Multimodal treatment of ADHD in the MTA: an alternative outcome analysis

Hyped-up or meditate: A scoping review of mindfulness-based group interventions for adolescents with attention deficit hyperactivity disorder

The objective of this scoping review is to evaluate the effectiveness of mindfulness training in improving functioning in adolescents (aged 12-19 years) diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). Previous research has demonstrated that psychological interventions improve functioning in a myriad of domains for individuals diagnosed with ADHD, such as attention training, interpersonal relationships, and social skills. Mindfulness-based interventions (MBI) are indicated as an intervention in attention training. It maybe argued that group based MBI programmes should begin early, for children and adolescents at a time that is critical in their development. Methods and reporting are in line with the PRISMA extension for scoping reviews, the protocol is preregistered in the (Open Science Framework register). The study outcomes included attention, impulsivity, and relationships of adolescents with ADHD. Findings demonstrated preliminary evidence for the use of group-based mindfulness interventions with adolescents continues to be nascent. Although studies reported positive results, the evidence of its effectiveness for adolescents with ADHD is inconclusive, due to limited studies available and the limitations of the study design. This scoping review provides a panorama of MBI for ADHD adolescents.

Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior

OBJECTIVE

To evaluate the prevalence, trends, and factors associated with psychotropic medication use and polypharmacy among children and adolescents initiating intensive behavioral therapy for severe challenging behavior over a 10-year period.

STUDY DESIGN

In this retrospective observational study, we examined data from caregiver interviews and patient medical records on the number and types of psychotropic medications prescribed to patients initiating intensive behavioral therapy between January 1, 2013, and December 31, 2022. Trends in medication use and polypharmacy across the 10-year period were analyzed using regression analysis, while differences in demographics and clinical factors for patients with use and polypharmacy were analyzed using nonparametric statistical analysis with odds ratios presented for significant factors.

RESULTS

Data from all 302 pediatric patients initiating intensive behavioral therapy across the 10-year period were analyzed. Among all patients and all years, 83.8% were taking at least 1 psychotropic medication and 68.2% experienced polypharmacy. There were no changes in the prevalence of use, mean number of medications taken, or polypharmacy across the 10-year period. Patients diagnosed with attention-deficit/hyperactivity disorder or anxiety disorder, as well as those exhibiting self-injurious behavior had higher use of psychotropic medication and polypharmacy and were taking more medications overall.

CONCLUSIONS

Psychotropic medication use and polypharmacy were extremely high for children and adolescents with severe challenging behavior, but use and polypharmacy did not change over the 10-year period of data collection. Further research is needed to establish the generality of these findings to other regions of the US.

Reducing disparities in behavioral health treatment in pediatric primary care: a randomized controlled trial comparing Partnering to Achieve School Success (PASS) to usual ADHD care for children ages 5 to 11 - study protocol

BACKGROUND

Integrating behavioral health services into pediatric primary care can improve access to care, especially for children marginalized by poverty and racial/ethnic minority status. In primary care, a common presenting concern is attention-deficit/hyperactivity disorder (ADHD). Services in primary care for marginalized children with ADHD typically include medication alone; therapy to improve skills and build relationships is less available. This study evaluates the effectiveness of a behavioral intervention offered through primary care for marginalized families coping with ADHD (Partnering to Achieve School Success, PASS) compared to treatment as usual (TAU).

METHOD

Three hundred participants will be randomly assigned to PASS or TAU. Participants include children ages 5 to 11 who have ADHD and are from economically marginalized families. PASS is a personalized, enhanced behavioral intervention that includes evidence-based behavior therapy strategies and enhancements to promote family engagement, increase caregiver distress tolerance, and provide team-based care to improve academic and behavioral functioning. TAU includes services offered by primary care providers and referral for integrated behavioral health or community mental health services. Outcomes will be assessed at mid-treatment (8 weeks after baseline), post-treatment (16 weeks), and follow-up (32 weeks) using parent- and teacher-report measures of service use, child academic, behavioral, and social functioning, parenting practices, family empowerment, and team-based care. Mixed effects models will examine between-group differences at post-treatment and follow-up. Analyses will examine the mediating role of parenting practices, family empowerment, and team-based care. Subgroup analyses will examine differential effects of intervention by child clinical characteristics and socioeconomic factors.

DISCUSSION

This study is unique in targeting a population of children with ADHD marginalized by low socioeconomic resources and examining an intervention designed to address the challenges of families coping with chronic stress related to poverty.

TRIAL REGISTRATION

This study was registered on clinicaltrials.gov (NCT04082234) on September 5, 2019, prior to enrollment of the first participant. The current version of the protocol and IRB approval date is October 4, 2023. Results will be submitted to ClinicalTrials.gov no later than 30 days prior to the due date for the submission of the draft of the final research report to the Patient-Centered Outcomes Research Institute.

ADHD Prevalence Rose, Yet Disparities Remain: Commentary on the 2022 National Survey of Children's Health

This is a commentary on Danielson and colleagues' report entitled "ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment," which provides updated prevalence rates related to ADHD diagnosis and treatment utilization using data from the 2022 National Survey of Children's Health (NSCH). This timely article is among the first to report on ADHD prevalence rates since the COVID-19 pandemic, and highlights important patterns related to ADHD diagnosis and treatment utilization. In this commentary, we contextualize these findings with consideration to the COVID-19 pandemic and within the existing literature on health disparities among youth with ADHD and their families. We end with recommendations for future work involving researchers, clinicians, and policymakers with the intention of reducing disparities in ADHD diagnosis and treatment in the U.S.

Developmental psychopathology as a meta-paradigm: From zero-sum science to epistemological pluralism in theory and research

In a thoughtful commentary in this journal a decade ago, Michael Rutter reviewed 25 years of progress in the field before concluding that developmental psychopathology (DP) initiated a paradigm shift in clinical science. This deduction requires that DP itself be a paradigm. According to Thomas Kuhn, canonical paradigms in the physical sciences serve unifying functions by consolidating scientists' thinking and scholarship around single, closed sets of discipline-defining epistemological assumptions and methods. Paradigm shifts replace these assumptions and methods with a new field-defining framework. In contrast, the social sciences are multiparadigmatic, with thinking and scholarship unified locally around open sets of epistemological assumptions and methods with varying degrees of inter-, intra-, and subdisciplinary reach. DP challenges few if any of these local paradigms. Instead, DP serves an essential pluralizing function, and is therefore better construed as a metaparadigm. Seen in this way, DP holds tremendous untapped potential to move the field from zero-sum thinking and scholarship to positive-sum science and epistemological pluralism. This integrative vision, which furthers Dante Cicchetti's legacy of interdisciplinarity, requires broad commitment among scientists to reject zero-sum scholarship in which portending theories, useful principles, and effective interventions are jettisoned based on confirmation bias, errors in logic, and ideology.

Benefits of a 12-Week Non-Drug "Brain Fitness Program" for Patients with Attention-Deficit/Hyperactive Disorder, Post-Concussion Syndrome, or Memory Loss

Background

Non-pharmacologic interventions can potentially improve cognitive function, sleep, and/or mood in patients with attention-deficit/hyperactive disorder (ADHD), post-concussion syndrome (PCS), or memory loss.

