Socioeconomic status as a moderator of ADHD treatment outcomes

A longitudinal investigation of parental ratings and performance metrics for executive functioning and symptom severity in clinically referred youth with ADHD

There remains a knowledge gap concerning the persistence of attention deficit hyperactivity disorder (ADHD) over the longer term. The current study aimed to investigate the change in parent-rated, and performance-based metrics of executive functioning (EF) and the relationship between these EF metrics and ADHD symptoms in individuals with ADHD from childhood/adolescence to young adulthood. This was done by examining possible improvements in parent-rated EF and performance-based measures of inattention and inhibition over a three-year interval and their relationship to ADHD outcomes in 137 clinically referred youth with ADHD (mean age = 12.4 years, SD = 3.1). Participants' parents completed the Behavior Rating Inventory of Executive Function (BRIEF) and the Swanson-Nolan-Pelham Scale at baseline and follow-up. Participants completed the Conners' Continuous Performance Test, Version II (CPT II) at baseline and follow-up. Statistical analyses were performed with Linear Mixed Models. The sex- and age-standardized measures Commission and Hit reaction time (RT) subscales of the CPT II and parent-rated metacognitive, and behavior regulation composites of the BRIEF were largely stable between measuring points. CPT Omissions, Hit RT standard error (reaction time variability), and parent-rated ADHD symptom scores improved slightly. BRIEF composites and reaction time variability were related to ADHD symptoms using longitudinal data. Overall, behavioral aspects of EF, as observed by parents in the home context, appear to play a significant role in the trajectory of childhood ADHD.

Athletes With Attention-Deficit/Hyperactivity Disorder: Position Statement of the American Medical Society for Sports Medicine

ABSTRACT

Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.

Cross-sectional study evaluating the association of haemophilia-related distress and clinically relevant outcomes

INTRODUCTION

In chronic diseases, disease-related distress can impact disease outcomes. Distress and haemophilia-related distress has been demonstrated in people with haemophilia (PwH). The association of haemophilia-related distress on disease outcomes among PwH is unknown.

AIM

To study the association of haemophilia-related distress with haemophilia specific outcomes, including adherence to prophylactic therapy, the presence of a target joint, healthcare utilization and work-impairment.

METHODS

In a cross-sectional study, adults with haemophilia A or B were enrolled in a study to validate the haemophilia-related distress questionnaire (HRDq). In this planned analysis, univariate and multivariate associations between the HRDq total score and disease outcomes were explored.

RESULTS

The 114 participants in this analysis were male, mostly with haemophilia A (92%) and severe disease (52%) with a median age of 31.9 years. On univariate analysis, HRDq total score (5-point change) was associated with the presence of a target joint (P = .002), high healthcare utilization (P = .011), poor adherence (P = .033) and work-impairment (P ≤ .001). After adjustment for age, race, severity and other potential confounders, adherence (aβ 0.33, 95% CI .17, .49) and work-impairment (aβ 4.69, 95% CI 3.27-6.1) remained statistically significantly associated with HRDq total score.

CONCLUSION

Haemophilia-related distress is associated with poor adherence to factor prophylaxis and work-impairment. The direction of the association (causation) is yet to be determined and requires future study.

Association between oppositional defiant disorder and parenting style in children with attention deficit hyperactivity disorder

OBJECTIVES

To study the association between oppositional defiant disorder (ODD) and parenting style in children with attention deficit hyperactivity disorder (ADHD).

METHODS

A case-control study was performed on 482 children with ADHD, among whom 322 did not have ODD (simple ADHD group) and 160 had ODD (ADHD+ODD group). General demographic data and the Parenting Style Scale assessment scores were collected from the two groups. A multivariate logistic regression analysis was used to identify the association between parenting style and ODD in children with ADHD.

RESULTS

There was no significant difference in parenting style scores (including rejection factor, emotional warmth factor, overprotection factor, and preference factor) and general demographic data between the simple ADHD and ADHD+ODD groups (P>0.05). Among the children with the predominantly inattentive type of ADHD, the older the child or the lower the father's educational level, the higher the risk of ODD (P<0.05), while there was no significant association between parenting style and the development of ODD (P>0.05).

CONCLUSIONS

Parenting style is not significantly associated with the development of ODD in children with ADHD. In clinical practice, it is necessary to eliminate the stereotype that the parents of children with ADHD and comorbid ODD have a poor parenting style and look for the causes of development of ODD from multiple perspectives, so as to provide reasonable intervention recommendations.

The impact and causal directions for the associations between diagnosis of ADHD, socioeconomic status, and intelligence by use of a bi-directional two-sample Mendelian randomization design

BACKGROUND

Previous studies have reported associations between attention-deficit/hyperactivity disorder (ADHD) and lower socioeconomic status and intelligence. We aimed to evaluate the causal directions and strengths for these associations by use of a bi-directional two-sample Mendelian randomization (MR) design.

METHODS

We used summary-level data from the largest available genome-wide association studies (GWAS) to identify genetic instruments for ADHD, intelligence, and markers of socioeconomic status including the Townsend deprivation index, household income, and educational attainment. Effect estimates from individual genetic variants were combined using inverse-variance weighted regression.

RESULTS

A genetically predicted one standard deviation (SD) increment in the Townsend deprivation index conferred an odds ratio (OR) of 5.29 (95% confidence interval (CI) 1.89-14.76) for an ADHD diagnosis (p<0.001). A genetically predicted one SD higher education level conferred an OR of 0.30 (95% CI 0.25-0.37) (p<0.001), and a genetically predicted one SD higher family income provided an OR of 0.35 (95% CI 0.25-0.49; p<0.001). The associations remained after adjustment for intelligence whereas the lower odds of an ADHD diagnosis with higher intelligence did not persist after adjustment for liability to greater educational attainment (adjusted OR 1.03, 95% CI 0.68-1.56; p=0.87). The MR analysis of the effect of ADHD on socioeconomic markers found that genetic liability to ADHD was statistically associated with each of them (p<0.001) but not intelligence. However, the average change in the socioeconomic markers per doubling of the prevalence of ADHD corresponded only to 0.05-0.06 SD changes.

CONCLUSIONS

Our results indicate that an ADHD diagnosis may be a direct and strong intelligence-independent consequence of socioeconomic related factors, whereas ADHD appears to lead only to modestly lowered socioeconomic status. Low intelligence seems not to be a major independent cause or consequence of ADHD.

Social gradients in ADHD by household income and maternal education exposure during early childhood: Findings from birth cohort studies across six countries

OBJECTIVE

This study aimed to examine social gradients in ADHD during late childhood (age 9-11 years) using absolute and relative relationships with socioeconomic status exposure (household income, maternal education) during early childhood (<5 years) in seven cohorts from six industrialised countries (UK, Australia, Canada, The Netherlands, USA, Sweden).

METHODS

Secondary analyses were conducted for each birth cohort. Risk ratios, pooled risk estimates, and absolute inequality, measured by the Slope Index of Inequality (SII), were estimated to quantify social gradients in ADHD during late childhood by household income and maternal education measured during early childhood. Estimates were adjusted for child sex, mother age at birth, mother ethnicity, and multiple births.

