis is provided because insufficient data were retrieved to combine ADHD-RS-IV total scores or effect sizes. Effect sizes for ADHD-RS-IV total scores were available for ten RCTs and ranged from 0.46 to 1.0 for ATX and from 0.92 to 2.0 for GXR across comorbidities. The numbers and types of adverse events in children with comorbidities were consistent with those in children without comorbidities, but treatment should be individualized to ensure children can tolerate the lowest effective dose.

Conclusion

Limited information is available from placebo-controlled RCTs on the efficacy (by ADHD-RS-IV) or safety of medication in children with ADHD and psychiatric comorbidities. Further studies are required to support evidence-based drug selection for these populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40120-021-00249-0.

A Pilot Study of Emotional Response to Time-Out in Children With Conduct Problems and Callous-Unemotional Traits

Little research has examined how children with conduct problems and concurrent callous-unemotional traits (CPCU) emotionally and behaviorally respond to time-out. This pilot study examined the distribution and stability of emotions during time-out as well as the association between emotions and negative behaviors. Participants were 11 children (M_age = 9.8 years) with CPCU who participated in a summer treatment program designed specifically for children with CPCU. Summer treatment program counselors rated each child's emotion when time-out was first assigned and then as the time-out progressed and indicated whether the child had negative behavior during time-out. These ratings were completed for approximately 30% of time-outs that occurred. Results showed that children were mostly rated as "unemotional" or "calm" and that these emotions were relatively stable throughout time-out. Furthermore, negative behaviors were most common during time-outs when children's emotions were rated as "amused." Results provide groundwork for future research to extend upon the methods used in the current study to further examine the emotional and behavioral response to time-out in children with CPCU.

Social skills training for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) in children is associated with hyperactivity and impulsivity, attention problems, and difficulties with social interactions. Pharmacological treatment may alleviate the symptoms of ADHD but this rarely solves difficulties with social interactions. Children with ADHD may benefit from interventions designed to improve their social skills. We examined the benefits and harms of social skills training on social skills, emotional competencies, general behaviour, ADHD symptoms, performance in school of children with ADHD, and adverse events.

OBJECTIVES

To assess the beneficial and harmful effects of social skills training in children and adolescents with ADHD.

SEARCH METHODS

In July 2018, we searched CENTRAL, MEDLINE, Embase, PsycINFO, 4 other databases and two trials registers.We also searched online conference abstracts, and contacted experts in the field for information about unpublished or ongoing randomised clinical trials. We did not limit our searches by language, year of publication, or type or status of publication, and we sought translation of the relevant sections of non-English language articles.

SELECTION CRITERIA

Randomised clinical trials investigating social skills training versus either no intervention or waiting-list control, with or without pharmacological treatment of both comparison groups of children and adolescents with ADHD.

DATA COLLECTION AND ANALYSIS

We conducted the review in accordance with the Cochrane Handbook for Systematic Reviews of Intervention. We performed the analyses using Review Manager 5 software and Trial Sequential Analysis. We assessed bias according to domains for systematic errors. We assessed the certainty of the evidence with the GRADE approach.

MAIN RESULTS

We included 25 randomised clinical trials described in 45 reports. The trials included a total of 2690 participants aged between five and 17 years. In 17 trials, participants were also diagnosed with various comorbidities.The social skills interventions were described as: 1) social skills training, 2) cognitive behavioural therapy, 3) multimodal behavioural/psychosocial therapy, 4) child life and attention skills treatment, 5) life skills training, 6) the "challenging horizon programme", 7) verbal self-instruction, 8) meta-cognitive training, 9) behavioural therapy, 10) behavioural and social skills treatment, and 11) psychosocial treatment. The control interventions were no intervention or waiting list.The duration of the interventions ranged from five weeks to two years. We considered the content of the social skills interventions to be comparable and based on a cognitive-behavioural model. Most of the trials compared child social skills training or parent training combined with medication versus medication alone. Some of the experimental interventions also included teacher consultations.More than half of the trials were at high risk of bias for generation of the allocation sequence and allocation concealment. No trial reported on blinding of participants and personnel. Most of the trials did not report on differences between groups in medication for comorbid disorders. We used all eligible trials in the meta-analyses, but downgraded the certainty of the evidence to low or very low.We found no clinically relevant treatment effect of social skills interventions on the primary outcome measures: teacher-rated social skills at end of treatment (standardised mean difference (SMD) 0.11, 95% confidence interval (CI) 0.00 to 0.22; 11 trials, 1271 participants; I2 = 0%; P = 0.05); teacher-rated emotional competencies at end of treatment (SMD -0.02, 95% CI -0.72 to 0.68; two trials, 129 participants; I2 = 74%; P = 0.96); or on teacher-rated general behaviour (SMD -0.06 (negative value better), 95% CI -0.19 to 0.06; eight trials, 1002 participants; I2 = 0%; P = 0.33). The effect on the primary outcome, teacher-rated social skills at end of treatment, corresponds to a MD of 1.22 points on the social skills rating system (SSRS) scale (95% CI 0.09 to 2.36). The minimal clinical relevant difference (10%) on the SSRS is 10.0 points (range 0 to 102 points on SSRS).We found evidence in favour of social skills training on teacher-rated core ADHD symptoms at end of treatment for all eligible trials (SMD -0.26, 95% CI -0.47 to -0.05; 14 trials, 1379 participants; I2= 69%; P = 0.02), but the finding is questionable due to lack of support from sensitivity analyses, high risk of bias, lack of clinical significance, high heterogeneity, and low certainty.The studies did not report any serious or non-serious adverse events.

AUTHORS' CONCLUSIONS

The review suggests that there is little evidence to support or refute social skills training for children and adolescents with ADHD. We may need more trials that are at low risk of bias and a sufficient number of participants to determine the efficacy of social skills training versus no training for ADHD. The evidence base regarding adolescents is especially weak.

Effects of Intensive Behavioral Treatment for Children With Varying Levels of Conduct Problems and Callous-Unemotional Traits

The purpose of this study was to examine whether callous-unemotional (CU) traits moderated the effects of intensive behavior therapy in elementary school-age children with varying levels of conduct problems (CP). Both treatment response (magnitude of change between pre- and posttreatment) and treatment outcomes (likelihood of normalization from treatment) were examined. Participants were 67 children (n = 49 boys, M_age = 9.6 years) with varying levels of CP and CU who participated in an intensive 8-week summer treatment program (STP) in which behavior therapy was delivered to children in recreational and classroom settings and to parents via weekly parent training sessions. Effects of treatment were measured using parent and teacher ratings of oppositional defiant disorder (ODD), conduct disorder (CD), callous behavior, and impairment. Results showed that CU moderated treatment effects for CD and callous behavior but not ODD or impairment. The moderating effects showed some evidence that participants with high CP and high CU before treatment had better treatment responses (larger change between pre- and posttreatment) but worse treatment outcomes (lower likelihood of normalization after treatment). These results suggest that intensive treatment, such as the STP, may be necessary but not sufficient for children with CP and CU traits.