Objective

We evaluated the benefits of a brain rehabilitation program in an outpatient neurology practice that consists of targeted cognitive training, lifestyle coaching, and electroencephalography (EEG)-based neurofeedback, twice weekly (90 minutes each), for 12 weeks.

Methods

223 child and adult patients were included: 71 patients with ADHD, 88 with PCS, and 64 with memory loss (mild cognitive impairment or subjective cognitive decline). Patients underwent a complete neurocognitive evaluation, including tests for Verbal Memory, Complex Attention, Processing Speed, Executive Functioning, and Neurocognition Index. They completed questionnaires about sleep, mood, diet, exercise, anxiety levels, and depression-as well as underwent quantitative EEG-at the beginning and the end of the program.

Results

Pre-post test score comparison demonstrated that all patient subgroups experienced statistically significant improvements on most measures, especially the PCS subgroup, which experienced significant score improvement on all measures tested (p≤0.0011; d_z≥0.36). After completing the program, 60% to 90% of patients scored higher on cognitive tests and reported having fewer cognitive and emotional symptoms. The largest effect size for pre-post score change was improved executive functioning in all subgroups (ADHD d_z= 0.86; PCS d_z= 0.83; memory d_z= 1.09).

Conclusion

This study demonstrates that a multimodal brain rehabilitation program can have benefits for patients with ADHD, PCS, or memory loss and supports further clinical trials in this field.

Non-pharmacological interventions for attention-deficit hyperactivity disorder in children and adolescents

Attention-deficit hyperactivity disorder (ADHD) affects approximately 5% of children and adolescents globally and is associated with negative life outcomes and socioeconomic costs. First-generation ADHD treatments were predominantly pharmacological; however, increased understanding of biological, psychological, and environmental factors contributing to ADHD has expanded non-pharmacological treatment possibilities. This Review provides an updated evaluation of the efficacy and safety of non-pharmacological treatments for paediatric ADHD, discussing the quality and level of evidence for nine intervention categories. Unlike medication, no non-pharmacological treatments showed a consistent strong effect on ADHD symptoms. When considering broad outcomes (eg, impairment, caregiver stress, and behavioural improvement), multicomponent (cognitive) behaviour therapy joined medication as a primary ADHD treatment. With respect to secondary treatments, polyunsaturated fatty acids showed a consistent modest effect on ADHD symptoms when taken for at least 3 months. Additionally, mindfulness and multinutrient supplementation with four or more ingredients showed modest efficacy on non-symptom outcomes. All other non-pharmacological treatments were safe; clinicians might tolerate their use but should educate families of childrenand adolescents with ADHD on the disadvantages, including costs, burden to the service user, absence of proven efficacy relative to other treatments, and delay of proven treatment.

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.

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

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

Stakeholder-Generated Implementation Strategies to Promote Evidence-Based ADHD Treatment in Community Mental Health

Community implementation of evidence-based practices (EBPs) for Attention Deficit/Hyperactivity Disorder (ADHD) is greatly lacking. A recent randomized community-based trial of an EBP for ADHD (Supporting Teens' Autonomy Daily; STAND) demonstrated suboptimal implementation and effectiveness outcomes. In the present study, we conducted an Innovation Tournament (IT) with agency staff stakeholders (N = 26) to identify barriers to successful implementation of STAND and implementation strategies for a revised service delivery model. We conducted member-checking of agency staff-generated ideas with parents (N = 226) and subsequent querying of additional parent (N = 226) and youth-generated (N = 205) strategies to improve care. Go-Zone plots were utilized to identify strategies with the highest feasibility and importance. Practical barriers (i.e., transportation, scheduling difficulties) and parent/youth engagement were the most commonly cited obstacles to successful implementation of STAND in community contexts. Eighteen "winning" implementation strategies were identified that survived member checking. These were classified as train and educate stakeholders (n = 5; e.g., train agency supervisors to deliver supervision, digitize treatment materials and trainings), engage consumers (n = 9; e.g., begin treatment with rapport building sessions, increase psychoeducation), provide interactive assistance (n = 2; e.g., add group supervision, increase roleplay in supervision), and use of evaluative/iterative strategies (n = 2; e.g., perform fidelity checks, supervisor review of session recordings). Parents and youth desired longer duration of treatment and increased focus on maintenance. Strategies will be developed and tested as part of a pilot effectiveness trial designed to refine STAND's service delivery model.Trial Registration NCT02694939 www.clinicaltrials.gov.

Temperament Traits Mark Liability for Coexisting Psychiatric Symptoms in Children With Elevated ADHD Symptoms

Objective: Among children with ADHD, coexisting psychiatric disorders are common and associated with greater impairment and symptom persistence. Given that temperament traits are easily measured, developmentally stable, and variable among youth with ADHD, temperament profiles may be clinically useful for predicting liability for coexisting psychiatric symptoms in this population. Methods: Eighty-three children with ADHD symptoms participated. Caregivers rated their child's surgency, negative emotionality, and effortful control, as well as severity of internalizing and externalizing psychiatric symptoms. Hierarchical linear regressions were conducted to estimate associations between temperament traits and psychiatric symptoms, controlling for severity of ADHD. Results: Temperament ratings explained significant variance in psychiatric symptoms above and beyond ADHD symptoms alone. Symptoms of each coexisting psychiatric disorder was associated with a distinct temperament and ADHD symptom profile. Conclusion: Temperament ratings appear to have clinical utility for predicting coexisting psychiatric symptoms in children with elevated ADHD symptoms.

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

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

The mediating role of ADHD symptoms between executive function and social skills in children with neurofibromatosis type 1

Children with neurofibromatosis type 1 (NF1) often experience executive dysfunction, attention deficit/hyperactivity disorder (ADHD) symptoms and poor social skills, however, the nature of the relationships between these domains in children with NF1 is unclear. This study investigated these relationships using primary caregiver ratings of executive functions, ADHD symptoms and social skills in children with NF1. Participants were 136 children with NF1 and 93 typically developing (TD) controls aged 3-15 years recruited from 3 multidisciplinary neurofibromatosis clinics in Melbourne and Sydney, Australia, and Washington DC, USA. Mediation analysis was performed on primary outcome variables: parent ratings of executive functions (Behavior Rating Inventory of Executive Function, Metacognition Index), ADHD symptoms (Conners-3/Conners ADHD Diagnostic and Statistical Manual for Mental Disorders Scales) and social skills (Social Skills Improvement System-Rating Scale), adjusting for potential confounders (full scale IQ, sex, and social risk). Results revealed significantly poorer executive functions, elevated ADHD symptoms and reduced social skills in children with NF1 compared to controls. Poorer executive functions significantly predicted elevated ADHD symptoms and poorer social skills. Elevated ADHD symptoms significantly mediated the relationship between executive functions and social skills problems although did not fully account for social dysfunction. This study provides evidence for the importance of targeting ADHD symptoms as part of future interventions aimed at promoting prosocial behaviors in children with NF1.