FINDINGS

All cohorts demonstrated social gradients by household income and maternal education in early childhood, except for maternal education in Quebec. Pooled risk estimates, relating to 44,925 children, yielded expected gradients (income: low 1.83(CI 1.38,2.41), middle 1.42(1.13,1.79), high (reference); maternal education: low 2.13(1.39,3.25), middle 1.42(1.13,1.79)). Estimates of absolute inequality using SII showed that the largest differences in ADHD prevalence between the highest and lowest levels of maternal education were observed in Australia (4% lower) and Sweden (3% lower); for household income, the largest differences were observed in Quebec (6% lower) and Canada (all provinces: 5% lower).

CONCLUSION

Findings indicate that children in families with high household income or maternal education are less likely to have ADHD at age 9-11. Absolute inequality, in combination with relative inequality, provides a more complete account of the socioeconomic status and ADHD relationship in different high-income countries. While the study design precludes causal inference, the linear relation between early childhood social circumstances and later ADHD suggests a potential role for policies that promote high levels of education, especially among women, and adequate levels of household income over children's early years in reducing risk of later ADHD.

Social Determinants of Health and ADHD Symptoms in Preschool-Age Children

OBJECTIVE

Attention-Deficit/Hyperactivity Disorder (ADHD) disproportionately affects socioeconomically disadvantaged children, but for unclear reasons. We examined the association between social determinants of health (SDH) and ADHD symptoms in a national sample of preschool-age children.

METHODS

We conducted exploratory factor analysis (EFA) and exploratory structural equation modeling (ESEM) with a sample of 7,565 preschool-age children from the 2016 National Survey of Children's Health, to examine the association between ADHD symptoms and SDH.

RESULTS

EFA indicated a one-factor structure for ADHD symptoms, and three factors for SDH (socioeconomic status, access to basic needs, and caregiver well-being). Independently, all three SDH were significantly associated with higher ADHD symptoms. However, in the ESEM model, only worse caregiver well-being (β = .39, p < .01) was significantly associated with ADHD symptoms, and fully mediated the relationship between SDH and ADHD symptoms.

CONCLUSION

Addressing caregiver well-being in preschoolers with ADHD symptoms could be an early intervention strategy.

Predictors of Treatment Engagement and Outcome Among Adolescents With Attention-Deficit/Hyperactivity Disorder: An Integrative Data Analysis

OBJECTIVE

To identify patient- and treatment-level factors that predict intervention engagement and outcome for adolescents with attention-deficit/hyperactivity disorder (ADHD), guiding efforts to enhance care.

METHOD

Integrative data analysis was used to pool data from 4 randomized controlled trials of adolescent ADHD treatment with participants (N = 854) receiving various evidence-based behavioral therapy packages in 5 treatment arms (standard [STANDARD], comprehensive [COMP], engagement-focused [ENGAGE]), community-based usual care (UC), or no treatment (NOTX). Participants also displayed varying medication use patterns (negligible, inconsistent, consistent) during the trial. Regression and latent growth curve analyses examined treatment- and patient-level predictors of engagement and outcome.

RESULTS

Compared with COMP, ENGAGE was associated with higher parent engagement in behavioral therapy (d = 1.35-1.73) when delivered in university, but not community, clinics. Under some conditions, ENGAGE also predicted youth engagement in behavioral therapy (d = 1.21) and lower likelihood of negligible medication use (odds ratio = 0.49 compared with NOTX). UC was associated with poorer parent engagement compared with COMP (d = -0.59) and negligible medication use (odds ratio = 2.29) compared with NOTX. Compared with COMP, ENGAGE (in university settings) was consistently associated with larger ADHD symptom improvements (d = 0.41-0.83) at 6-month follow-up and sometimes associated with larger grade point average (d = 0.68) and parent-teen conflict (d = 0.41) improvements. Consistent medication use during behavioral therapy was associated with larger improvements in ADHD symptoms (d = 0.28) and parent-teen conflict (d = 0.25-0.36). An ADHD+internalizing clinical profile predicted larger improvements in grade point average (d = 0.45). Family adversity predicted poorer parent and youth engagement (rate ratio = 0.90-0.95), negligible medication use (odds ratio = 1.22), and smaller improvements in grade point average (d = -0.23). African American race predicted smaller improvements in parent-teen conflict (d = -0.49).

CONCLUSION

Engagement-focused behavioral therapy and consistent medication use most frequently predicted stronger clinical engagement and outcomes for adolescents with ADHD. Youths who are African American or who experience family adversity may demonstrate treatment-related disparities for certain outcomes; youths with ADHD+internalizing symptoms may demonstrate excellent academic outcomes following behavioral therapy.

DATA SHARING

The full ADHD TIDAL dataset is publicly available through the National Data Archive (https://nda.nih.gov), including a data dictionary. The study protocol is also publicly available: https://doi.org/10.1186/s12888-020-02734-6.

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

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

Patterns of Parental Adherence and the Association to Child and Parenting Outcomes Following a Multicomponent School-Home Intervention for Youth With ADHD

The goal of the present study was to evaluate the role of parent adherence in the Collaborative Life Skills (CLS) program, a multicomponent school-home intervention, for predicting child and parenting outcomes. A sample of 129 children (63% male; M age = 8.22, SD = 1.10; grades 2-5) with attention-deficit/hyperactivity disorder (ADHD) and their parents participated in CLS, which included 10 weekly behavioral parent training group sessions. Each week, parents provided information on their CLS skill use between sessions (at home) as part of the intervention. Outcome measures included parent and teacher ratings of child behavior and parenting at post-intervention and 6 months follow-up. Growth mixture models examining weekly parent skill use trajectories throughout the intervention significantly predicted parent- and teacher-reported outcomes including parent-rated child behavior, teacher-rated academic competence, and positive parenting behaviors. Fifty-two percent of parents displayed moderate skill use throughout the intervention, whereas the remaining parents had either low (20%) or high (28%) initial levels of use but demonstrated high skill utilization by the middle of the intervention. Results highlight the importance of examining individual differences in parents between session strategy use for behavioral parent training interventions targeting child and parenting outcomes.

The Impact of Social Determinants of Health on the Efficacy of School-Based Interventions for Adolescents with ADHD

Adolescents with Attention-deficit/hyperactivity disorder (ADHD) experience significant impairment in functioning. There are multiple clinic-based interventions that address these impairments (e.g., behavioral parent training). However, clinic-based interventions are often associated with barriers to care (e.g., transportation and financial resources), which can limit access based upon social determinants of health (e.g., parental income). School-based interventions have been developed to address the impairments adolescents with ADHD experience, with the goal of also improving access to care and limiting the impact social determinants of health. Despite this, to date, there has been almost no research evaluating the role of social determinants of health on the efficacy of school-based ADHD interventions. In a sample of 222 adolescents with ADHD randomly assigned to receive two different interventions, the present study evaluates the impact of income, maternal education, single-parent status, and race, on intervention efficacy. Single-parent status had the greatest impact on intervention efficacy, resulting in diminished improvements for two of the three outcomes. There was also a significant moderation effect for income, but only for parent-rated homework performance. In addition, main effects were found for single-parent status and race that represent disparities present at baseline that remained post-intervention. Overall, this study suggests that although school-based models of service delivery have the potential to significantly improve access to care, social determinants of health, and single-parent status, in particular, still need to be considered and addressed.