DAT1 methylation is associated with methylphenidate response on oppositional and hyperactive-impulsive symptoms in children and adolescents with ADHD

OBJECTIVES

To examine the association of the DNA methylation of DAT1 and DRD4 gene with methylphenidate (MPH) response in attention deficit hyperactivity disorder (ADHD).

METHODS

One hundred and eleven DSM-IV defined ADHD Chinese Han children were recruited. Inattention, hyperactivity-impulsivity and oppositional symptoms were evaluated by the Swanson, Nolan and Pelham-IV-parent rating scale (SNAP-IV-P) at baseline and 6 weeks after MPH treatment. DNA methylation of CpG sites in the promoter sequences of DAT1 and DRD4 was examined for association with treatment response.

RESULTS

Greater improvement on the SNAP-IV-P total score and percentage change from baseline score were both significantly correlated with DAT1 methylation (rho =-0.222, P = .019 and rho = -0.203, P = .032, respectively). A secondary analysis demonstrated that the effect of DAT1 methylation on symptom response was primarily related to the percentage change in oppositional symptoms (rho = -0.242; P = .012), with a smaller significant effect on hyperactivity-impulsivity (rho = -0.192; P = .045). No significant correlation was found between the treatment effect on inattention and DAT1 methylation (rho = -0.101; P = .292). No significant correlation was observed between mean DRD4 methylation and measures of treatment outcome or baseline symptoms.

CONCLUSIONS

Our findings provide initial evidence for the involvement of the epigenetic alterations of DAT1 in modulating the response to MPH treatment in ADHD, primarily on oppositional and hyperactive-impulsive symptoms.

The pharmacological treatment of aggression in children and adolescents with conduct disorder. Do callous-unemotional traits modulate the efficacy of medication?

BACKGROUND

Children and adolescents with conduct disorder (CD) show repetitive and persistent patterns of aggressive behaviour and the more severe forms are often associated with callous-unemotional (CU) traits.

OBJECTIVES

To systematically review and, where data are adequate, conduct meta-analyses on the efficacy of medication on aggression in children and adolescent with CD considering the impact of CU traits.

RESULTS

Few studies have investigated patients with CD as primary diagnosis, and few of these have discriminated between different types of aggression or reported measures of CU traits. Methylphenidate and risperidone showed the largest effects on aggression in randomized controlled trials; other antipsychotics showed clinical efficacy on CD but this evidence is mainly revealed by open label trials. There is some low quality evidence to support a small effect of mood stabilizers and other agents. There were only two papers describing the effects of CU traits thus providing inconclusive results.

CONCLUSION

Considering heterogeneity of the disorder, more proof-of-concept clinical studies are needed to define effects of medication and role of CU traits.

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.

Summer Treatment Programs for Youth with Attention-deficit/hyperactivity Disorder

Children with attention-deficit/hyperactivity disorder (ADHD) require intensive treatments to remediate functional impairments and promote the development of adaptive skills. The summer treatment program (STP) is an exemplar of intensive treatment of ADHD. STP intervention components include a reward and response-cost point system, time-out, use of antecedent control (clear commands, establishment of rules and routines), and liberal praise and rewards for appropriate behavior. Parents also participate in parent management training programming to learn how to implement similar procedures within the home setting. There is strong evidence supporting the efficacy of the STP as an intervention for ADHD.

A dose-ranging study of behavioral and pharmacological treatment in social settings for children with ADHD

Placebo and three doses of methylphenidate (MPH) were crossed with 3 levels of behavioral modification (no behavioral modification, NBM; low-intensity behavioral modification, LBM; and high-intensity behavior modification, HBM) in the context of a summer treatment program (STP). Participants were 48 children with ADHD, aged 5-12. Behavior was examined in a variety of social settings (sports activities, art class, lunch) that are typical of elementary school, neighborhood, and after-school settings. Children received each behavioral condition for 3 weeks, order counterbalanced across groups. Children concurrently received in random order placebo, 0.15 mg/kg/dose, 0.3 mg/kg/dose, or 0.6 mg/kg/dose MPH, 3 times daily with dose manipulated on a daily basis in random order for each child. Both behavioral and medication treatments produced highly significant and positive effects on children's behavior. The treatment modalities also interacted significantly. Whereas there was a linear dose-response curve for medication in NBM, the dose-response curves flattened considerably in LBM and HBM. Behavior modification produced effects as large as moderate doses, and on some measures, high doses of medication. These results replicate and extend to social-recreational settings previously reported results in a classroom setting from the same sample (Fabiano et al., School Psychology Review, 36, 195-216, 2007). Results illustrate the importance of taking dosage/intensity into account when evaluating combined treatments; there were no benefits of combined treatments when the dosage of either treatment was high but combination of the low-dose treatments produced substantial incremental improvement over unimodal treatment.

Social skills training for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 5 to 18 years

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) in children is associated with hyperactivity and impulsitivity, attention problems, and difficulties with social interactions. Pharmacological treatment may alleviate symptoms of ADHD but seldom solves difficulties with social interactions. Social skills training may benefit ADHD children in their social interactions. We examined the effects of social skills training on children's social competences, general behaviour, ADHD symptoms, and performance in school.

OBJECTIVES

To assess the effects of social skills training in children and adolescents with ADHD.

SEARCH METHODS

We searched the following electronic databases: CENTRAL (2011, Issue1), MEDLINE (1948 to March 2011), EMBASE (1980 to March 2011), ERIC (1966 to March 2011 ), AMED (1985 to June 2011), PsycINFO (1806 to March 2011), CINAHL (1980 to March 2011), and Sociological Abstracts (1952 to March 2011). We also searched the metaRegister of Controlled Trials on 15 October 2010. We did not apply any language or date restrictions to the searches. We searched online conference abstracts and contacted 176 experts in the field for possible information about unpublished or ongoing RCTs.

SELECTION CRITERIA

Randomised trials investigating social skills training for children with ADHD as a stand alone treatment or as an adjunct to pharmacological treatment.

DATA COLLECTION AND ANALYSIS

We conducted the review according to the Cochrane Handbook for Systematic Reviews of Intervention. Two authors (OJS, MS) extracted data independently using an appropriate data collection form. We performed the analyses using Review Manager 5 software.