Effectiveness of a digital therapeutic as adjunct to treatment with medication in pediatric ADHD

STARS-Adjunct was a multicenter, open-label effectiveness study of AKL-T01, an app and video-game-based treatment for inattention, as an adjunct to pharmacotherapy in 8-14-year-old children with attention-deficit/hyperactivity disorder (ADHD) on stimulant medication (n = 130) or not on any ADHD medication (n = 76). Children used AKL-T01 for 4 weeks, followed by a 4-week pause and another 4-week treatment. The primary outcome was change in ADHD-related impairment (Impairment Rating Scale (IRS)) after 4 weeks. Secondary outcomes included changes in IRS, ADHD Rating Scale (ADHD-RS). and Clinical Global Impressions Scale-Improvement (CGI-I) on days 28, 56, and 84. IRS significantly improved in both cohorts (On Stimulants: -0.7, p < 0.001; No Stimulants: -0.5, p < 0.001) after 4 weeks. IRS, ADHD-RS, and CGI-I remained stable during the pause and improved with a second treatment period. The treatment was well-tolerated with no serious adverse events. STARS-Adjunct extends AKL-T01's body of evidence to a medication-treated pediatric ADHD population, and suggests additional treatment benefit.

Influences on Teachers’ Intention to Apply Classroom Management Strategies for Students with ADHD: A Model Analysis

Students with attention deficit/hyperactivity disorder (ADHD) show reduced on-task behavior at school and educational problems due to the symptoms associated with this diagnosis. Classroom management strategies (CMS) are important to reduce impairment due to ADHD symptoms but are not yet well implemented. In this study we analyzed whether the facilitators and barriers regarding the intention to apply CMS identified for pre-service teachers are replicable in a sample of teachers in service. Overall, 599 teachers in service completed an online survey on the intention to apply CMS, their attitude towards CMS and towards students with ADHD, direct experiences, individual differences, and social influences. We calculated path models that significantly clarified variance in the intention to apply CMS (R2intention to use effective CMS = 0.47, p < 0.01 and R2intention to use ineffective CMS = 0.39, p < 0.01). It turns out that similar variables are relevant to teachers in service as well as pre-service teachers. A models’ extension to include variables that do justice to the difference between the two groups, such as work experience, shows a better model fit. Especially, attitude towards CMS, attitude towards students with ADHD, strain, perceived behavioral control and teachers’ affiliation with primary or special needs schools are important variables regarding the intention to apply CMS. The implementation of effective and elimination of ineffective CMS should thus be addressed by targeting teacher’s attitudes towards children with ADHD. Furthermore, strain prevention and education might enhance the application of effective CMS.

Bibliometric Review: Classroom Management in ADHD—Is There a Communication Gap Concerning Knowledge Between the Scientific Fields Psychiatry/Psychology and Education?

Many students with ADHD experience educational attainment difficulties. Nevertheless, evidence-based classroom management strategies (CMS) are seldom used. This science–practitioner gap might be due to a lack of shared knowledge between the scientific fields of psychology/psychiatry and education. This review uses science mapping to explore the basis of the current stock of knowledge in each of the two scientific fields, compares current approaches, and examines whether implementation methods and related barriers are investigated topics. We conducted a systematic search of the literature to identify articles on CMS in ADHD. We then conducted co-citation analyses and bibliographic coupling analysis. The former revealed six clusters of psychology/psychiatry and five clusters of education. Bibliographic coupling analysis resulted in eight clusters, with literature from both fields. The majority of the research is conducted in the field of psychology/psychiatry; teachers’ perspectives are focused only in the field of education. The number of studies on implementation and potential barriers is small. There was thus relatively little communication between the sciences, but the scientific fields have seemed to converge recently. Connecting the scientific fields more and concentrating on implementation methods and barriers is strongly needed to close the science–practitioner gap.

Mutations in sphingolipid metabolism genes are associated with ADHD

Attention deficit hyperactivity disorder (ADHD) is the most prevalent neurodevelopmental disorder in children, with genetic factors accounting for 75-80% of the phenotypic variance. Recent studies have suggested that ADHD patients might present with atypical central myelination that can persist into adulthood. Given the essential role of sphingolipids in myelin formation and maintenance, we explored genetic variation in sphingolipid metabolism genes for association with ADHD risk. Whole-exome genotyping was performed in three independent cohorts from disparate regions of the world, for a total of 1520 genotyped subjects. Cohort 1 (MTA (Multimodal Treatment study of children with ADHD) sample, 371 subjects) was analyzed as the discovery cohort, while cohorts 2 (Paisa sample, 298 subjects) and 3 (US sample, 851 subjects) were used for replication. A set of 58 genes was manually curated based on their roles in sphingolipid metabolism. A targeted exploration for association between ADHD and 137 markers encoding for common and rare potentially functional allelic variants in this set of genes was performed in the screening cohort. Single- and multi-locus additive, dominant and recessive linear mixed-effect models were used. During discovery, we found statistically significant associations between ADHD and variants in eight genes (GALC, CERS6, SMPD1, SMPDL3B, CERS2, FADS3, ELOVL5, and CERK). Successful local replication for associations with variants in GALC, SMPD1, and CERS6 was demonstrated in both replication cohorts. Variants rs35785620, rs143078230, rs398607, and rs1805078, associated with ADHD in the discovery or replication cohorts, correspond to missense mutations with predicted deleterious effects. Expression quantitative trait loci analysis revealed an association between rs398607 and increased GALC expression in the cerebellum.

Development of a Composite Primary Outcome Score for Children with Attention-Deficit/Hyperactivity Disorder and Emotional Dysregulation

Objective: Study goals were to (1) provide a rationale for developing a composite primary outcome score that includes symptom severity for attention-deficit/hyperactivity disorder (ADHD) and emotional dysregulation, plus symptom-induced impairment; (2) demonstrate weighting methods to calculate the composite score using a sample of children diagnosed with ADHD and aggression; and (3) identify the optimal weighting method most sensitive to change, as measured by effect sizes. Methods: We conducted secondary data analyses from the previously conducted Treatment of Severe Childhood Aggression (TOSCA) study. Children aged 6-12 years were recruited through academic medical centers or community referrals. The composite primary outcome comprised the ADHD, oppositional defiant disorder, disruptive mood dysregulation disorder, and peer conflict subscales from the Child and Adolescent Symptom Inventory (CASI), a DSM (Diagnostic and Statistical Manual)-referenced rating scale of symptom severity and symptom-induced impairment. Five weighting methods were tested based on input from senior statisticians. Results: The composite score demonstrated a larger (Cohen's d) effect size than the individual CASI subscales, irrespective of the weighting method (10%-55% larger). Across all weighting methods, effect sizes were similar and substantial: approximately a two-standard deviation symptom reduction (range: -1.97 to -2.04), highest for equal item and equal subscale weighting, was demonstrated, from baseline to week 9, among all TOSCA participants. The composite score showed a medium positive correlation with the Clinical Global Impressions-Severity scores, 0.46-0.47 for all weighting methods. Conclusions: A composite score that included severity and impairment ratings of ADHD and emotional dysregulation demonstrated a more robust pre-post change than individual subscales. This composite may be a more useful indicator of clinically relevant improvement in heterogeneous samples with ADHD than single subscales, avoiding some of the statistical limitations associated with multiple comparisons. Among the five similar weighting methods, the two best appear to be the equal item and equal subscale weighting methods.