Does Poverty Moderate Psychosocial Treatment Efficacy for ADHD? A Systematic Review

Objective: To determine the extent to which children in poverty show differential benefit versus non-impoverished peers when undergoing behavioral treatment for ADHD. Method: Multiple readers conducted a systematic review using four research databases, one national treatment database, and multiple recent reviews and meta-analyses to identify appropriate studies. Results: Of 1192 initial search results, only five studies met inclusion criteria and were fully abstracted. Conclusion: Results suggest mixed evidence that low-income children may benefit less, compared with peers from higher income families, from psychosocial treatment for ADHD. Findings point to the need for more consistent, more precise, and higher quality reporting of income information.

Comorbidity and Factors Affecting Treatment Non-Persistence in ADHD

Objective: The aim of the study was to identify factors for treatment non-persistence in patients with ADHD. Method: Data for 100 patients with ADHD aged 5 to 16 who completed the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version-Korean Version (K-SADS-PL-K) and Korean Wechsler Intelligence Scale for Children (K-WISC) were obtained between 2008 and 2013. Patients were classified as treatment-persistent and treatment-non-persistent based on 6-month follow-up. Sociodemographic data, comorbidities, intelligence quotient (IQ), severity, and social/school functioning were compared. Results: Adolescence and poor parental spousal relationships significantly predicted treatment non-persistence. Although comorbid major depressive disorder and absence of transient tic disorder were associated with treatment non-persistence, there was no difference in overall psychiatric comorbidity. No differences existed for IQ, Clinical Global Impressions-Severity (CGI-S) score, peer relationships, and academic achievement. Conclusion: Lower treatment persistence was associated with adolescence, comorbid depression, absence of tics, and poor parental spousal relationships, but not with symptom severity or impairment of the disorder.

The Role of Parental Knowledge and Attitudes about ADHD and Perceptions of Treatment Response in the Treatment Utilization of Families of Children with ADHD

The present study examined the impact of parental knowledge and attitudes about attention-deficit/hyperactivity disorder (ADHD), and parental perceptions of treatment response on the utilization of behavioral and pharmacological ADHD treatments, using data from a longitudinal treatment study designed to assess physical growth in children with ADHD. It also explored if these relations were moderated by race/ethnicity. Participants include 230 (74% Hispanic) families of treatment naïve children with ADHD (M age = 7.56, SD = 1.94; 73% male). Families were randomly assigned to receive behavior therapy (BT) or stimulant medication (MED; which also included low dose BT). After 6 months, families whose children still showed at least moderate impairment had access to either treatment for a total of 30 months. Utilization was measured using the number of BT sessions attended and total mg of MED taken over the study period. Families who reported more willingness to use medication for their child's ADHD at baseline were more likely to use MED and less likely to use BT, regardless of race/ethnicity. Parental knowledge about ADHD was only important in predicting BT utilization for White non-Hispanic families. Greater reduction in ADHD symptoms and impairment significantly predicted more MED utilization for Hispanic families. Results highlight the need to explore multiple parent (e.g., medication willingness) and child (e.g., symptom severity) factors when considering treatment utilization. Results also highlight ethnic differences in which factors affect treatment utilization.

An investigation of predictors of attendance for fathers in behavioral parent training programs for children with ADHD

Behavioral parent training programs are evidence-based treatment for children with attention-deficit/hyperactivity disorder (ADHD), yet attendance in such programs is variable. Relative to mothers of children with ADHD, far less is known about fathers and what predicts their attendance in treatment. The current study aimed to explore predictors of father (N = 171) attendance using data from four studies that tested the efficacy of behavioral parent training programs aimed specifically at fathers. A hierarchical regression was performed to test four potential predictors of attendance, including father race/ethnicity, father education level, child medication status, and father ratings of the child's oppositional defiant disorder symptoms. Father education level was determined to be a significant predictor of attendance, whereas father race/ethnicity, child medication status, and father ratings of the child's ODD behavior were not. The results suggest that future parent training interventions may need to be adapted to improve attendance from fathers of lower education levels.

Maternal personality traits moderate treatment response in the Multimodal Treatment Study of attention-deficit/hyperactivity disorder

Some mothers of children with attention-deficit/hyperactivity disorder (ADHD) present with maladaptive personality profiles (high neuroticism, low conscientiousness). The moderating effect of maternal personality traits on treatment outcomes for childhood ADHD has not been examined. We evaluate whether maternal neuroticism and conscientiousness moderated response in the Multimodal Treatment Study of Children with ADHD. This is one of the first studies of this type. In a randomized controlled trial (RCT), 579 children aged 7-10 (M = 8.5); 19.7% female; 60.8% White with combined-type ADHD were randomly assigned to systematic medication management (MedMgt) alone, comprehensive multicomponent behavioral treatment (Beh), their combination (Comb), or community comparison treatment-as-usual (CC). Latent class analysis and linear mixed effects models included 437 children whose biological mothers completed the NEO Five-Factor Inventory at baseline. A 3-class solution demonstrated best fit for the NEO: MN&MC = moderate neuroticism and conscientiousness (n = 284); HN&LC = high neuroticism, low conscientiousness (n = 83); LN&HC = low neuroticism, high conscientiousness (n = 70). Per parent-reported symptoms, children of mothers with HN&LC, but not LN&HC, had a significantly better response to Beh than to CC; children of mothers with MN&MC and LN&HC, but not HN&LC, responded better to Comb&MedMgt than to Beh&CC. Per teacher-reported symptoms, children of mothers with HN&LC, but not LN&HC, responded significantly better to Comb than to MedMgt. Children of mothers with high neuroticism and low conscientiousness benefited more from behavioral treatments (Beh vs. CC; Comb vs. MedMgt) than other children. Evaluation of maternal personality may aid in treatment selection for children with ADHD, though additional research on this topic is needed.

Associations Between Family and Community Protective Factors and Attention-Deficit/Hyperactivity Disorder Outcomes Among US Children

BACKGROUND

Evidence has established the association between risk factors and attention-deficit/hyperactivity disorder (ADHD) severity, but less is known about factors that may have protective effects on clinical, academic, and social outcomes among children with ADHD.

OBJECTIVE

To examine associations between family cohesion, caregiver social support, community support, and (1) ADHD severity, (2) school engagement, and (3) difficulty making or keeping friends.

METHODS

Cross-sectional study of school-aged and adolescent children with ADHD using data from the 2016 National Survey of Children's Health. Our outcomes were (1) parent-rated ADHD severity, (2) school engagement, and (3) difficulty making or keeping friends. Our independent variables were (1) family cohesion, (2) caregiver social support, and (3) community support. We used logistic regression models to examine associations between our independent variables and each of our outcome variables, adjusting for child and parent sociodemographic characteristics.

