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Zhao L, Agazzi H, Du Y, Meng H, Maku R, Li K, Aspinall P, Garvan CW, Fang S. A Digital Cognitive-Physical Intervention for Attention-Deficit/Hyperactivity Disorder: Randomized Controlled Trial. J Med Internet Res 2024; 26:e55569. [PMID: 38728075 PMCID: PMC11127175 DOI: 10.2196/55569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/15/2024] [Accepted: 04/25/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Pharmacotherapy has been the primary treatment for ADHD, supplemented by behavioral interventions. Digital and exercise interventions are promising nonpharmacologic approaches for enhancing the physical and psychological health of children with ADHD. However, the combined impact of digital and exercise therapies remains unclear. OBJECTIVE The aim of this study was to determine whether BrainFit, a novel digital intervention combining gamified cognitive and exercise training, is efficacious in reducing ADHD symptoms and executive function (EF) among school-aged children with ADHD. METHODS This 4-week prospective randomized controlled trial included 90 children (6-12 years old) who visited the ADHD outpatient clinic and met the diagnostic criteria for ADHD. The participants were randomized (1:1) to the BrainFit intervention (n=44) or a waitlist control (n=46) between March and August 2022. The intervention consisted of 12 30-minute sessions delivered on an iPad over 4 weeks with 3 sessions per week (Monday, Wednesday, and Friday after school) under the supervision of trained staff. The primary outcomes were parent-rated symptoms of attention and hyperactivity assessed according to the Swanson, Nolan, and Pelham questionnaire (SNAP-IV) rating scale and EF skills assessed by the Behavior Rating Inventory of Executive Function (BRIEF) scale, evaluated pre and post intervention. Intention-to-treat analysis was performed on 80 children after attrition. A nonparametric resampling-based permutation test was used for hypothesis testing of intervention effects. RESULTS Among the 145 children who met the inclusion criteria, 90 consented and were randomized; ultimately, 80 (88.9%) children completed the study and were included in the analysis. The participants' average age was 8.4 (SD 1.3) years, including 63 (78.8%) male participants. The most common ADHD subtype was hyperactive/impulsive (54/80, 68%) and 23 (29%) children had severe symptoms. At the endpoint of the study, the BrainFit intervention group had a significantly larger improvement in total ADHD symptoms (SNAP-IV total score) as compared to those in the control group (β=-12.203, 95% CI -17.882 to -6.523; P<.001), owing to lower scores on the subscales Inattention (β=-3.966, 95% CI -6.285 to -1.647; P<.001), Hyperactivity/Impulsivity (β=-5.735, 95% CI -8.334 to -3.137; P<.001), and Oppositional Defiant Disorder (β=-2.995, 95% CI -4.857 to -1.132; P=.002). The intervention was associated with significant reduction in the Metacognition Index (β=-6.312, 95% CI -10.973 to -1.650; P=.006) and Global Executive Composite (β=-5.952, 95% CI -10.214 to -1.690; P=.003) on the BRIEF. No severe intervention-related adverse events were reported. CONCLUSIONS This novel digital cognitive-physical intervention was efficacious in school-age children with ADHD. A larger multicenter effectiveness trial with longer follow-up is warranted to confirm these findings and to assess the durability of treatment effects. TRIAL REGISTRATION Chinese Clinical Trial Register ChiCTR2300070521; https://www.chictr.org.cn/showproj.html?proj=177806.
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Affiliation(s)
- Licong Zhao
- Department of Child Healthcare, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Heather Agazzi
- Department of Pediatrics & Department of Psychiatry and Behavioral Neurosciences, College of Medicine, University of South Florida, Tampa, FL, United States
| | - Yasong Du
- Department of Child & Adolescent Psychiatry, Shanghai Mental Health Center, Shanghai Jiaotong University, Shanghai, China
| | - Hongdao Meng
- College of Behavioral & Community Sciences, University of South Florida, Tampa, FL, United States
| | - Renya Maku
- College of Public Health, University of South Florida, Tampa, FL, United States
| | - Ke Li
- Department of Child Healthcare, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | | | - Cynthia Wilson Garvan
- Department of Anesthesiology, College of Medicine, University of Florida, Tampa, FL, United States
| | - Shuanfeng Fang
- Department of Child Healthcare, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
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Brikell I, Yao H, Li L, Astrup A, Gao L, Gillies MB, Xie T, Zhang-James Y, Dalsgaard S, Engeland A, Faraone SV, Haavik J, Hartman C, Ip P, Jakobsdóttir Smári U, Larsson H, Man KK, de Oliveira Costa J, Pearson SA, Hostrup Nielsen NP, Snieder H, Wimberley T, Wong IC, Zhang L, Zoega H, Klungsøyr K, Chang Z. ADHD medication discontinuation and persistence across the lifespan: a retrospective observational study using population-based databases. Lancet Psychiatry 2024; 11:16-26. [PMID: 38035876 DOI: 10.1016/s2215-0366(23)00332-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Although often intended for long-term treatment, discontinuation of medication for ADHD is common. However, cross-national estimates of discontinuation are missing due to the absence of standardised measures. The aim of this study was to determine the rate of ADHD treatment discontinuation across the lifespan and to describe similarities and differences across countries to guide clinical practice. METHODS We did a retrospective, observational study using population-based databases from eight countries and one Special Administrative Region (Australia, Denmark, Hong Kong, Iceland, the Netherlands, Norway, Sweden, the UK, and the USA). We used a common analytical protocol approach and extracted prescription data to identify new users of ADHD medication. Eligible individuals were aged 3 years or older who had initiated ADHD medication between 2010 and 2020. We estimated treatment discontinuation and persistence in the 5 years after treatment initiation, stratified by age at initiation (children [age 4-11 years], adolescents [age 12-17 years], young adults [age 18-24 years], and adults [age ≥25 years]) and sex. Ethnicity data were not available. FINDINGS 1 229 972 individuals (735 503 [60%] males, 494 469 females [40%]; median age 8-21 years) were included in the study. Across countries, treatment discontinuation 1-5 years after initiation was lowest in children, and highest in young adults and adolescents. Within 1 year of initiation, 65% (95% CI 60-70) of children, 47% (43-51) of adolescents, 39% (36-42) of young adults, and 48% (44-52) of adults remained on treatment. The proportion of patients discontinuing was highest between age 18 and 19 years. Treatment persistence for up to 5 years was higher across countries when accounting for reinitiation of medication; at 5 years of follow-up, 50-60% of children and 30-40% of adolescents and adults were covered by treatment in most countries. Patterns were similar across sex. INTERPRETATION Early medication discontinuation is prevalent in ADHD treatment, particularly among young adults. Although reinitiation of medication is common, treatment persistence in adolescents and young adults is lower than expected based on previous estimates of ADHD symptom persistence in these age groups. This study highlights the scope of medication treatment discontinuation and persistence in ADHD across the lifespan and provides new knowledge about long-term ADHD medication use. FUNDING European Union Horizon 2020 Research and Innovation Programme.