A Commercial Insurance Claims Analysis of Correlates of Behavioral Therapy Use Among Children With ADHD

OBJECTIVE

The study examined factors associated with uptake of behavioral therapy among children with attention-deficit hyperactivity disorder (ADHD).

METHODS

Insurance claims data from 2008-2014 (MarketScan) were reviewed to examine associations between behavioral therapy use and demographic, patient, family, and provider factors. The association between ADHD medication use and future uptake of behavioral therapy was examined with logistic regression adjusted for covariates found to affect behavioral therapy use.

RESULTS

Among 827,396 youths with ADHD, under 50% received any billable behavioral therapy services over the 7 years. ADHD severity, gender, region of residence, assessment year, comorbid behavioral disorders, and behavioral therapy use by siblings were significantly associated with behavioral therapy use (p<0.001). Parent psychopathology and sibling medication use was not. Children prescribed ADHD medication were 2.5 times less likely than those not prescribed medication to use behavioral therapy, even after adjustment for severity of behavioral health symptoms and other covariates (odds ratio [OR]= 0.41, 95% confidence interval [CI]=.40-.41, p<0.001). Effects of medication use were stronger for future uptake of behavioral therapy (OR=0.25, 95% CI =0.24-0.25, p<.001). The impact of medication use on behavioral therapy use was equally strong for children under age 6 and for older children and did not weaken after release of 2011 guidelines recommending behavioral therapy as the initial ADHD treatment for young children.

CONCLUSIONS

Multiple systems, family, patient and provider factors affected behavioral therapy uptake. ADHD medication was a robust and potentially modifiable factor. It may be advisable to engage families in behavioral therapy prior to initiation of ADHD medication.

Association between circulating zinc/ferritin levels and parent Conner's scores in children with attention deficit hyperactivity disorder

ADHD is one of the most common neurobehavioral disorders among children and adolescents. In this prospective study, we aimed to measure circulating zinc and ferritin levels in children with ADHD, pick up the deficient ones to give zinc and iron supplements then compare before and after treatment according to their Conner's scores and Wecsler IQ test. Current study included fifty children diagnosed as having ADHD by DSMV criteria, their zinc and ferritin levels were measured by Colorimetric method and enzyme-linked immunosorbent assay (ELISA) respectively. They were divided into: group I (zinc only deficient),group II (zinc and ferritin deficient),group III (non-deficient), cases with mineral deficiency received zinc (55 mg/day) and/or iron (6 mg/kg/day) for 6 months then reassessed by parent Conner's rating scale. In group 1, there was no significant difference between the Wecsler verbal and non-verbal IQ scores and oppositional and cognitive problems in Conner's scores before and after zinc supplements, although there was significant improvement in attention, hyperactivity, emotional liability and impulsivity. In group II, there was significant improvement in verbal and total IQ but not in performance IQ, also there was significant improvement in hyperactivity, emotional liability and impulsivity with no significant difference in oppositional, cognitive problems and inattention before and after zinc/ iron supplements. In Conclusion, Zinc supplements in adjuvant to the main treatment significantly improved symptoms of ADHD children. However, a combined zinc and iron supplements was superior to zinc alone in alleviating ADHD symptoms as well as IQ improvement.

Perceptions of ADHD Among Diagnosed Children and Their Parents: A Systematic Review Using the Common-Sense Model of Illness Representations

Research on children and parents' experiences of ADHD has grown in recent years, attracting attention to their subjective perception of ADHD as a disorder. Theoretical accounts of illness perception suggest that it is multi-dimensional, consisting of at least five core constructs (see the common-sense model of illness representations or CSM: Leventhal et al., in: Rachman (ed) Medical psychology, Pergamon, New York, vol 2, pp 7-30, 1980, in: Baum, Taylor, Singer (eds) Handbook of psychology and health: social psychological aspects of health, Earlbaum, Hillsdale, vol 4, pp 219-252, 1984). We suggest that the application of CSM in children/adolescents with ADHD and their parents may play an important role in understanding their coping behavior, treatment adherence, and emotional well-being. A systematic search identified 101 eligible studies that investigated the perception of ADHD among diagnosed children/adolescents and their parents. In general, these studies support the existence of the multiple facets of illness representations proposed by the CSM in both diagnosed youngsters and parents indicating substantial variability among both parents and youngsters on each of these facets. The comprehensive assessment of the representations of ADHD indicates imbalance attention to the different representations of ADHD in the literature; disproportional research attention has been paid to the perceived effectiveness of treatment (i.e., treatment control dimension) compared to other illness representations (e.g., timeline, consequence, and coherence), despite research showing their relevance to treatment adherence among other implications. The review identifies the limitation of existing relevant research, needed foci for future studies, specific testable hypotheses, and potential clinical implications of the multifaceted representations of ADHD among youngsters and carers alike.

The Effect of Childhood ADD/ADHD on Parental Workforce Participation

OBJECTIVE

This research aimed to examine the impact of attention deficit disorder (ADD)/ADHD in children on parental labor force participation across different child age groups.

METHOD

This study utilized a longitudinal, quantitative analyses approach. All data were collected from Wave 6 of the Growing Up in Australia: The Longitudinal Study of Australian Children (LSAC) survey.

RESULTS

After adjusting for various confounders, mothers whose children were 10/11 years old and had been diagnosed with ADD/ADHD were significantly more likely to be out of the labor force compared with those mothers whose child had not been diagnosed with ADD/ADHD. The impact was more pronounced for single mothers. No significant influence on paternal labor force participation was found.

CONCLUSION

In assessing the cost-effectiveness of interventions for ADD/ADHD, policy makers and researchers must consider the long-term social and economic effects of ADD/ADHD on maternal workforce participation when considering costs and outcomes.

Attendance and Engagement in Parent Training Predict Child Behavioral Outcomes in Children Pharmacologically Treated for Attention-Deficit/Hyperactivity Disorder and Severe Aggression

OBJECTIVES

We examined the association of parent training (PT)-related factors with therapeutic success in the Treatment of Severe Childhood Aggression (TOSCA) study. Our aims were (1) to evaluate demographic and clinical characteristics as predictors of parent attendance and engagement in PT and (2) to examine the associations of parent attendance and engagement in PT with study-targeted child behavior outcomes (i.e., attention-deficit/hyperactivity disorder [ADHD] and disruptive behavior symptoms). TOSCA was a randomized clinical trial evaluating the effect of placebo versus risperidone when added to PT and psychostimulant for childhood ADHD with severe aggression.

METHODS

Data for 167 parents and children 6-12 years old with ADHD, oppositional defiant disorder (ODD) or conduct disorder, and severe physical aggression were examined. Analyses used generalized linear models.