MAIN RESULTS

We included 11 randomised trials described in 26 records (all full text articles) in the review. The trials included a total of 747 participants. All participants were between five and 12 years of age. No trials assessed adolescents. In 10 of the trials the participants suffered from different comorbidities.The duration of the interventions ranged from eight to 10 weeks (eight trials) up to two years. The types of social skills interventions were named social skills training, cognitive behavioural intervention, multimodal behavioural/psychosocial therapy, behavioural therapy/treatment, behavioural and social skills treatment, and psychosocial treatment. The content of the social skills interventions were comparable and based on a cognitive behavioural model. Most of the trials compared child social skills training and parent training plus medication versus medication alone. Some of the experimental interventions also included teacher consultations.More than half of the trials were at high risk of bias regarding generation of the allocation sequence and allocation concealment. No trial reported blinding of participants and personnel and most of the trials had no reports regarding differences between groups in collateral medication for comorbid disorders. Overall, the trials had high risk of bias due to systematic errors. Even so, as recommended by the Cochrane Handbook of Systematic Reviews of Interventions, we used all eligible trials in the meta-analysis, but the results are downgraded to low quality evidence.There were no statistically significant treatment effects either on social skills competences (positive value = better for the intervention group) (SMD 0.16; 95% CI -0.04 to 0.36; 5 trials, n = 392), on the teacher-rated general behaviour (negative value = better for the intervention group) (SMD 0.00; 95% CI -0.21 to 0.21; 3 trials, n = 358), or on the ADHD symptoms (negative value = better for the intervention group) (SMD -0.02; 95% CI -0.19 to 0.16; 6 trials, n = 515).No serious or non-serious adverse events were reported.

AUTHORS' CONCLUSIONS

The review suggests that there is little evidence to support or refute social skills training for adolescents with ADHD. There is need for more trials, with low risk of bias and with a sufficient number of participants, investigating the efficacy of social skills training versus no training for both children and adolescents.

Effects of guanfacine extended release on oppositional symptoms in children aged 6-12 years with attention-deficit hyperactivity disorder and oppositional symptoms: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the efficacy and safety of guanfacine extended release (XR, Intuniv; Shire Development Inc., Wayne, PA, USA) in the treatment of oppositional symptoms in children aged 6-12 years with a diagnosis of attention-deficit hyperactivity disorder (ADHD) and the presence of oppositional symptoms.

SUBJECTS AND METHODS

In this randomized, double-blind, placebo-controlled, multicentre, flexible-dose, dose-optimization study, children aged 6-12 years were randomized to receive guanfacine XR (1-4 mg/day) or placebo for 9 weeks. Screening and washout periods were followed by a 5-week dose-optimization period, a 3-week dose-maintenance period and a 1-week tapering period. The primary efficacy measure was change from baseline to endpoint in the oppositional subscale of the Conners' Parent Rating Scale-Revised: Long Form (CPRS-R:L) score. Change in ADHD Rating Scale IV (ADHD-RS-IV) total score was a secondary efficacy measure. Safety assessments included adverse events (AEs), vital signs, ECG readings and laboratory studies.

RESULTS

A total of 217 children were enrolled: 138 were randomized to receive guanfacine XR and 79 to receive placebo. Least-squares mean reductions from baseline to endpoint in CPRS-R:L oppositional subscale scores were 10.9 in the guanfacine XR group compared with 6.8 in the placebo group (p < 0.001; effect size = 0.59). A significantly greater reduction in ADHD-RS-IV total score from baseline to endpoint was also seen in the guanfacine-treated group compared with the placebo group (23.8 vs 11.5, respectively; p < 0.001; effect size = 0.92). A post hoc correlation analysis between percentage reduction from baseline to endpoint in CPRS-R:L oppositional subscale and ADHD-RS-IV total scores indicated that the decreases in oppositional symptoms and ADHD symptoms were highly correlated (r = 0.74). The most commonly reported, treatment-emergent AEs (TEAEs) in the guanfacine XR group were somnolence (50.7%), headache (22.1%), sedation (13.2%), upper abdominal pain (11.8%) and fatigue (11.0%) and most were mild or moderate in severity. TEAEs of sedation, somnolence or hypersomnia were experienced by 62.5% of subjects in the guanfacine XR group. These events were most common during the dose-titration period but most (63.5%) resolved prior to the taper period. TEAEs of fatigue, lethargy and asthenia were reported in 11.0%, 3.7% and 0.0% of subjects in the guanfacine XR group, respectively. Most subjects receiving guanfacine XR demonstrated modest changes in blood pressure, pulse rate and ECG readings that were not considered clinically significant.

CONCLUSIONS

In this population of children aged 6-12 years with ADHD and the presence of oppositional symptoms, significant reductions in CPRS-R:L oppositional subscale and ADHD-RS-IV total scores were observed with guanfacine XR treatment compared with placebo. Treatment with guanfacine XR at optimized doses was associated with mostly mild or moderate TEAEs. The findings of this study support the efficacy of guanfacine XR in the treatment of children with ADHD and the presence of oppositional symptoms.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00367835.

Safety of stimulant treatment in attention deficit hyperactivity disorder: Part I

BACKGROUND

The safety profile of newer stimulant products is of interest. Because most studies focus on school-age children, there is also an increased interest in the treatment of other populations. Concern continues for the risk of substance abuse in the use of stimulants.

OBJECTIVE

The purpose of this paper is to review published data on the safety and tolerability of the newer forms of stimulants, treatment in special populations, and the risks of substance abuse and dependence in the treatment of attention deficit hyperactivity disorder.

METHODS

Literature obtained through Medline and Pubmed from 1995 were reviewed as well as key articles referenced in the literature.

CONCLUSIONS

The use of the newer stimulant agents shows a safety profile of frequent, but usually mild side effects. They are generally safe in special populations. The risk of developing long-term substance abuse with attention deficit hyperactivity disorder, without co-morbidities, is small and may decrease with proper treatment. More research is needed.

Predictive factors for persistent use and compliance of immediate-release methylphenidate: a 36-month naturalistic study

AIM

The objective of this study was to evaluate predictors of long-term adherence to treatment with methylphenidate (MPH).

METHODS

A total of 134 children (ages 4-16) with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) determined by specific protocols, including a semistructured parent interview, Conners' Teacher/Parent Rating Scales, cognitive and learning evaluation, and child self-reports for anxiety and depression, were assessed monthly for up to 36 months. At the end of the study (36 months), three outcomes were evaluated (continuing medication, medication withdrawn due to functional remission, and medication withdrawn for other reasons including poor compliance). Outcomes were first analyzed by mean of the chi-squared test, Mann-Whitney-U test, or t-test, and predictive models were subsequently generated using Cox proportional hazards model analysis. Age, ADHD subtype, co-morbidity, cognitive functioning, side effects, and family and social characteristics were considered as independent variables.

RESULTS

Thirty-six months after starting MPH, 62 children (46%) were still on treatment, 32 (24%) had stopped MPH due to functional remission, and 40 (30%) had suspended MPH for other reasons. Within the last group, 20 suspended for poor compliance, 10 for decrease of efficacy, 5 for side effects, and 5 because they entered in an atomoxetine clinical trial. The presence of associated disorders, younger age, female gender, and not living with both parents were predictors for continuing medication until end of the study (36 months); absence of associated disorders and older age were predictors of discontinuation medication due to functional remission before the end of study, older age, and hyperactive subtype were predictors of discontinuing medication for other reasons.