RESULTS

In our sample (N = 4,122, weighted N = 4,734,322), children exposed to family cohesion and community support had lower odds of moderate to severe ADHD [adjusted OR (aOR): 0.73 (0.55-0.97); aOR: 0.73 (0.56-0.95), respectively], higher odds of school engagement [aOR: 1.72, (1.25-2.37); aOR: 1.38, (1.04-1.84), respectively], and lower odds of difficulty making or keeping friends [aOR: 0.64, (0.48-0.85); aOR: 0.52, (0.40-0.67), respectively].

CONCLUSION

Among children with ADHD, family cohesion and community support show protective effects in clinical, academic, and social outcomes. Systematically identifying family- and community-level strengths may be important components of multimodal treatment strategies in children with ADHD.

ADHD remission, inclusive special education, and socioeconomic disparities

To understand how institutional environments and socioeconomic backgrounds may influence health outcomes, we examined the relationship among special education environments, socioeconomic status (SES), and likelihood of ADHD remission in children. While the majority of children experience remission by adulthood, the likelihood of remission varies across different SES levels and education environments. We find that for low SES children the likelihood of remission is higher in states that have more inclusive special education regimes. In contrast, for more advantaged children, the odds of remission do not depend on the level of special education inclusivity. Our findings suggest that providing more inclusive education can reduce disparities in behavioral disorders and are particularly important for less advantaged children. In doing so, this study contributes to the fundamental cause and health inequality literature by adding to a growing body of work showing how institutional environments can affect socioeconomic gradients in health treatment and outcomes.

A Review of Factors Influencing the Three Phases of Medication Adherence in People with Attention-Deficit/Hyperactivity Disorder

Objectives: Factors affecting adherence to medications in people with attention-deficit/hyperactivity disorder (ADHD) are not well understood in the context of their influence on the different phases of adherence, that is, initiation, implementation, and discontinuation. This review aimed to identify the factors affecting the three phases of medication adherence in people with ADHD. Methods: Six electronic databases, including Medline, PubMed, IPA, CINAHL, Embase, and PsycINFO, were systematically searched from inception through October 2018 with the limitations of English language and human studies. The search strategy was based on three concepts (adherence, ADHD, and factors) and their relevant terminologies. Results: Considerable variability was observed with regards to the criteria used to define adherence in identified studies (n = 48). Most studies focused on the implementation phase of adherence (n = 27), while only a handful focused on the initiation (n = 6) and discontinuation (n = 5) phase of adherence. The remaining studies (n = 10) examined multiple phases of adherence. Conflicting information received about medication, medication frequency, and fears of medication's effect on growth were the unique factors impacting initiation, implementation, and discontinuation, respectively. Moreover, factors within each phase of adherence also differed with different populations such as parents, children, adolescents, and adults. Fear of addiction, medication effectiveness, psychiatric comorbidity, and medication side effects were the most common factors identified in all three phases of adherence. Conclusions: This review found some unique factors in each phase of adherence while some overlap was also noted. Future interventions to improve adherence should be phase- and group specific rather than consider adherence as a single variable.

Improvements in Irritability with Open-Label Methylphenidate Treatment in Youth with Comorbid Attention Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder

OBJECTIVE

The purpose of this open-label study was to examine the effects of long-acting methylphenidate (MPH) treatment on irritability and related emotional symptoms associated with disruptive mood dysregulation disorder (DMDD) in youth with comorbid attention-deficit/hyperactivity disorder (ADHD).

METHODS

The sample included 22 medication-free male and female subjects (ages 9-15) who met criteria for both DMDD and ADHD. Participants underwent a 4-week trial of long-acting MPH treatment (Concerta^®), with weekly dosing increases until a therapeutic dose was reached. Repeated measures t-tests were used to compare pre- and posttreatment ratings of primary and secondary measures. The primary outcome was self-report irritability. Secondary outcomes included parent and child ratings of emotional frequency, emotional lability, and negative affect (NA). Multiple regression was used to examine the impact baseline hyperactivity, age, gender, race, socioeconomic status, or comorbid diagnosis had on treatment outcomes.

RESULTS

Significant improvements (medium to large effect sizes) in child-rated irritability as well as parent and child ratings of emotional lability, NA, and anger were found. As anticipated, ADHD symptoms also improved. While a majority of the sample saw improvement in child-rated irritability (71%), symptoms worsened a small proportion (19%), and an even smaller portion experienced no change (10%). No demographics, psychiatric comorbidities, or severity of ADHD symptoms influenced treatment outcomes.

CONCLUSIONS

Study findings suggest that MPH treatment significantly improved mood and emotional symptoms associated with DMDD comorbid with ADHD. These findings, coupled with good tolerability in this open-label pilot study supports further research into the use of MPH as a first-line treatment for DMDD. Future work examining MPH treatment of youth with DMDD with and without comorbid ADHD is needed.

Moderators Influencing the Effectiveness of a Behavioral Teacher Program

Objective: This study assessed which moderators influenced the effectiveness of a low-intensive behavioral teacher program for children with symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD).

Methods: Primary school children (N = 114) with ADHD symptoms in the classroom were randomly assigned to the intervention program (n = 58; 91% male) or control group (n = 56; 77% male). Multilevel regression analyses assessed differential treatment gains of the intervention program in terms of ADHD symptoms and social skills. Moderators included demographic characteristics (gender, age, parental educational level), severity and comorbidity of problem behavior (ADHD symptoms, conduct and internalizing problems), social functioning, and classroom variables (teaching experience, class size).

Results: Results revealed larger program effects for older children and children from highly educated families and smaller beneficial effects for children with comorbid conduct or anxiety problems.

Conclusion: The intervention program seems more beneficial for highly educated families and children without comorbid problem behavior, but more intensive treatments appear necessary for children facing additional challenges.

ClinicalTrials.gov registration number: NCT02518711

Association Between Age of Beginning Primary School and Attention Deficit Hyperactivity Disorder

OBJECTIVE

In April 2012, the Turkish national education system was modified, and the compulsory school age of entry (first grade) was redefined as a minimum of 60 months and a maximum of 66 months (replacing the former minimum criterion of 72 months). In this study, we hypothesized that students starting school before 72 months (the previous age standard for the first grade) may experience (1) a greater number of symptoms of attention deficit hyperactivity disorder (ADHD) and (2) lower functioning in social, behavioral, and academic domains.

METHOD

We performed a cross-sectional community-based study in the first and second grades of all primary schools (4356 students) located in the Kadıköy county of Istanbul, Turkey. Teachers completed Swanson, Nolan, and Pelham version IV and Conners' Teacher's report forms for symptoms of ADHD, the Perceived Competence Scale for functioning, and a sociodemographic questionnaire.

RESULTS

Among first graders, the group that began primary school before the age of 72 months had a higher ADHD prevalence than both of the groups that began primary school between the ages of 72 to 77 months and 78 to 83 months (p < .001 for both groups). ADHD symptoms diminished and academic, social, and behavioral functioning improved with age for the first and second grade students.

CONCLUSION

The probability of displaying ADHD symptoms (and caseness) is greater among the "earlier" beginners, whereas the "conventional" classmates exhibited better academic, social, and behavioral functioning.