RESULTS

Most parents (72%) attended seven or more of nine sessions. The average parental engagement, that is, the percentage of PT elements fully achieved across participants and sessions, was 85%. The average therapist rating of goal completion was 92%. Parents of non-white and/or Hispanic children (p = 0.01) and children with lower intelligence quotient (p = 0.02) had lower PT attendance; parents with lower family incomes (p = 0.01) were less engaged. Attendance and engagement predicted better scores on the primary child behavior outcomes of disruptive behavior (Nisonger Child Behavior Rating Form Disruptive Behavior Total) and ADHD and ODD symptoms, adjusting for baseline severity.

CONCLUSIONS

When the clinical picture is sufficiently severe to warrant prescribing an atypical antipsychotic, PT is feasible for families of children with ADHD and co-occurring severe aggression. The promotion of attendance and engagement in PT is important to enhance clinical outcomes among this challenging population. Methods for overcoming barriers to participation in PT deserve vigorous investigation, particularly for those with low family income, non-white race, Hispanic ethnicity, or when children have lower cognitive level.

Effectiveness of Parents-Focused Cognitive-Behavioral Therapy on Attention Deficit Hyperactivity Disorder Symptoms, Obesity and Self-Esteem of Overweight Children with Attention Deficient Hyperactivity Disorder

Background:

Attention deficit hyperactivity disorder (ADHD) is the most common behavioral problems that cause hyperactivity, attention deficits, academic failure, and emotional and behavioral problems in preschool and elementary school that is often hidden from the parents' eyes. The aim of this study was to determine the effectiveness of parent-based cognitive-behavioral therapy (CBT) on ADHD symptoms (including attention deficit disorder, restlessness, and impulsivity), overweight and self-esteem of 6–11-year-old obese children with attention deficit hyperactivity in Isfahan.

Materials and Methods:

This quasi-experimental study was carried out on 40 children aged 6–11 years with ADHD and overweight or obesity (above the 85^th percentile in weight for age, height, and sex diagram) that their parents referred to Isfahan child and adolescent psychiatric clinic of Ali Asghar Hospital in 2015. For twenty patients, only ADHD treatment was applied, and they received no other intervention, but the others in experimental group participated in CBT sessions. Analysis tools were Coppersmith Self-Esteem Scale, ADHD conners' test, and the body mass index (BMI). Data were analyzed using analysis of variance with repeated measurements.

Results:

CBT by teaching parents had a significant effect on ADHD symptoms, the self-esteem of overweight and obese children with ADHD in posttest and follow-up. The results also showed that had a significant effect on ADHD symptoms, overweight and self-esteem of the obese children with ADHD (P < 0.001).

Conclusions:

Parents focused CBT can be considered as a complementary treatment for reducing ADHD symptoms and BMI and increased self-esteem in the obese ADHD children.

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.

Current issues in child and adolescent psychopharmacology. Part 1: Attention-deficit hyperactivity and affective disorders

Drug treatments play an important role in the treatment of child and adolescent psychiatric disorders. However, there is often a long delay before research findings are translated into clinical practice; furthermore, changes in clinical practice outstrip the available evidence. This paper focuses on current issues and research findings on the pharmacological treatment of attention-deficit hyperactivity disorder (ADHD) and affective disorders. Clinical findings from a US study of the treatment of ADHD with extended-release stimulants and non-stimulants, and the development and use of clinical guidelines are discussed. Clinical trials of selective serotonin reuptake inhibitors for early-onset depression, approaches to managing treatment-resistant depression and guidance on the drug treatment of early-onset mania are considered.

Group cognitive behavioral therapy for children and adolescents with ADHD

The present study analyzed the use of group CBT protocol to treat ADHD by comparing two types of treatment, unimodal (medication only) and multimodal (medication combined with CBT), in terms of their effects on cognitive and behavioral domains, social skills, and type of treatment effect by ADHD subtype. Participants were 60 children with ADHD, subtypes inattentive and combined, aged 7 to 14, 48 boys. Combined treatment included 20 CBT sessions while all children were given Ritalin LA® 20 mg. Cognitive and behavioral outcome measures showed no differences between treatment groups. On social skills, multimodal showed more improvement in frequency indicators on empathy, assertiveness, and self-control subscales and in the difficulty on assertiveness and self-control subscales. Using a group CBT protocol for multimodal ADHD treatment may improve patient adherence and ADHD peripheral symptoms.

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.

Efficacy and Safety of Omega-3/6 Fatty Acids, Methylphenidate, and a Combined Treatment in Children With ADHD

OBJECTIVE

To compare efficacy of Omega-3/6 fatty acids (Equazen eye q™) with methylphenidate (MPH) and combined MPH + Omega-3/6 in children with ADHD.

METHOD

Participants ( N = 90) were randomized to Omega-3/6, long-acting MPH, or combination for 12 months. ADHD symptoms were assessed using the ADHD Rating Scale and Clinical Global Impressions-Severity (CGI-S) scale.

RESULTS

ADHD symptoms decreased in all treatment arms. Although significant differences favoring Omega + MPH over Omega-3/6 alone were found for ADHD Total and Hyperactivity-Impulsivity subscales, results on the Inattention subscale were similar. CGI-S scores decreased slowly and consistently with Omega-3/6, compared with a rapid decrease and subsequent slight increase in the MPH-containing arms. Adverse events were numerically less frequent with Omega-3/6 or MPH + Omega-3/6 than MPH alone.

CONCLUSION

The tested combination of Omega-3/6 fatty acids had similar effects to MPH, whereas the MPH + Omega combination appeared to have some tolerability benefits over MPH.

Differential impact of a multimodal versus pharmacological therapy on the core symptoms of attention deficit/hyperactivity disorder in childhood

The aim of this study was to analyze the relative and differential efficacy of a combined versus medical treatment to reduce the symptoms of ADHD children in the school and family environment. A total of 100 subjects participated: 20 children with ADHD, their 40 parents and their 40 teachers. Half of the subjects were assigned to the drug group and half to the combined (drug plus psychosocial, psychoeducational intervention with teachers and mothers/fathers).

RESULTS

The group analyses indicated that both treatments were effective, without significant differences between them. Individualized clinical analyses indicated that higher percentages of improvement and normalization were obtained in the children in the combined group than in the drug only group. Our findings point to the desirability of implementing long-lasting multimodal, multicontextual interventions for ADHD in childhood.

Neurofeedback Therapy for Enhancing Visual Attention: State-of-the-Art and Challenges

We have witnessed a rapid development of brain-computer interfaces (BCIs) linking the brain to external devices. BCIs can be utilized to treat neurological conditions and even to augment brain functions. BCIs offer a promising treatment for mental disorders, including disorders of attention. Here we review the current state of the art and challenges of attention-based BCIs, with a focus on visual attention. Attention-based BCIs utilize electroencephalograms (EEGs) or other recording techniques to generate neurofeedback, which patients use to improve their attention, a complex cognitive function. Although progress has been made in the studies of neural mechanisms of attention, extraction of attention-related neural signals needed for BCI operations is a difficult problem. To attain good BCI performance, it is important to select the features of neural activity that represent attentional signals. BCI decoding of attention-related activity may be hindered by the presence of different neural signals. Therefore, BCI accuracy can be improved by signal processing algorithms that dissociate signals of interest from irrelevant activities. Notwithstanding recent progress, optimal processing of attentional neural signals remains a fundamental challenge for the development of efficient therapies for disorders of attention.