CONCLUSION

Clinical outcome of ADHD treatment is heterogeneous: Specific clinical and social predictive parameters for long-term MPH use and compliance can be identified. An accurate tailoring of clinical intervention to the individual child appears crucial for good outcome.

Atomoxetine hydrochloride in the treatment of children and adolescents with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder: A placebo-controlled Italian study

OBJECTIVE

The primary aim of this study was to assess the efficacy of atomoxetine in improving ADHD and ODD symptoms in paediatric patients with ADHD and comorbid oppositional defiant disorder (ODD), non-responders to previous psychological intervention with parent support.

METHODS

This was a multicentre, randomised, placebo-controlled trial conducted in patients aged 6-15 years, with ADHD and ODD diagnosed according to the DSM-IV criteria by a structured clinical interview (K-SADS-PL). Only subjects who are non-responders to a 6-week standardized parent training were randomised to atomoxetine (up to 1.2 mg/kg/day) or placebo (in a 3:1 ratio) for the following 8-week double blind phase.

RESULTS

Only 2 of the 156 patients enrolled for the parent support phase (92.9% of males; mean age: 9.9 years), improved after the parent training program; 139 patients were randomised for entering in the study and 137 were eligible for efficacy analysis. At the end of the randomised double blind phase, the mean changes in the Swanson, Nolan and Pelham Rating Scale-Revised (SNAP-IV) ADHD subscale were -8.1+/-9.2 and -2.0+/-4.7, respectively in the atomoxetine and in the placebo group (p<0.001 between groups); changes in the ODD subscale were -2.7+/-4.1 and -0.3+/-2.6, respectively in the two groups (p=0.001 between groups). The CGI-ADHD-S score decreased in the atomoxetine group (median change at endpoint: -1.0) compared to no changes in the placebo group (p<0.001 between groups). Statistically significant differences between groups, in favour of atomoxetine, were found in the CHIP-CE scores for risk avoidance domain, emotional comfort and individual risk avoidance subdomains. An improvement in all the subscales of Conners Parents (CPRS-R:S) and Teacher (CTRS-R:S) subscales was observed with atomoxetine, except in the cognitive problems subscale in the CTRS-R:S. Only 3 patients treated with atomoxetine discontinued the study due to adverse events. No clinically significant changes of body weight, height and vital signs were observed in both groups.

CONCLUSIONS

Treatment with atomoxetine of children and adolescents with ADHD and ODD, who did not initially respond to parental support, was associated with improvements in symptoms of ADHD and ODD, and general health status. Atomoxetine was well tolerated.

Community vs. clinic-based modular treatment of children with early-onset ODD or CD: a clinical trial with 3-year follow-up

This study examines the treatment outcomes of 139, 6-11 year-old, clinically referred boys and girls diagnosed with Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) who were randomly assigned to a modular-based treatment protocol that was applied by research study clinicians either in the community (COMM) or a clinic office (CLINIC). To examine normative comparisons, a matched sample of 69 healthy control children was included. Multiple informants completed diagnostic interviews and self-reports at six assessment timepoints (pretreatment to 3-year follow-up) to evaluate changes in the child's behavioral and emotional problems, psychopathic features, functional impairment, diagnostic status, and service involvement. Using HLM and logistic regression models, COMM and CLINIC showed significant and comparable improvements on all outcomes. By 3-year follow-up, 36% of COMM and 47% of CLINIC patients no longer met criteria for either ODD or CD, and 48% and 57% of the children in these two respective conditions had levels of parent-rated externalizing behavior problems in the normal range. We discuss the nature and implications of these novel findings regarding the role of treatment context or setting for the treatment and long-term outcome of behavior disorders.

How can the study of biological processes help design new interventions for children with severe antisocial behavior?

Children with severe antisocial behavior have an increased risk of showing violently aggressive and other forms of problem behavior in adolescence and adulthood. It is well established that both biological and social factors are involved in the development of antisocial behavior. The primary aim of this paper is to discuss the evidence that specific neurobiological systems are involved in the etiology of childhood-onset antisocial behavior. These factors are responsible for the severity of the behavioral problems observed in antisocial children, but they also play a role in their persistence, because they influence children's interactions with their environment. We will discuss the possible causes of disruptions in neurobiological systems in childhood antisocial behavior and point out the implications of these findings for theory and clinical practice. We will argue that familial factors (e.g., genetic influences, early childhood adversity) are linked to negative behavioral outcomes (e.g., antisocial behavior problems) through the mediating and transactional interplay with neurobiological deficits. An investigation of neurobiological functioning in antisocial children might not only indicate which children are most likely to persist in engaging in severe antisocial behavior, but also guide the development of new interventions.

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

Pelham, Wheeler, and Chronis (1998) reviewed the treatment literature on attention-deficit/hyperactivity disorder (ADHD) and concluded behavioral parent training (BPT) and behavioral classroom management (BCM) were well-established treatments for children with ADHD. This review updates and extends the finding of the prior review. Studies conducted since the 1998 review were identified and coded based on standard criteria, and effect sizes were calculated where appropriate. The review reinforces the conclusions of Pelham, Wheeler, and Chronis regarding BPT and BCM. Further, the review shows that intensive peer-focused behavioral interventions implemented in recreational settings (e.g., summer programs) are also well-established. The results of this update are discussed in the context of the existing treatment literature on ADHD. Implications for practice guidelines are suggested, as are directions for future research.

Methylphenidate in children with oppositional defiant disorder and both comorbid chronic multiple tic disorder and ADHD

Our primary objective was to determine if immediate-release methylphenidate is an effective treatment for oppositional defiant disorder diagnosed from mother's report in children with both chronic multiple tic disorder and attention-deficit hyperactivity disorder (ADHD). Children (n = 31) aged 6 to 12 years received placebo and 3 doses of methylphenidate twice daily for 2 weeks each under double-blind conditions and were assessed with ratings scales and laboratory measures. Results indicated significant improvement in both oppositional and ADHD behaviors with medication; however, the magnitude of treatment effect varied considerably as a function of disorder (ADHD > Oppositional behaviors), informant (teacher > mother), assessment instrument, and specific oppositional behavior (rebellious > disobeys rules). Drug response was comparable with that in children (n = 26) who did not have diagnosed oppositional defiant disorder, but comorbidity appeared to alter the perceived benefits for ADHD according to mother's report. Methylphenidate is an effective short-term treatment for oppositional behavior in children with comorbid ADHD and chronic multiple tic disorder.

Critical influences affecting response to various treatments in young children with ADHD: a case series

BACKGROUND

While the use of stimulant medication as a treatment for children with attention deficit hyperactivity disorder (ADHD) has been the most studied therapy in child psychiatry, there is debate about its use with young children. This study describes a series of cases seen in a normal clinical context, treated with one of four different treatment programmes.