Impact of Mental Health Comorbidities on the Community-Based Pediatric Treatment and Outcomes of Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE

Children with attention deficit hyperactivity disorder (ADHD) often exhibit psychiatric comorbidities, which may impact illness presentation, diagnosis, and treatment outcomes. Guidelines exist for dealing with these complex cases but little is known about how comorbidities are being handled in community pediatric settings. The purpose of this study was to evaluate how mental health comorbidities affect community physicians' ADHD care practices and patients' symptom trajectories.

METHOD

Medical charts of 319 children presenting at primary care clinics for ADHD-related concerns were reviewed. Physician assessment and treatment behaviors were extracted and parents rated ADHD symptoms at the time of diagnosis and at 3, 6, and 12 months. Baseline ratings were used to group children, as no comorbid mental health condition, internalizing, or externalizing comorbid condition. Multilevel analyses compared community physician care behaviors and ADHD symptom trajectories across groups.

RESULTS

Approximately, 50 percent of the sample met screening criteria for a comorbid mental health condition. For children diagnosed with ADHD and treated with medication, community physician care largely did not differ across groups, but children with internalizing comorbidities made significantly smaller improvements in inattentive and hyperactive/impulsive symptoms compared with children with no comorbidities.

CONCLUSION

Children with ADHD and mental health comorbidities, particularly internalizing disorders, exhibit less robust response to ADHD medication and may require additional testing before starting medication and/or alternative treatment approaches. Potential barriers to conducting comprehensive assessments and to providing multi-modal treatment are discussed.

Assessing health disparities in children using a modified housing-related socioeconomic status measure: a cross-sectional study

OBJECTIVES

Socioeconomic status (SES) is a well-established risk factor for many health outcomes. Recently, we developed an SES measure based on 4 housing-related characteristics (termed HOUSES) and demonstrated its ability to assess health disparities. In this study, we aimed to evaluate whether fewer housing-related characteristics could be used to provide a similar representation of SES.

STUDY SETTING AND PARTICIPANTS

We performed a cross-sectional study using parents/guardians of children aged 1-17 years from 2 US Midwestern counties (n=728 in Olmsted County, Minnesota, and n=701 in Jackson County, Missouri).

PRIMARY AND SECONDARY OUTCOME MEASURES

For each participant, housing-related characteristics used in the formulation of HOUSES (assessed housing value, square footage, number of bedrooms and number of bathrooms) were obtained from the local government assessor's offices, and additional SES measures and health outcomes with known associations to SES (obesity, low birth weight and smoking exposure) were collected from a telephone survey. Housing characteristics with the greatest contribution for predicting the health outcomes were added to formulate a modified HOUSES index.

RESULTS

Among the 4 housing characteristics used in the original HOUSES, the strongest contributions for predicting health outcomes were observed from assessed housing value and square footage (combined contribution ranged between 89% and 96%). Based on this observation, these 2 were used to calculate a modified HOUSES index. Correlation between modified HOUSES and other SES measures was comparable to the original HOUSES for both locations. Consistent with the original HOUSES formula, the strongest association with modified HOUSES was observed with smoking exposure (OR=0.24 with 95% CI 0.11 to 0.49 for comparing participants in highest HOUSES vs lowest group; overall p<0.001).

CONCLUSIONS

The modified HOUSES requires only 2 readily available housing characteristics thereby improving the feasibility of using this index as a proxy for SES in multiple communities, especially in the US Midwestern region.

Qualitative Treatment-Subgroup Interactions in a Randomized Clinical Trial of Treatments for Adolescents with ADHD: Exploring What Cognitive-Behavioral Treatment Works for Whom

Objective

This study explored qualitative treatment-subgroup interactions within data of a RCT with two cognitive behavioral treatments (CBT) for adolescents with ADHD: a planning-focused (PML) and a solution-focused CBT (SFT). Qualitative interactions imply that which treatment is best differs across subgroups of patients, and are therefore most relevant for personalized medicine.

Methods

Adolescents with ADHD (N = 159) received either PML or SFT. Pre-, post- and three-month follow-up data were gathered on parent-rated ADHD symptoms and planning problems. Pretreatment characteristics were explored as potential qualitative moderators of pretest to follow-up treatment effects, using an innovative analyses technique (QUINT; Dusseldorp & Van Mechelen, 2014). In addition, qualitative treatment-subgroup interactions for the therapeutic changes from pre- to posttest and from post- to follow-up test were investigated.

Results

For the entire time span from pretest to follow-up only a quantitative interaction was found, while from posttest to follow-up qualitative interactions were found: Adolescents with less depressive symptoms but more anxiety symptoms showed more improvement when receiving PML than SFT, while for other adolescents the effects of PML and SFT were comparable.

Discussion

Whereas subgroups in both treatments followed different trajectories, no subgroup was found for which SFT outperformed PML in terms of the global change in symptoms from pretest to three months after treatment. This implies that, based on this exploratory study, there is no need for personalized treatment allocation with regard to the CBTs under study for adolescents with ADHD. However, for a subgroup with comorbid anxiety symptoms but low depression PML clearly appears the treatment of preference.

Trial Registration

Nederlands Trial Register NTR2142

Association Between Childhood Sleep-Disordered Breathing and Disruptive Behavior Disorders in Childhood and Adolescence

We examined the association between sleep-disordered breathing (SDB) and disruptive behavior disorders in 605 children participating in a population-based cohort study. Nineteen percent of children snored (sometimes or often) and 10% had obstructive sleep apnea (OSA) symptoms. Thirteen percent had an ADHD diagnosis or symptoms and 5-9% had behavioral problems or a conduct disorder. Snoring or OSA symptoms were associated with a twofold difference in the odds of ADHD diagnosis or symptoms. OSA symptoms were associated with a threefold to fourfold difference in the odds of behavioral problems or conduct disorder. Clinicians should consider inquiring about SDB in children with disruptive behavior disorders and should also consider disruptive behavior disorders as potential sequelae of SDB.

The role of parental education in the relation between ADHD symptoms and executive functions in children

OBJECTIVE

Using a population-based sample of 9-year-old children, this study examined whether the relation between symptoms of ADHD and executive functions (EFs) depended on socioeconomic status (SES; indexed by parental education).

METHOD

Parents and teachers rated the children's ADHD symptoms, and parents also indicated their educational level in a questionnaire. The children performed a comprehensive set of EF tasks.

RESULTS

Whereas working memory was similarly related to ADHD symptoms in the lower and higher parental education group, the relations of inhibition and mental set-shifting with ADHD symptoms were generally stronger in the higher educational group, a pattern that was supported by several significant group differences in correlations.

CONCLUSION

This suggests that the EF pathway in contemporary multiple pathway models of ADHD etiology may be particularly relevant in higher SES parts of the population.