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.

Cognitive Improvement of Attention and Inhibition in the Late Afternoon in Children With Attention-Deficit Hyperactivity Disorder (ADHD) Treated With Osmotic-Release Oral System Methylphenidate

Long-acting medications have been developed and approved for use in the treatment of attention-deficit hyperactivity disorder (ADHD). These compounds are intended to optimize and maintain symptoms control throughout the day. We tested prolonged effects of osmotic-release oral system methylphenidate on both attention and inhibition, in the late afternoon. A double-blind, randomized, placebo-controlled study was conducted in 36 boys (7-12 years) with ADHD and 40 typically developing children. The ADHD children received an individualized dose of placebo or osmotic-release oral system methylphenidate. They were tested about 8 hours after taking with 2 continuous performance tests (continuous performance test-X [CPT-X] and continuous performance test-AX [CPT-AX]) and a counting Stroop. A positive effect of osmotic-release oral system methylphenidate was present in CPT-AX with faster and less variable reaction times under osmotic-release oral system methylphenidate than under placebo, and no difference with typically developing children. In the counting Stroop, we found a decreased interference with osmotic-release oral system methylphenidate but no difference between children with ADHD under placebo and typically developing children.

Group therapy for adolescents with attention-deficit/hyperactivity disorder: a randomized controlled trial

OBJECTIVE

To determine the efficacy of group cognitive-behavioral therapy (CBT) on adolescents with attention-deficit/hyperactivity disorder (ADHD) who were in pharmacological treatment but still had persistent symptoms.

METHOD

We conducted a multicenter, randomized, rater-blinded, controlled trial between April 2012 and May 2014 in a cohort of 119 adolescents (15-21 years of age). Participants were randomly assigned to 12 manualized group CBT sessions (n = 45) or a waiting list control group (n = 44). Primary outcomes were assessed by a blinded evaluator (ADHD Rating Scale [ADHD-RS], Clinical Global Impression Scale for Severity [CGI-S], Global Assessment of Functioning [GAF]) before and after treatment, as well as by self-report and parent informant ratings.

RESULTS

Of the initial 119 participants enrolled, 89 completed treatment. A mixed-effects model analysis revealed that participants who were assigned to the group CBT sessions experienced significantly reduced ADHD symptoms compared to the control group (ADHD-RS Adolescent: -7.46, 95% CI = -9.56 to -5.36, p < .001, d = 7.5; ADHD-RS Parents: -9.11, 95% CI = -11.48 to -6.75, p < .001, d = 8.38; CGI-S Self-Report: -0.68, 95% CI = -0.98 to -0.39, p < .001, d = 3.75; CGI-S Clinician: -0.79, 95% CI = -0.95 to -0.62, p < .001; d = 7.71). Functional impairment decreased significantly in the CBT group according to parents (Weiss Functional Impairment Scale -4.02, 95% CI = -7.76 to -0.29, p < .05, d = 2.29) and according to the blinded evaluator (GAF: -7.58, 95% CI = -9.1 to -6.05, p < .001, d = 7.51).

CONCLUSION

Group CBT associated with pharmacological treatment is an efficacious intervention for reducing ADHD symptoms and functional impairment in adolescents. Clinical trial registration information-CBT Group for Adolescents With ADHD: a Randomized Controlled Trial; http://clinicaltrials.gov/; NCT02172183.

Effect of treatment modality on long-term outcomes in attention-deficit/hyperactivity disorder: a systematic review

Background

Evaluation of treatments for attention-deficit/hyperactivity disorder (ADHD) previously focused on symptom control, but attention has shifted to functional outcomes. The effect of different ADHD treatment periods and modalities (pharmacological, non-pharmacological, and combination) on long-term outcomes needs to be more comprehensively understood.

Methods

A systematic search of 12 literature databases using Cochrane’s guidelines yielded 403 English-language peer-reviewed, primary studies reporting long-term outcomes (≥2 years). We evaluated relative effects of treatment modalities and durations and effect sizes of outcomes reported as statistically significantly improved with treatment.

Results

The highest proportion of improved outcomes was reported with combination treatment (83% of outcomes). Among significantly improved outcomes, the largest effect sizes were found for combination treatment. The greatest improvements were associated with academic, self-esteem, or social function outcomes. A majority of outcomes improved regardless of age of treatment initiation (60%–75%) or treatment duration (62%–72%). Studies with short treatment duration had shorter follow-up times (mean 3.2 years total study length) than those with longer treatment durations (mean 7.1 years total study length). Studies with follow-up times <3 years reported benefit with treatment for 93% of outcomes, whereas those with follow-up times ≥3 years reported treatment benefit for 57% of outcomes. Post-hoc analysis indicated that this result was related to the measurement of outcomes at longer periods (3.2 versus 0.4 years) after treatment cessation in studies with longer total study length.

Conclusions

While the majority of long-term outcomes of ADHD improve with all treatment modalities, the combination of pharmacological and non-pharmacological treatment was most consistently associated with improved long-term outcomes and large effect sizes. Older treatment initiation age or longer durations did not markedly affect proportion of improved outcomes reported, but measurement of outcomes long periods after treatment cessation may attenuate results.

Toward quality care in ADHD: defining the goals of treatment

OBJECTIVE

Therapeutic goals for chronic mental disorders like major depressive disorder (MDD) and schizophrenia have evolved in parallel with the growing medical knowledge about the course and treatment of these disorders. Although the knowledge base regarding the clinical course of ADHD, a chronic psychiatric disorder, has evolved beyond symptomatic improvement and short-term treatment response, long-term goals, such as functional remission, have not yet been clearly defined.

METHOD

A PubMed literature search was conducted to investigate the therapeutic goals of pharmacologic treatment referenced in the published literature from January 1998 through February 2010 using the following commonly used ADHD treatments as keywords: amphetamine, methylphenidate, atomoxetine, lisdexamfetamine, guanfacine, and clonidine. This search was then combined with an additional search that included the following outcome keywords: remission, relapse, remit, response, normal, normalization, recovery, and effectiveness.

RESULTS

Our search identified 102 publications. The majority (88.2% [90/102]) of these contained predefined criteria for treatment response. Predefined criteria for normalization and remission and/or relapse were presented in 4.9% (5/102), 12.7% (13/102), and 3.9% (4/102) of publications, respectively. There was a lack of consistency between the instruments used to measure outcomes as well as the criteria used to define treatment response, normalization, and remission as well as relapse.

CONCLUSION

The therapeutic goals in treating ADHD should address optimal treatment outcomes that go beyond modest reductions of ADHD symptoms to include syndromatic, symptomatic, and functional remission. Future work should focus on reliable and valid tools to measure these outcomes in the clinical trial setting.