METHODS

Sixteen pre-school children diagnosed with ADHD and their parents were randomly assigned to receive one of four treatments: (1) 0.3 mg/kg methylphenidate, parent training programme; (2) 0.3 mg/kg methylphenidate, parent support programme; (3) placebo medication, parent training; and (4) placebo medication, parent support. Changes were assessed at the individual level, using clinical observations, parent and teacher rating scales and measures of parenting and family factors.

RESULTS

Children were more likely to improve when the treatment involved at least one active component (medication or parent training). However, there was notable variability in individual parental and child participants' responses to all treatment conditions, indicating the importance of interactions between treatment variables and other factors.

CONCLUSIONS

Findings are discussed within the framework of a transactional model, and inferences are drawn about the limitations of the idea that there is a 'best treatment' that is universally applicable.

Attention-deficit/hyperactivity disorder: a neuropsychological perspective towards DSM-V

Neuropsychological methods and techniques have much to offer in the evaluation of the individual suspected as having Attention-Deficit/Hyperactivity Disorder (ADHD). After a review of the historical evolution of the ADHD concept, incidence and prevalence, and DSM-IV criteria for diagnosis, especially as regards omission related to gender differences, and other associated cultural, familial, socioenvironmental, and subject influences, this paper describes a number of dilemmas and obstacles encountered in clinical practice. Included are the confounds associated with the wide range of possible comorbidities, the insufficiency of current DSM-IV criteria, the emergence of subtype differentiation and its impact on diagnosis and treatment. The complex relationship between neuropsychological constructs and ADHD, and obstacles to valid assessment are also addressed. The complexities associated with a thorough ADHD evaluation are viewed within an impressive and expansive existing scientific framework and recommendations are made for future directions.

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.

Long-acting methylphenidate has an effect on aggressive behavior in children with attention-deficit/hyperactivity disorder

INTRODUCTION

Aggression is frequently observed in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to assess the efficacy with regard to oppositional and aggressive behavior of a new long-acting methylphenidate preparation (Medikinet retard, MPH-MR), with equal portions of the immediate-release and the sustained-release active substance, and especially to look at correlations between either teacher or parent assessment of aggression and ADHD sub-symptomatology.

METHODS

Eighty five children and adolescents (6-16 years) were investigated in a double-blind, randomized, clinical trial over 5 weeks under a treatment with MPH-MR using symptom checklists for ADHD, oppositional-defiant and conduct disorder according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).

RESULTS

A total of 64.9% of the children showed oppositional defiant disorder/conduct disorder (ODD/CD) symptoms. A statistically significant effect was found in the group treated with MPH (verum-group). On the basis of Cohen's criteria, high effects were found for aggressive symptoms in school (d = 1.0), but not in the afternoon (d = 0.4). There were also lower effect sizes for more severe aggressive symptoms. We found characteristic correlations between ODD/CD symptoms and the ADHD subscale hyperactivity/impulsivity compared to the subscale inattention.

CONCLUSIONS

Long-acting MPH is effective in the treatment of oppositional-defiant and aggressive behavior, especially concerning milder symptoms. The expected correlation between impulsivity and aggressiveness could be confirmed.

Treating common psychiatric disorders associated with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) often occurs along with other psychiatric disorders, with estimated comorbidity rates of 50--90%. Comorbidity greatly influences presentation, diagnosis and prognosis, complicates treatment and significantly increases the morbidity and disease burden of ADHD. Commonly co-occurring psychiatric disorders are disruptive behavior disorder, anxiety, depression, bipolar disorder and substance use disorders. This article provides a brief review of effective strategies for treating the most common psychiatric disorders associated with ADHD. This paper also discusses knowledge gaps in the understanding of treatment of comorbid disorders associated with ADHD, and directions for future research.

Systematic review of pharmacotherapy of disruptive behavior disorders in children and adolescents

RATIONALE

Pharmacotherapy is frequently considered in the treatment of disruptive behavior disorders (DBDs) in children and adolescents. There are, however, no systematic reviews of this literature.

OBJECTIVES

The aim of this work is to determine whether medication is effective in treating pediatric disruptive behavior disorders and related problems of impulse control, as well as to examine differences in the treatment response and tolerability of different medication classes and agents.

MATERIALS AND METHODS

Randomized controlled trials of the pharmacotherapy of DBDs in children and adolescents were reviewed, and a meta-analysis of 14 trials (823 participants) was conducted.

RESULTS

There is some evidence of the effectiveness of medication in treating DBDs, with positive outcomes for lithium and risperidone in particular. Pharmacotherapy also demonstrated some efficacy in reducing symptoms of aggression. Medication was relatively well-tolerated, as indicated by equivalent dropout rates in medication and comparison groups.

CONCLUSIONS

There are relatively few controlled trials of the pharmacotherapy of disruptive behavior disorders or other impulse control disorders, despite the importance of research in this area. Given the potential adverse effects of agents such as lithium and risperidone, a careful risk-benefit analysis is needed for each patient.

Effect of comorbid symptoms of oppositional defiant disorder on responses to atomoxetine in children with ADHD: a meta-analysis of controlled clinical trial data

RATIONALE

Up to 60% of children with attention-deficit/hyperactivity disorder (ADHD) suffer from comorbid affective or behavioral impairments, the most common condition being oppositional defiant disorder (ODD), which occurs in 40-60% of children with ADHD.

OBJECTIVES

This post hoc meta-analysis was performed to determine the effect of the presence of comorbid ODD symptoms on clinical outcomes among pediatric and adolescent subjects being treated for ADHD.

METHODS

Acute-phase data were analyzed from three randomized, double-blind, placebo-controlled studies in outpatients aged 6-16 and meeting the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria for ADHD. Subjects received placebo or atomoxetine (max 1.8 mg/kg/day, daily) for 6-8 weeks. Patients were diagnosed with comorbid ODD on structured diagnostic interview (Schedule for Affective Disorders and Schizophrenia for School-aged Children-Present and Lifetime Versions).

RESULTS

Of the 512 subjects studied, 158 were diagnosed with comorbid ODD. Relative to placebo, atomoxetine treatment significantly reduced ADHD symptoms in both ODD-comorbid and noncomorbid subjects irrespective of the comorbidity with ODD. ADHD subjects also showed significant improvements from baseline on most of the psychosocial measures of the child health questionnaire irrespective of the comorbidity with ODD. Reduction in ODD symptoms was highly related to the magnitude of ADHD response.

CONCLUSIONS

Atomoxetine treatment significantly reduced ADHD symptoms in both ODD-comorbid and noncomorbid subjects to similar extents, indicating that the presence of comorbid symptoms of oppositionality does not affect clinical outcomes of treatment of ADHD with atomoxetine.