[Has the prevalence of parent-reported diagnosis of attention deficit hyperactivity disorder (ADHD) in Germany increased between 2003-2006 and 2009-2012? Results of the KiGGS-study: first follow-up (KiGGS Wave 1)]

Recent international studies have reported a considerable increase in the diagnosis of attention deficit hyperactivity disorder (ADHD). Data from German statutory health insurance companies suggest a comparable trend for Germany. Based on data from the nationally representative study KiGGS Wave 1 (2009-2012) it was the aim of this study to report on the prevalence rates of parent-reported ADHD diagnoses in children and adolescents aged 3-17 years as well as to report on time trends in comparison with the KiGGS baseline study (2003-2006). ADHD caseness was met if a parent reported that a physician or a psychologist diagnosed their child with ADHD. Participants without a reported ADHD diagnosis but who scored ≥ 7 (clinical range) on the parent-rated hyperactivity subscale of the Strengths and Difficulties Questionnaire (SDQ) were considered as potential ADHD cases. The prevalence of diagnosed ADHD was 5.0% (prevalence of potential ADHD cases 6.0%). An ADHD diagnosis was more than four and a half times more likely to be reported among boys than girls. Children from families with low socioeconomic status (SES) were more than two and a half times more likely to be diagnosed with ADHD than children from families with high SES. Among potential cases, boys were twice as common as girls, and children from families with low SES were approximately three times more common compared with those from high SES families. The proportion of lifetime ADHD diagnoses increased with age and was highest in 11- to 17-year-olds. In every fifth child with ADHD the initial diagnosis was made by the age of 6 years and in 1 out of 11 children with ADHD the initial diagnosis was made by the age of 5 years. In total, we observed no significant changes regarding the frequency of ADHD diagnosis compared to the KiGGS baseline study. Increases reported using data from German statuary health insurance companies were not reflected in the KiGGS data.

Implementation and outcome of child psychotherapy compared with other psychiatric treatments in a naturalistic clinical setting

BACKGROUND

Mental health problems of children are commonly treated by psychotherapy and other psychosocial treatments. Studies comparing different treatments in naturalistic clinical settings are few, however.

AIMS

We assessed the differences: 1) in symptoms and diagnoses; 2) in treatment outcome between psychotherapy and other psychosocial treatments; and 3) evaluated the effect of family background and life circumstances on the outcome.

METHODS

The data were collected from the psychiatric hospital records of Oulu University Hospital, Finland. All 118 children (aged < 16 years) referred to psychotherapy from the Department of Child Psychiatry in 1996-2005 and 118 age- and sex-matched children undergoing other psychosocial treatments were included. A lack of later recorded psychiatric problems was used as an indicator of good treatment outcome.

RESULTS

On referral, functional ability was severely impaired in almost half of the children (Children's Global Assessment Scale score < 55). Internalizing symptoms were more common in the psychotherapy group, while no difference was found in externalizing symptoms between the groups. In both groups, later psychiatric problems were associated with a child's low functional ability and poor parental coping with their responsibilities. Children with internalizing problems had impaired prognosis if they had psychosocial treatments other than psychotherapy.

CONCLUSIONS

Individual psychotherapy should especially be considered for children with internalizing symptoms, but the outcome of psychiatric treatment depends not only on children's own functional abilities, but also on parental abilities.

Comorbid symptomatology moderates response to risperidone, stimulant, and parent training in children with severe aggression, disruptive behavior disorder, and attention-deficit/hyperactivity disorder

OBJECTIVE

In this study, we evaluated parent and child characteristics as predictors and moderators of response in the four-site Treatment of Severe Childhood Aggression (TOSCA) study.

METHODS

A total of 168 children with severe aggression, disruptive behavior disorder, and attention-deficit/hyperactivity disorder (ADHD) were enrolled in a 9-week trial of basic treatment (n=84, stimulant+parent training+placebo) versus augmented treatment (n=84, stimulant+parent training+risperidone). In the initial report, augmented treatment surpassed basic treatment in reducing the primary outcome of disruptive behavior (D-Total) scores. In the current study, we evaluated parent (income, education, family functioning, employment) and child variables (intelligence quotient [IQ], aggression type, comorbid symptomatology) as predictors or moderators, using linear mixed models and the MacArthur guidelines.

RESULTS

Higher scores on ADHD symptom severity and callous/unemotional traits predicted better outcome on D-Total regardless of treatment assignment. Two moderators of D-Total were found: Higher anger/irritability symptoms and lower mania scores were associated with faster response, although not better overall effect at endpoint, in the augmented but not the basic group. Several variables moderated response on secondary outcomes (ADHD severity and prosocial behavior), and were characterized by faster response, although not better outcome, in the augmented but not in the basic group. Maternal education moderated outcome on the measure of positive social behavior; children of mothers with less education benefited more from augmented treatment relative to basic than those with more education.

CONCLUSION

Although these findings require validation, they tentatively suggest that augmented treatment works equally well across the entire sample. Nevertheless, certain child characteristics may be useful indicators for the speed of response to augmented treatment.

ADHD symptomatology and risky health, driving, and financial behaviors in college: the mediating role of sensation seeking and effortful control

OBJECTIVE

To examine the extent to which effortful control (EC) and sensation seeking (SS) tendencies explain the association between the severity of ADHD symptoms and risky behaviors.

METHOD

Participants included 555 college students (66% females) who completed self-report measures assessing their ADHD symptoms, EC abilities, SS tendencies, and risky health (e.g., substance use) and driving/financial behaviors (e.g., misuse of credit cards).

RESULTS

Severity of college students' ADHD symptoms, EC abilities, and SS tendencies were related to all risky behaviors. Multiple mediational analyses further indicated that students' SS tendencies significantly mediated the association between ADHD symptoms and the risky health factor but not the risky driving/financial factor. EC, however, significantly mediated the association between ADHD symptoms and both the risky health and driving/financial factors.

CONCLUSION

The current study provides initial data showing potentially different mechanisms that explain the link between college students' severity of ADHD symptoms and risky behaviors.

Increasing Understanding in Children of Depressed Parents: Predictors and Moderators of Intervention Response

We evaluated predictors and moderators of differential response to two family-based depression prevention programs for families with a depressed parent: a clinician-facilitated intervention and a lecture group intervention. Individual and family level variables were examined using regression analyses with generalized estimating equations. For the outcome of child understanding of depression, parental changes in child-related behaviors and attitudes predicted greater child understanding (p < 0.001). For the parent outcome of behavior and attitude change, across intervention conditions, younger parent age (p < 0.05), female parent gender (p < 0.01), more chronic and severe parental depression history (p < 0.05), lower SES (p < 0.05), and single-parent status (p < 0.05) were associated with better outcomes across conditions. Effect sizes were moderate, ranging from 0.4 to 0.7 SD. Family and marital functioning were not found to be predictors of any outcomes. When both parents were depressed at baseline, there was no difference in the clinician- versus lecture-based approach, and when only the father was depressed, families reported more changes with the clinician condition than with the lecture condition (p < 0.05). Findings from this study can help identify intervention strategies that are appropriate for different types of at-risk individuals and families.

A 36 month naturalistic retrospective study of clinic-treated youth with attention-deficit/hyperactivity disorder

OBJECTIVE

The purpose of this study was to investigate factors for pharmacotherapy adherence in patients with attention-deficit/hyperactivity disorder (ADHD), with an emphasis on medication possession ratio (MPR).