ADHD, Multimodal Treatment, and Longitudinal Outcome: Evidence, Paradox, and Challenge

Given major increases in the diagnosis of attention-deficit hyperactivity disorder (ADHD) and in rates of medication for this condition, we carefully examine evidence for effects of single versus multimodal (i.e., combined medication and psychosocial/behavioral) interventions for ADHD. Our primary data source is the Multimodal Treatment Study of Children with ADHD (MTA), a 14-month, randomized clinical trial in which intensive behavioral, medication, and multimodal treatment arms were contrasted with one another and with community intervention (treatment-as-usual), regarding outcome domains of ADHD symptoms, comorbidities, and core functional impairments. Although initial reports emphasized the superiority of well-monitored medication for symptomatic improvement, reanalyses and reappraisals have highlighted (a) the superiority of combination treatment for composite outcomes and for domains of functional impairment (e.g., academic achievement, social skills, parenting practices); (b) the importance of considering moderator and mediator processes underlying differential patterns of outcome, including comorbid subgroups and improvements in family discipline style during the intervention period; (c) the emergence of side effects (e.g., mild growth suppression) in youth treated with long-term medication; and (d) the diminution of medication's initial superiority once the randomly assigned treatment phase turned into naturalistic follow-up. The key paradox is that whereas ADHD clearly responds to medication and behavioral treatment in the short term, evidence for long-term effectiveness remains elusive. We close with discussion of future directions and a call for greater understanding of relevant developmental processes in the attempt to promote optimal, generalized, and lasting treatments for this important and impairing neurodevelopmental disorder.

Intervention in the context of development: pathways toward new treatments

Neuropsychiatric disorders vary substantially in age of onset but are best understood within the context of neurodevelopment. Here, we review opportunities for intervention at critical points in developmental trajectories. We begin by discussing potential opportunities to prevent neuropsychiatric disorders. Once symptoms begin to emerge, a number of interventions have been studied either before a diagnosis can be made or shortly after diagnosis. Although some of these interventions are helpful, few are based upon an understanding of pathophysiology, and most ameliorate rather than resolve symptoms. As such, in the next portion of the review, we turn our discussion to genetic syndromes that are rare phenocopies of common diagnoses such as autism spectrum disorder or schizophrenia. Cellular or animal models of these syndromes point to specific regulatory or signaling pathways. As examples, findings from the mouse models of Fragile X and Rett syndromes point to potential treatments now being tested in randomized clinical trials. Paralleling oncology, we can hope that our treatments will move from nonspecific, like chemotherapies thrown at a wide range of tumor types, to specific, like the protein kinase inhibitors that target molecularly defined tumors. Some of these targeted treatments later show benefit for a broader, yet specific, array of cancers. We can hope that medications developed within rare neurodevelopmental syndromes will similarly help subgroups of patients with disruptions in overlapping signaling pathways. The insights gleaned from treatment development in rare phenocopy syndromes may also teach us how to test treatments based upon emerging common genetic or environmental risk factors.

Psychosocial treatments for ADHD: a systematic appraisal of the evidence

OBJECTIVE

Children with learning disabilities often experience comorbid ADHD, impacting on the effectiveness of interventions for those children. In addition to pharmacologic intervention, clinicians and educators employ a variety of psychosocial methods to address the behavioral and social issues that arise in children with ADHD, including those with co-occurring learning disabilities. Numerous systematic reviews and meta-analyses have been conducted examining treatment studies using psychosocial interventions for children with ADHD. Because of the importance of such reviews to evidence based clinical and educational practice, it is essential that reviews be conducted with rigorous methodologies to avoid bias in conclusions (Schlosser, Wendt, & Sigafoos, 2007). The purpose of this study was to evaluate the quality of systematic reviews and meta-analyses conducted for psychosocial treatments of ADHD in children.

METHOD

Electronic databases were searched for peer-reviewed, English language studies of psychosocial treatments for ADHD in children up to 18-years-old from 1998 to 2010. Twenty-one studies were identified that met inclusion criteria (13 systematic reviews, 8 meta-analyses). Independent examiners used the quality rating scale proposed by Auperin, Pignon, and Pynard (1997) to rate the characteristics of good systematic reviews and meta-analyses.

RESULTS

Results indicated that certain methodological characteristics were common across trials reviewed, yet shortcomings were common among most reviews, including inadequate descriptions of data extraction methods and lack of quality ratings for trials included in the reviews.

CONCLUSION

Synthesis of findings from the five top-rated reviews and the literature on ADHD suggest that psychosocial treatments contribute to improvements on behavioral and social outcomes. How ADHD and LD interplay in treatment outcomes is largely unexplored.

Differential impact of methylphenidate and atomoxetine on sustained attention in youth with attention-deficit/hyperactivity disorder

BACKGROUND

This study examined the effects of atomoxetine (ATX) and OROS methylphenidate (MPH) on laboratory measures of inhibitory control and attention in youth with attention-deficit/hyperactivity disorder (ADHD). It was hypothesized that performance would be improved by both treatments, but response profiles would differ because the medications work via different mechanisms.

METHODS

One hundred and two youth (77 male; mean age = 10.5 ± 2.7 years) with ADHD received ATX (1.4 ± 0.5 mg/kg) and MPH (52.4 ± 16.6 mg) in a randomized, double-blind, crossover design. Medication was titrated in 4-6-week blocks separated by a 2-week placebo washout. Inhibitory control and attention measures were obtained at baseline, following washout, and at the end of each treatment using Conners' Continuous Performance Test II (CPT-II), which provided age-adjusted T-scores for reaction time (RT), reaction time variability (RT variability), and errors. Repeated-measures analyses of variance were performed, with Time (premedication, postmedication) and Treatment type (ATX, MPH) entered as within-subject factors. Data from the two treatment blocks were checked for order effects and combined if order effects were not present.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov: NCT00183391.

RESULTS

Main effects for Time on RT (p = .03), RTSD (p = .001), and omission errors (p = .01) were significant. A significant Drug × Time interaction indicated that MPH improved RT, RTSD, and omission errors more than ATX (p < .05). Changes in performance with treatment did not correlate with changes in ADHD symptoms.

CONCLUSIONS

MPH has greater effects than ATX on CPT measures of sustained attention in youth with ADHD. However, the dissociation of cognitive and behavioral change with treatment indicates that CPT measures cannot be considered proxies for symptomatic improvement. Further research on the dissociation of cognitive and behavioral endpoints for ADHD is indicated.

Risperidone added to parent training and stimulant medication: effects on attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, and peer aggression

OBJECTIVE

In this study, we aimed to expand on our prior research into the relative efficacy of combining parent training, stimulant medication, and placebo (Basic therapy) versus parent training, stimulant, and risperidone (Augmented therapy) by examining treatment effects for attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms and peer aggression, symptom-induced impairment, and informant discrepancy.

METHOD

Children (6-12 years of age; N = 168) with severe physical aggression, ADHD, and co-occurring ODD/CD received an open trial of parent training and stimulant medication for 3 weeks. Participants failing to show optimal clinical response were randomly assigned to Basic or Augmented therapy for an additional 6 weeks.