Pharmacological aspects of the treatment of conduct disorder in children and adolescents

In recent years, the rates of psychosocial disorders in children and adolescents have increased, with behavioural manifestations of conduct disorder being one of the most common reasons for referrals to community psychiatrists. Childhood conduct problems are associated with a variety of psychiatric disorders in adult life that extend beyond antisocial behaviour. An increased awareness of the costs of conduct disorder to individuals, families and society has led to advancements in the pharmacological and nonpharmacological therapeutic modalities for this disorder. Despite this, patients with conduct disorder are difficult to treat as the patterns of maladaptive behaviours they exhibit are diverse and can vary as a function of age and sex. A multidisciplinary approach to the treatment of conduct disorder, which includes behavioural parent training, interpersonal skills training, family therapy and the use of psychotropic agents targeted at a particular cluster of symptoms, can increase the overall effectiveness of each of the applied interventions. Aggression, hyperactivity, impulsivity and mood symptoms are the most sensitive proximal targets. Evidence suggests that antipsychotics, antidepressants, mood stabilisers, antiepileptic drugs, stimulants and adrenergic drugs can be well tolerated and effective therapeutic options for individuals with conduct disorder and comorbid psychiatric conditions. However, the most successful therapeutic outcomes are likely to be achieved by combining the current advances in psychopharmacology with behavioural and psychosocial interventions, aimed at modifying the excessive patterns of maladaptive behaviours observed in conduct disorder.

Pharmacotherapy and postdischarge outcomes of child inpatients admitted for aggressive behavior

OBJECTIVES

: (1) To ascertain the use rates of specific pharmacotherapy strategies for child psychiatric inpatients with aggressive behavior from preadmission care through 12 months after discharge, and (2) To examine the associations between these strategies and postdischarge outcomes.

METHOD

: Prospective follow-up of eighty-three 5- to 13-year-old children admitted to acute inpatient care for aggressive behavior in the context of a disruptive behavior disorder. Treatment and symptom severity data were obtained at admission, discharge, and 3, 6, and 12 months after discharge between 1998 and 2001.

RESULTS

: Utilization. The number of concurrent medications increased over assessment times. Changes in children's pharmacotherapy occurred most frequently during hospitalization and from discharge to 3 months after discharge. Treatment with antipsychotics and mood stabilizers increased over assessment times, whereas selective serotonin reuptake inhibitor (SSRI) treatment decreased. Outcomes. Children treated with stimulants and risperidone 3 months after discharge had significantly improved behavioral ratings, adjusted for admission scores and concurrent medications. Children treated with SSRIs at 6 months after discharge had higher problem severity ratings. Those who maintained lithium and SSRI treatment between 6 and 12 months showed improvements.

CONCLUSIONS

: The complexity of pharmacotherapy for child inpatients ratchets upwards from admission through 1 year after discharge. Hospital-initiated treatment is commonly altered soon after discharge. Within the limitations of observational methodology, the postdischarge outcomes seem related to specific pharmacotherapy regimens.

Long-term use of risperidone in children with disruptive behavior disorders and subaverage intelligence: efficacy, safety, and tolerability

OBJECTIVE

The aim of this study was to assess the long-term efficacy and tolerability of risperidone in the treatment of children and adolescents with disruptive behavior disorder (DBD) and below-average intelligence (IQ < 84) over a cumulative period of 2 years.

METHODS

We followed 48 patients (6-15 years of age), who had previously completed a 1- year open-label study of risperidone, for an additional year of treatment. Efficacy was assessed using the conduct problem subscale of the Nisonger Child Behavior Rating Form (N-CBRF) as a primary outcome measure; other N-CBRF subscales, the Aberrant Behavior Checklist (ABC), and the Clinical Global Impression (CGI) of severity were secondary efficacy measures. Safety and tolerability were also assessed.

RESULTS

Of the 48 patients enrolled in this extension study, 33 (69%) completed the trial. The efficacy benefits from the original study were maintained over the course of the extension study. Safety and tolerability were good overall, with the number of adverse events (AEs) decreasing in the extension trial, compared to the original trial. Six patients (13%) discontinued owing to AEs. Weight gain observed in the original trial stabilized during this extension trial. Cognitive testing demonstrated small, but significant, improvements in cognitive ability.

CONCLUSIONS

Risperidone is safe and effective in treating DBDs in children over a cumulative period of 2 years.

Prescribing practices of psychiatrists and primary care physicians caring for children with mental illness

OBJECTIVE

Although several studies have found that the most effective treatment for both youths and adults diagnosed with mood disorders is the combination of psychotherapy and medications, psychiatrists have been increasingly providing psychotropic medications without psychotherapy to these populations. At the same time, primary care physicians (PCPs) have become increasingly involved in prescribing psychotropic medications. This study compared the prescribing patterns of PCPs and psychiatrists caring for children with mental illness.

METHODS

Data were extracted from the MarketScan database, which compiles claims from private health insurance plans nationwide. Of 40,639 children who received mental health services during calendar year 2000 (6.33% of all covered children), we identified 5485 who initiated a new episode of treatment. Multiple regression was use to adjust for differences in patient characteristics.

RESULTS

While PCPs were more likely to see young children and psychiatrists saw children with more numerous mental illnesses, there were no significant differences between PCPs and psychiatrists in either the proportion of patients who received psychotropic medication, the frequency of clinical contacts, or the dosages or types of medications prescribed. Patients seen in more actively managed Point of Service plans were more likely to receive medication than those seen in preferred provider or indemnity plans.

CONCLUSIONS

This study found no significant differences between psychiatrists and PCPs in psychotropic prescribing practices. In view of the limited availability of child psychiatrists and the decreased availability of psychotherapy in combination with medications, collaborative care models in which non-physician mental health specialists and PCPs work together may increase the availability of effective mental health services for youths.

Classes of adolescents with disruptive behaviors in a general population sample

BACKGROUND

To study disruptive behaviors adequately, we need to distinguish between individuals with different types of problems that may have a different etiology. The availability of a taxonomic system that helps in identifying homogeneous groups of individuals, with similar patterns of disruptive behaviors, is crucial to achieve this goal. Therefore, we examine which classes of preadolescents with symptoms of Attention Deficit/Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD) can be identified in the general population.

METHODS

Disruptive behaviors of 2,230 10-12 year olds from the Dutch general population were assessed with the Child Behavior Checklist and Youth Self-Report.

RESULTS

Latent class analysis revealed three classes of preadolescents: the first characterized by high scores on ADHD, ODD, and CD items; a second by high probabilities of ADHD and ODD symptoms; a third with low scores on all items.

CONCLUSIONS

Because classes of preadolescents with symptoms of only one type of disruptive behavior problems could not be identified, it can be questioned how useful separate diagnostic distinctions are in general population studies.