METHODS

The medical records of 300 clinic-treated youth diagnosed with ADHD were retrospectively reviewed. Patients from March 2005 through January 2009 were diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, 4(th) ed., Text Revision (DSM-IV-TR) and psychological tests. Patients were classified based on the time period from the initial visit to the last visit. We selectively compared the early dropout group within 6 months and the long-term medication group over 36 months (LMed) to identify long-term follow-up characteristics. The short-term follow-up group was divided into an early dropout group without pharmacotherapy commencement (EDO) and a short-term medication group (SMed). Sociodemographic data, psychological test scores, and average MPR of the EDO, SMed, and LMed groups were compared.

RESULTS

The number of EDO patients was 69 (23.0%) out of the 300 total patients who were studied, and there were 59 SMed patients (19.3%), and 60 LMed patients (20.0%). Compared with other groups, the EDO group included significantly more younger patients, younger parents, higher maternal education level, lower Short Form Korean-Conners' Parent Rating Scale (K-CPRS) score, and higher full scale and performance intelligence quotient (IQ). There was no significant correlation between the average MPR and the treatment duration.

CONCLUSIONS

Within the first 6 months of visiting the hospital, >40% of the patients dropped out of treatment regardless of methylphenidate (MPH) use. Twenty percent of the subjects showed adherence to MPH medication after 36 months.

Behavioral interventions in attention-deficit/hyperactivity disorder: a meta-analysis of randomized controlled trials across multiple outcome domains

OBJECTIVE

Behavioral interventions are recommended as attention-deficit/hyperactivity disorder (ADHD) treatments. However, a recent meta-analysis found no effects on core ADHD symptoms when raters were probably blind to treatment allocation. The present analysis is extended to a broader range of child and parent outcomes.

METHOD

A systematic search in PubMed, Ovid, Web of Knowledge, ERIC, and CINAHAL databases (up to February 5, 2013) identified published randomized controlled trials measuring a range of patient and parent outcomes for children and adolescents diagnosed with ADHD (or who met validated cutoffs on rating scales).

RESULTS

Thirty-two of 2,057 nonduplicate screened records were analyzed. For assessments made by individuals closest to the treatment setting (usually unblinded), there were significant improvements in parenting quality (standardized mean difference [SMD] for positive parenting 0.68; SMD for negative parenting 0.57), parenting self-concept (SMD 0.37), and child ADHD (SMD 0.35), conduct problems (SMD 0.26), social skills (SMD 0.47), and academic performance (SMD 0.28). With probably blinded assessments, significant effects persisted for parenting (SMD for positive parenting 0.63; SMD for negative parenting 0.43) and conduct problems (SMD 0.31).

CONCLUSION

In contrast to the lack of blinded evidence of ADHD symptom decrease, behavioral interventions have positive effects on a range of other outcomes when used with patients with ADHD. There is blinded evidence that they improve parenting and decrease childhood conduct problems. These effects also may feed through into a more positive parenting self-concept but not improved parent mental well-being.

Barriers to evidence-based treatment for children with attention-deficit/hyperactivity disorder

A number of evidence-based treatments are available for attention-deficit/hyperactivity disorder (ADHD), including pharmacological, psychosocial, or a combination of the two treatments. For a significant number of children diagnosed with ADHD, however, these treatments are not utilized or adhered to for the recommended time period. Given that adherence to treatment regimens is necessary for reducing the symptoms of ADHD, it is crucial to develop a comprehensive understanding of why adherence rates are so low. The current review examines the literature to date that has directly explored utilization and adherence issues related to the treatment of ADHD in order to identify the key barriers to treatment. This review focused on four main factors that could account for the poor rates of treatment utilization and adherence: personal characteristics (socio-demographic characteristics and diagnostic issues), structural barriers, barriers related to the perception of ADHD, and barriers related to perceptions of treatment for ADHD. This review included 63 papers and covered a variety of barriers to treatment that have been found in research to have an impact on treatment adherence. Based on this review, we conclude that there are complex and interactive relationships among a variety of factors that influence treatment utilization and adherence. Four main gaps in the literature were identified: (1) there is limited information about barriers to psychosocial interventions, compared to pharmacological interventions; (2) there is a limited variety of research methodology being utilized; (3) treatment barrier knowledge is mostly from parents' perspectives; and (4) treatment utilization and treatment adherence are often studied jointly. Information from this review can help practitioners to identify potential barriers to their clients being adherent to treatment recommendations.

Application of a novel socioeconomic measure using individual housing data in asthma research: an exploratory study

BACKGROUND

A housing-based socioeconomic index (HOUSES) was previously developed to overcome an absence of socioeconomic status (SES) measures in common databases. HOUSES is associated with child health outcomes in Olmsted County, Minnesota, USA, but generalisability to other geographic areas is unclear.

AIM

To assess whether HOUSES is associated with asthma outcomes outside Olmsted County, Minnesota, USA.

METHODS

Using a random sample of children with asthma from Sanford Children's Hospital, Sioux Falls, SD, USA, asthma status was determined. The primary outcome was asthma control status using Asthma Control Test and a secondary outcome was risk of persistent asthma. Home address information and property data were merged to formulate HOUSES. Other SES measures were examined: income, parental education (PE), Hollingshead and Nakao-Treas index.

RESULTS

Of a random sample of 200 children, 80 (40%) participated in the study. Of those, 13% had poorly controlled asthma. Addresses of 94% were matched with property data. HOUSES had moderate-good correlation with other SES measures except PE. Poor asthma control rates were 31.6%, 4.8% and 5.6% for patients in the lowest, intermediate and highest tertiles of HOUSES, respectively (P=0.023). HOUSES as a continuous variable was inversely associated with poorly controlled asthma (adjusted odds ratio (OR)=0.21 per 1 unit increase of HOUSES, 95% confidence interval (CI), 0.05-0.89, P=0.035). HOUSES as a continuous variable was inversely related to risk of persistent asthma (OR: 0.36 per 1 unit increase of HOUSES, 95% CI, 0.12-1.04, P=0.06).

CONCLUSIONS

HOUSES appears to be generalisable and available as a measure of SES in asthma research in the absence of conventional SES measures.

The Influence of Comorbid Depression and Conduct Disorder on MET/CBT Treatment Outcome for Adolescent Substance Use Disorders

Although depression and conduct disorder frequently co-occur with substance use disorders (SUDs), few studies have investigated the individual and interactive effects of these conditions on SUD treatment outcome. Data were collected from 90 adolescents aged 13-21 (M = 17.1, SD = 2.07) who received a brief evidence-based intervention for SUD. Hierarchical regressions assessed the relationship among demographic variables, depression, conduct disorder, and two substance use outcomes (frequency and problems) at two intervals (three months, six months). Results revealed that higher baseline substance use and lower socioeconomic status significantly predicted higher substance problems and frequency at three-months. At six months, higher three month substance problems and lower depressive symptoms predicted substance problems. In addition, an interaction indicated that the effect of conduct disorder on substance problems was greatest at lower levels of depression. Results are discussed in the context of previous research indicating mixed effects of depression on SUD treatment outcome.