RESULTS

Compared with Basic therapy, children receiving Augmented therapy experienced greater reduction in parent-rated ODD severity (p = .002, Cohen's d = 0.27) and peer aggression (p = .02, Cohen's d = 0.32) but not ADHD or CD symptoms. Fewer children receiving Augmented (16%) than Basic (40%) therapy were rated by their parents as impaired by ODD symptoms at week 9/endpoint (p = .008). Teacher ratings indicated greater reduction in ADHD severity (p = .02, Cohen's d = 0.61) with Augmented therapy, but not for ODD or CD symptoms or peer aggression. Although both interventions were associated with marked symptom reduction, a relatively large percentage of children were rated as impaired for at least 1 targeted disorder at week 9/endpoint by parents (Basic 47%; Augmented 27%) and teachers (Basic 48%; Augmented 38%).

CONCLUSION

Augmented therapy was superior to Basic therapy in reducing severity of ADHD and ODD symptoms, peer aggression, and symptom-induced impairment, but clinical improvement was generally context specific, and effect sizes ranged from small to moderate. Clinical trial registration information-Treatment of Severe Childhood Aggression (The TOSCA Study); http://clinicaltrials.gov/; NCT00796302.

Attention deficit hyperactivity disorder (ADHD): an affect-processing and thought disorder?

In the literature on child and adolescent psychoanalysis attention deficit hyperactivity disorder (ADHD) is described as complex syndrome with wide-ranging psychodynamic features. Broadly speaking, the disorder is divided into three categories: 1. a disorder in early object relations leading to the development of a maniform defence organization in which object-loss anxieties and depressed affects are not worked through via symbolization but are organized in a body-near manner; 2. a triangulation disorder in which the cathexis of the paternal position is not stable; structures providing little support alternate with excessive arousal, affect regulation is restricted; 3. current emotional stress or a traumatic experience. I suggest taking a fresh look at ADHD from a psychoanalytic vantage point. With respect to the phenomenology of the disorder, the conflict-dynamic approach should be supplemented by a perspective regarding deficits in α-function as constitutive for ADHD. These deficits cause affect-processing and thought disorders compensated for (though not fully) by the symptomatology. At a secondary level, a vicious circle develops through the mutual reinforcement of defective processing of sense data and affects into potential thought content, on the one hand, and secondary, largely narcissistic defence processes on the other. These considerations have major relevance for the improved understanding of ADHD and for psychoanalytic technique.

Pharmacological and psychosocial treatments for adolescents with ADHD: an updated systematic review of the literature

Smith, Waschbusch, Willoughby, and Evans (2000) reviewed a small treatment literature on ADHD in adolescents and concluded that methylphenidate stimulant medication was a well-established treatment and behavior therapy (BT) demonstrated preliminary efficacy. This review extends and updates the findings of the prior one based on the previous 15years of research. Studies published since 1999 were identified and coded using standard criteria and effect sizes were calculated where appropriate. Highlights of the last 15years of research include an expansion of pharmacological treatment options and developmentally appropriate psychosocial treatment packages for adolescents with ADHD. Additionally, nonstimulant medications (e.g., atomoxetine) are now approved for the treatment of ADHD in adolescence. The review concludes that medication and BT produce a similar range of therapeutic effects on the symptoms of adolescents with ADHD. However, results suggest that BT may produce greater overall benefits on measures of impairment. There was no evidence that cognitive enhancement trainings, such as working memory training or neurofeedback improved the functioning of adolescents with ADHD. Whether to use medication, BT, or their combination to treat an adolescent with ADHD is complicated and we provide evidence-informed guidelines for treatment selection. The reviewed evidence does not support current American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry professional guidelines, which state that stimulant medication is the preferred treatment for adolescents with ADHD. Recommendations for assessment, practice guidelines, and future research are discussed.

Methylphenidate HCl: therapy for attention deficit hyperactivity disorder

Methylphenidate is a first-line therapy for attention deficit hyperactivity disorder, the most prevalent neuropsychiatric disorder of childhood. The compound is a piperidine and the D-threo-isomer is considered the biologically active form. The compound is available in multiple short- and long-acting preparations, having different delivery systems leading to varying kinetics without clear superiority in efficacy or tolerability at the group level. Common adverse effects are insomnia, appetite disturbance, stomach ache, headache and dizziness. Its mechanism of action is linked to the monoamines dopamine and norepinephrine. The compound appears to predominantly increase the synaptic concentration of dopamine, presumably via inhibition of the dopamine transporter DAT1. There also appears to be effects on presynaptic vesicular trafficking and distribution of dopamine. Both immediate- and sustained-release preparations of methylphenidate have proven efficacy in children and adults with attention deficit hyperactivity disorder. Analysis of the National Institutes of Health-sponsored multimodal treatment study of attention deficit hyperactivity disorder supports a combined medication and behavioral therapy approach.

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

The purpose of this research was to update the Pelham and Fabiano ( 2008 ) review of evidence-based practices for children and adolescents with attention-deficit/hyperactivity disorder. We completed a systematic review of the literature published between 2007 and 2013 to establish levels of evidence for psychosocial treatments for these youth. Our review included the identification of relevant articles using criteria established by the Society of Clinical Child and Adolescent Psychology (see Southam-Gerow & Prinstein, in press ) using keyword searches and a review of tables of contents. We extend the conceptualization of treatment research by differentiating training interventions from behavior management and by reviewing the growing literature on training interventions. Consistent with the results of the previous review we conclude that behavioral parent training, behavioral classroom management, and behavioral peer interventions are well-established treatments. In addition, organization training met the criteria for a well-established treatment. Combined training programs met criteria for Level 2 (Probably Efficacious), neurofeedback training met criteria for Level 3 (Possibly Efficacious), and cognitive training met criteria for Level 4 (Experimental Treatments). The distinction between behavior management and training interventions provides a method for considering meaningful differences in the methods and possible mechanisms of action for treatments for these youth. Characteristics of treatments, participants, and measures, as well as the variability in methods for classifying levels of evidence for treatments, are reviewed in relation to their potential effect on outcomes and conclusions about treatments. Implications of these findings for future science and practice are discussed.

Barriers to, and facilitators of, parenting programmes for childhood behaviour problems: a qualitative synthesis of studies of parents' and professionals' perceptions

Disruptive behaviour problems (DBPs) during childhood exert a high burden on individuals, families and the community as a whole. Reducing this impact is a major public health priority. Early parenting interventions are recommended as valuable ways to target DBPs; however, low take-up of, and high drop-out rates from, these programmes seriously reduce their effectiveness. We present a review of published qualitative evidence relating to factors that block or facilitate access and engagement of parents with such programmes using a thematic synthesis approach. 12 papers presenting views of both parents and professionals met our inclusion and quality criteria. A large number of barriers were identified highlighting the array of challenges parents can face when considering accessing and engaging with treatment for their child with behavioural problems. Facilitating factors in this area were also identified. A series of recommendations were made with regard to raising awareness of programmes and recruiting parents, providing flexible and individually tailored support, delivering programmes through highly skilled, trained and knowledgeable therapists, and highlighting factors to consider when delivering group-based programmes. Clinical guidelines should address barriers and facilitators of engagement as well as basic efficacy of treatment approaches.