Evidence-Based Assessment of Attention Deficit Hyperactivity Disorder in Children and Adolescents

This article examines evidence-based assessment practices for attention deficit hyperactivity disorder (ADHD). The nature, symptoms, associated features, and comorbidity of ADHD are briefly described, followed by a selective review of the literature on the reliability and validity of ADHD assessment methods. It is concluded that symptom rating scales based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994), empirically and rationally derived ADHD rating scales, structured interviews, global impairment measures, and behavioral observations are evidence-based ADHD assessment methods. The most efficient assessment method is obtaining information through parent and teacher rating scales; both parent and teacher ratings are needed for clinical purposes. Brief, non-DSM based rating scales are highly correlated with DSM scales but are much more efficient and just as effective at diagnosing ADHD. No incremental validity or utility is conferred by structured interviews when parent and teacher ratings are utilized. Observational procedures are empirically valid but not practical for clinical use. However, individualized assessments of specific target behaviors approximate observations and have both validity and treatment utility. Measures of impairment that report functioning in key domains (peer, family, school) as well as globally have more treatment utility than nonspecific global measures of impairment. DSM diagnosis per se has not been demonstrated to have treatment utility, so the diagnostic phase of assessment should be completed with minimal time and expense so that resources can be focused on other aspects of assessment, particularly treatment planning. We argue that the main focus of assessment should be on target behavior selection, contextual factors, functional analyses, treatment planning, and outcome monitoring.

Treatment of attention-deficit/hyperactivity disorder: overview of the evidence

The American Academy of Pediatrics' Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, reviewed and analyzed the current literature for the purpose of developing an evidence-based clinical practice guideline for the treatment of the school-aged child with attention-deficit/hyperactivity disorder (ADHD). This review included several key reports, including an evidence review from the McMaster Evidence-Based Practice Center (supported by the Agency for Healthcare Research and Quality), a report from the Canadian Coordinating Office for Health Technology Assessment, the Multimodal Treatment for ADHD comparative clinical trial (supported by the National Institute of Mental Health), and supplemental reviews conducted by the subcommittee. These reviews provided substantial information about different treatments for ADHD and their efficacy in improving certain characteristics or outcomes for children with ADHD as well as adverse effects and benefits of multiple modes of treatment compared with single modes (eg, medication or behavior therapies alone). The reviews also compared the effects of different medications. Other evidence documents the long-term nature of ADHD in children and its classification as a chronic condition, meriting the application of general concepts of chronic-condition management, including an individual treatment plan with a focus on ongoing parent and child education, management, and monitoring. The evidence strongly supports the use of stimulant medications for treating the core symptoms of children with ADHD and, to a lesser degree, for improving functioning. Behavior therapy alone has only limited effect on symptoms or functioning of children with ADHD, although combining behavior therapy with medication seems to improve functioning and may decrease the amount of (stimulant) medication needed. Comparison among stimulants (mainly methylphenidate and amphetamines) did not indicate that 1 class outperformed the other.

Motivational effects on motor timing in attention-deficit/hyperactivity disorder

OBJECTIVE

This study was designed to clarify whether poor performance of children with attention-deficit/hyperactivity disorder (ADHD) on motor timing tasks reflects a true deficit in the temporal organization of motor output or is due to a lack of intrinsic motivation.

METHOD

Eighteen children with ADHD (age 8-12) were compared with 18 age- and gender-matched normal controls with respect to timing precision, timing variability, and the frequency of extreme under- and overestimations during a 1-second interval production task. Monetary reward, response cost, and no reward were implemented to manipulate motivation.

RESULTS

Children with ADHD produced significantly more inaccurate and more variable time intervals and exhibited a larger number of extreme over- and underestimations than control children. Although all children performed significantly better when monetary incentives were applied, group differences were not eliminated.

CONCLUSIONS

In this study, no evidence was found for a motivational deficit as an explanation for impaired performance on a time production task in ADHD. Rather, results provide clear support for a generic motor timing deficit, probably due to a dysfunctional frontostriatocerebellar network involved in temporal aspects of motor preparation.

Effectiveness of an adaptive multimodal treatment in children with Attention-Deficit Hyperactivity Disorder -- global outcome

BACKGROUND

The meaning of different components within a multimodal treatment of ADHD remains to be further clarified.

OBJECTIVE

To evaluate the effectiveness of behaviour therapy and drug treatment within an adaptive and individually tailored multimodal treatment for children with ADHD.

METHOD

After an initial psychoeducation n = 75 school-children aged 6-10 years with a diagnosis of ADHD/HKD were assigned to either behaviour therapy (including continued psychoeducation) or medical management with methylphenidate plus psychoeducation. Depending on the effectiveness, the treatment was either terminated (if totally effective) with long-term aftercare and continuation of medication if needed, or (if partially effective) the other treatment component was added (combined treatment), or (if ineffective) the treatment components were replaced. Thus a treatment rationale was applied which resulted in an adaptive and individually tailored therapy -- similar to a strategy that may be useful in clinical practice.

RESULTS

Of the children who started with behaviour therapy after initial psychoeducation 26% received a combined treatment in later treatment stages. In most of the cases (82%) with initial medical management, behaviour therapy was added. ADHD symptoms, individually defined behaviour problems and comorbid symptoms were significantly reduced during the course of treatment. On core measures large pre-post effect sizes were found. On teacher ratings combined treatment was more effective than behaviour therapy.

CONCLUSIONS

Both, behaviour therapy and combined treatment are effective interventions within an adaptive and individually tailored multimodal treatment strategy.

Transtorno desafiador de oposição: uma revisão de correlatos neurobiológicos e ambientais, comorbidades, tratamento e prognóstico

Transtorno desafiador de oposição (TDO) é uma entidade diagnóstica independente, mas é freqüentemente estudada em conjunto com transtorno de déficit de atenção/hiperatividade (TDAH) ou com transtorno de conduta (TC). O objetivo deste artigo é o de fazer uma revisão das evidências existentes, obtidas por meio da base de dados PubMed, sobre achados neurobiológicos no transtorno desafiador de oposição, funcionamento familiar e escolar, comorbidades, prognóstico e opções terapêuticas para transtorno desafiador de oposição. A evidência de correlatos hormonais, genéticos e neurofuncionais de transtorno desafiador de oposição, a conexão com a família, as relações e desempenho escolares, a associação com transtornos do humor, ansiosos e disruptivos, o risco de evolução para transtorno de conduta e de persistência de sintomas de transtorno desafiador de oposição são descritos. Uma revisão do efeito da Terapia Cognitivo-Comportamental e tratamento farmacológico é apresentada. A análise das evidências disponíveis mostra que o impacto de transtorno desafiador de oposição não deve ser ignorado e que o transtorno desafiador de oposição deve ser devidamente abordado. O impacto do tratamento de transtorno desafiador de oposição no prognóstico de longo prazo dos pacientes ainda precisa ser determinado.

The effect of methylphenidate on oppositional defiant disorder comorbid with attention deficit/hyperactivity disorder

OBJECTIVE

To assess the effect of methylphenidate on the diagnosis of oppositional-defiant disorder (ODD) comorbid with attention-deficit hyperactivity disorder (ADHD).