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.

Individual differences in attention deficit hyperactivity disorder symptoms and associated executive dysfunction and traits: sex, ethnicity, and family income

The goal of the present investigation was to investigate sex, ethnic, and socioeconomic status (SES) influences on attention deficit hyperactivity disorder (ADHD) symptoms and risk markers, including executive dysfunction and temperament traits. Participants were 109 children who were 3 to 6 years old (64% male; 36% ethnic minority) and their primary caregivers and teachers who completed a multistage, multi-informant screening, and diagnostic procedure. Parents completed a diagnostic interview and diagnostic and temperament questionnaires, teachers completed questionnaires, and children completed cognitive control tasks. Because of targeted overrecruitment of clinical cases, 56% of children in the sample were diagnosed with ADHD. Results suggested minimal sex differences, but prominent ethnic differences, in ADHD symptoms and temperament and executive function risk markers. Further, low family income was associated with increased ADHD symptoms and more temperament and executive function risk markers, and low family income explained many ethnic differences in ADHD symptoms and these risk markers. There were prominent interactions among child sex, ethnicity, and family income. Thus, study results suggest that children with multiple individual difference demographic risk factors (e.g., such as being male and ethnic minority) are at highly increased risk of ADHD symptoms and associated risk markers in the temperament and executive function domains.

A camp-based psychosocialiIntervention to promote independence and social function in individuals with spina bifida: moderators of treatment effectiveness

PURPOSE

To replicate and extend O'Mahar and colleagues' (O'Mahar, K., Holmbeck, G. N., Jandasek, B., & Zuckerman, J. [2010]. A camp-based intervention targeting independence among individuals with spina bifida. Journal of Pediatric Psychology, 35, 848-856) findings in a new and larger sample of youth and young adults with spina bifida who participated in a modified camp-based intervention targeting independence and social skills. Moderators of intervention effectiveness and clinical significance were examined.

METHOD

In all, 119 campers aged 7-41 years participated in an intervention that included goal setting and interactive workshops. Campers and parents completed measures of campers' goal attainment, independence, and social functioning at preintervention and postintervention; counselors reported on campers' goal attainment daily throughout the intervention.

RESULTS

Parents and campers reported improvements in campers' goal attainment, management of health-related self-care, and independence. Although benefits were found for most campers, cognitive functioning and family income moderated some outcomes. Campers who improved most on their social goals perceived the intervention to be more effective.

CONCLUSIONS

Further support is provided for the effectiveness of a camp-based intervention targeting independence and social skills for individuals with spina bifida. More attention should be directed toward those with cognitive difficulties and low-income backgrounds.

Understanding Discipline in Families of Children with Attention-Deficit/Hyperactivity Disorder: A Structural Equation Model

One hundred and fifty-five mothers of children with attention deficit/hyperactivity disorder (ADHD) completed a semi-structured interview, the Parenting Stress Index Questionnaire (Abidin, 1990), to evaluate parenting stress. The Parenting Scale (Arnold, O'Leary, Wolff & Acker, 1993) was also administered to measure dysfunctional discipline strategies. Structural equation modeling was used to test a model in which the independent variables were the Child's Characteristics and the Socio-Educational Status of his or her family; intermediate variables were Parenting Stress concerning the Child Domain and concerning the Parent Domain; and the dependent variable was Parental Discipline. The results confirm our hypotheses. Interventions in these families should therefore incorporate a component focused on Parenting Stress (in both the Child Domain and the Parent Domain), as a determinant of Parental Discipline.

The effects of instructions on mothers' ratings of child attention-deficit/hyperactivity disorder symptoms

We examined whether instructional materials describing how to rate child ADHD symptoms would improve the accuracy of mothers' ratings of ADHD symptoms presented in standard child behavior stimuli, and whether instructions would be equally effective across a range of maternal depressive symptoms and family incomes. A community sample of 100 mothers with 5 to 12 year old sons were randomly assigned to either receive or not receive the instructions. All mothers watched standard video recordings of boys displaying nonproblem behavior, ADHD symptoms, ADHD plus oppositional behaviors, or ADHD plus anxious behaviors, and then rated the ADHD symptoms of the boys in the videos. These ratings were compared to ratings of the boys' ADHD symptoms made by objective coders. Results indicated an interaction such that the instructional materials improved the agreement between mothers' and coders' ratings, but only for mothers at lower family income levels. The instructional materials improved all mothers' open-ended responses regarding knowledge of ADHD. All mothers rated more ADHD symptoms in boys with comorbid oppositional or anxious behaviors, and this effect was not reduced by the instructional materials. The potential utility of these instructions to improve the accuracy of ratings of child ADHD symptoms is explored.

Development and initial testing of a new socioeconomic status measure based on housing data

Socioeconomic status (SES) has been associated with many health outcomes. Commonly used datasets such as medical records often lack data on SES but do include address information. The authors sought to determine whether an SES measure derived from housing characteristics is associated with other SES measures and outcomes known to be associated with SES. The data come from a telephone survey of parents/guardians of children aged 1-17 years who resided in Olmsted County, Minnesota, and Jackson County, Missouri. Seven variables related to housing and six neighborhood characteristics obtained from local government assessor's offices in Olmsted County, Minnesota, were appended to survey responses. An SES index derived from housing characteristics (hereafter, HOUSES) was constructed using principal components factor analysis. For criterion validity, we assessed Pearson's correlation coefficients between HOUSES and other SES measures, including self-reported parents' educational levels, income, Hollingshead Index, and Nakao-Treas Index. For construct validity, we determined the association between HOUSES and outcomes, risks of low birth weight, overweight, and smoking exposure at home. We applied HOUSES to subjects in another community by formulating HOUSES from housing data of subjects in Jackson County, Missouri, using the same statistical algorithm as HOUSES for subjects in Olmsted County, Minnesota. We found that HOUSES had modest to good correlation with other SES measures. Overall, as hypothesized, HOUSES was inversely associated with outcome measures assessed among subjects from both counties. HOUSES may be a useful surrogate measure of individual SES in epidemiologic research, especially when SES measures for individuals are not available.

The challenges to demonstrating long-term effects of psychostimulant treatment for attention-deficit/hyperactivity disorder

PURPOSE OF REVIEW

Questions about the long-term effects of psychostimulant medication are frequently raised in the public domain. There is a need to articulate the methodological challenges to addressing this question, both to assist in the interpretation of existing research and to inform future research.

RECENT FINDINGS

Two peer-reviewed studies and one published report have attempted to address the issue of long-term effects of psychostimulant medication. One is favourable, one found no benefit, and the third showed harm. All three studies struggled to deal with methodological challenges such as the variable time course of the disorder, variability in persistence and adherence with treatment, and self-selection for treatment continuation.

SUMMARY

Future research examining the long-term effects of psychostimulant treatment will of necessity be naturalistic, but must be able to control for treatment quality, treatment adherence, and natural variation in the course of attention-deficit/hyperactivity disorder. It would be helpful to distinguish between long-term effects of treatment and effects of long-term treatment.