METHOD

We conducted an open-label study in which 10 children and adolescents with a dual diagnosis of ODD and ADHD were assessed for their ODD symptoms and treated with methylphenidate. At least one month after ADHD symptoms were under control, ODD symptoms were reevaluated with the Parent form of the Children Interview for Psychiatric Syndromes (P-ChIPS).

RESULTS

Nine of the 10 patients no longer fulfilled diagnostic criteria for ODD after they were treated with methylphenidate for ADHD.

CONCLUSION

Methylphenidate seems to be an effective treatment for ODD, as well as for ADHD itself. The implications for the treatment of patients with ODD not comorbid with ADHD needs further investigation.

The Good Behavior Game: a best practice candidate as a universal behavioral vaccine

A "behavioral vaccine" provides an inoculation against morbidity or mortality, impacting physical, mental, or behavior disorders. An historical example of a behavioral vaccine is antiseptic hand washing to reduce childbed fever. In current society, issues with high levels of morbidity, such as substance abuse, delinquency, youth violence, and other behavioral disorders (multiproblems), cry out for a low-cost, widespread strategy as simple as antiseptic hand washing. Congruent research findings from longitudinal studies, twin studies, and other investigations suggest that a possibility might exist for a behavioral vaccine for multiproblem behavior. A simple behavioral strategy called the Good Behavior Game (GBG), which reinforces inhibition in a group context of elementary school, has substantial previous research to consider its use as a behavioral vaccine. The GBG is not a curriculum but rather a simple behavioral procedure from applied behavior analysis. Approximately 20 independent replications of the GBG across different grade levels, different types of students, different settings, and some with long-term follow-up show strong, consistent impact on impulsive, disruptive behaviors of children and teens as well as reductions in substance use or serious antisocial behaviors. The GBG, named as a "best practice" for the prevention of substance abuse or violent behavior by a number of federal agencies, is unique because it is the only practice implemented by individual teachers that is documented to have long-term effects. Presently, the GBG is only used in a small number of settings. However, near universal use of the GBG, in major political jurisdictions during the elementary years, could substantially reduce the incidence of substance use, antisocial behavior, and other adverse developmental or social consequences at a very modest cost, with very positive cost-effectiveness ratios.

Rates of adherence to pharmacological treatment among children and adolescents with attention deficit hyperactivity disorder

Pharmacological intervention, mainly with psychostimulants, alone or with psychotherapy or behavioural modification, was found to be effective in increasing sustained attention span, improving concentration, reducing hyperactive behaviour and improving areas of academic deficits in children and adolescents with the diagnosis of attention deficit-hyperactivity disorder (ADHD). Despite their proven efficacy, noncompliance of the children and adolescents to the prescribed medication presents serious problems to patients and health care providers alike.

OBJECTIVE

To investigate the rate of adherence to prescribed medication in a clinically referred sample of children and adolescents diagnosed as having ADHD. In addition, the stability of reports of adherence over a 3 month period was explored.

METHOD

Fifty-one children and adolescents (males: n = 42; females: n = 9) between the age of 7 years and 16.6 years diagnosed with ADHD and their parents were administered a children behaviour checklist, a teacher report form scale and a compliance with treatment opinion and attitude scale.

RESULTS

There were very high reports of adherence by children to prescribed medications for ADHD with rates of compliance greater than 70%. Correlation between the children and adolescents' reports and the parents' reports revealed high agreement both at the end of week 1 and at the end of the study (week 12). There were also findings of stability of adherence reports over a 3 month period.

CONCLUSION

The results of this study documented high rates of adherence to medication prescribed for symptoms of attention deficit hyperactivity disorder in a sample of children and adolescents. Their reports of adherence were well correlated with parents' reports. Several factors were found to be related to the high level of adherence.

Psychopharmacology and aggression. I: A meta-analysis of stimulant effects on overt/covert aggression-related behaviors in ADHD

OBJECTIVE

To determine by meta-analysis the effect size for stimulants on overt and covert aggression-related behaviors in children with attention-deficit/hyperactivity disorder (ADHD), separately from stimulant effects on the core symptoms of ADHD.

METHOD

A review of the literature from 1970 to 2001 revealed 28 studies meeting inclusion/exclusion criteria for meta-analysis. These studies yielded 28 independent effects of overt aggression and 7 independent effects of covert aggression.

RESULTS

The overall weighted mean effect size was 0.84 for overt and 0.69 for covert aggression related behaviors in ADHD. Comorbid conduct disorder is associated with diminishing stimulant effect size for overt aggression.

CONCLUSION

Stimulant effects for aggression-related behaviors in ADHD have effect sizes similar to those for the core symptoms of ADHD.

[Evaluated treatment approaches in child and adolescent psychiatry I]

OBJECTIVES

The principle of evidence-based medicine is to integrate data concerning the efficacy of interventions into clinical practice. This article assesses the level of evaluation of psychosocial, psychopharmacological and combined interventions for mental disorders in childhood and adolescence (autistic disorders, hyperkinetic disorders, conduct disorders, tic disorders, enuresis, and encopresis).

METHODS

Three different levels of evaluation were defined for both psychosocial and psychopharmacological interventions: A (> or = 2 randomized controlled studies), B (1 randomized controlled study), and C (open studies and case studies). The level of evaluation was judged on the basis of original papers found in a comprehensive literature search.

RESULTS

For most disorders presented in this article there are several A-level treatments. The efficacy of both psychosocial and psychopharmacological interventions that target specific problem behaviors or symptoms, respectively, has been repeatedly demonstrated with regard to autistic disorders. Many studies have evaluated treatment approaches for hyperkinetic disorders and conduct disorders. With regard to the treatment of tic disorders in children and adolescents, far more studies evaluated the efficacy of pharmacotherapy than of psychotherapy.

CONCLUSIONS

Further research should compare the efficacy of different treatment approaches, examine specific and differential treatment effects and investigate combined treatment approaches.

Families of children with attention-deficit/hyperactivity disorder: review and recommendations for future research

This review integrates and critically evaluates what is known about family characteristics associated with childhood Attention-Deficit/Hyperactivity Disorder (ADHD). Evidence suggests that the presence of ADHD in children is associated to varying degrees with disturbances in family and marital functioning, disrupted parent-child relationships, specific patterns of parental cognitions about child behavior and reduced parenting self-efficacy, and increased levels of parenting stress and parental psychopathology, particularly when ADHD is comorbid with conduct problems. However, the review reveals that little is known about the developmental mechanisms that underlie these associations, or the pathways through which child and family characteristics transact to exert their influences over time. In addition, the influence of factors such as gender, culture, and ADHD subtype on the association between ADHD and family factors remains largely unknown. We conclude with recommendations regarding the necessity for research that will inform a developmental psychopathology perspective of ADHD.