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Affiliation(s)
- Isabell Brikell
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Honghui Yao
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Lin Li
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Aske Astrup
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark; Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
| | - Le Gao
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Malcolm B Gillies
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Tian Xie
- Department of Psychiatry, Interdisciplinary Center of Psychopathology and Emotion Regulation, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Yanli Zhang-James
- Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Søren Dalsgaard
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark; Center for Child and Adolescent Psychiatry, Mental Health Services of the Capital Region, Glostrup, Denmark; Institute of Clinical Medicine, University of Copenhagen, København, Denmark
| | - Anders Engeland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Stephen V Faraone
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Jan Haavik
- Department of Biomedicine, University of Bergen, Bergen, Norway; Bergen Center of Brain Plasticity, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Catharina Hartman
- Department of Psychiatry, Interdisciplinary Center of Psychopathology and Emotion Regulation, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Patrick Ip
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Unnur Jakobsdóttir Smári
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Kenneth Kc Man
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong Special Administrative Region, China; Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK; Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK; Laboratory of Data Discovery for Health, Hong Kong Special Administrative Region, China
| | - Juliana de Oliveira Costa
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Sallie-Anne Pearson
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Nina Pil Hostrup Nielsen
- Center for Child and Adolescent Psychiatry, Mental Health Services of the Capital Region, Glostrup, Denmark
| | - Harold Snieder
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Theresa Wimberley
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark; Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
| | - Ian Ck Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong Special Administrative Region, China; Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK; Laboratory of Data Discovery for Health, Hong Kong Special Administrative Region, China; Aston Pharmacy School, Aston University, Birmingham, UK
| | - Le Zhang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Helga Zoega
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Kari Klungsøyr
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Department of Health Promotion, Norwegian Institute of Public Health, Bergen, Norway
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
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Dyresen A, Stubberud J, Fjermestad KW, Haugen I, Øie MG. Executive control training for adolescents with ADHD: Study protocol for a randomised controlled trial. Contemp Clin Trials 2024; 136:107404. [PMID: 38070766 DOI: 10.1016/j.cct.2023.107404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/18/2023] [Accepted: 12/02/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most prevalent neurodevelopmental conditions diagnosed during childhood and adolescence. In addition to the commonly observed symptoms of inattention, hyperactivity, and impulsivity, individuals with ADHD often experience impairments in executive functions (EFs). Goal management training (GMT) is a cognitive remediation intervention targeting EFs, with empirical support from studies with adult populations, including ADHD. The objective of the upcoming trial is to assess the effectiveness of GMT for adolescents with ADHD. METHODS This pre-registered protocol outlines a multi-centre randomised controlled trial (RCT) comparing GMT to treatment as usual (TAU) to improve EFs. We aim to recruit 120 participants, aged 12 to 18 years, recently diagnosed with ADHD. Participants will be randomly allocated to the group-based GMT intervention in addition to TAU, or the TAU condition, through block randomisation with site stratification. GMT will be delivered in groups of four to six participants, with weekly two-hour sessions for seven weeks, complemented by separate parent and teacher sessions. TAU is standard community mental health treatment. The primary outcome measure will be parent-reported EF assessed with the Behaviour Rating Inventory of Executive Function 2 (BRIEF-2). Secondary outcomes will include ADHD symptom measures, social functioning, quality of life, and neuropsychological tests (attention span, inhibition, working memory, and visuo-motor speed). The outcome assessments will be conducted at baseline, 12 weeks, 12 months, and 24 months post-treatment. CONCLUSION The study findings will contribute to determine the effectiveness of a non-pharmacological ADHD treatment, including outcome trajectories up to 24 months post-treatment.
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Affiliation(s)
- Agnete Dyresen
- Department of Psychology, University of Oslo, Norway; Lovisenberg Diaconal Hospital, Nic Waals Institute, Oslo, Norway.
| | - Jan Stubberud
- Department of Psychology, University of Oslo, Norway; Department of Research, Lovisenberg Diaconal Hospital, Norway
| | - Krister Westlye Fjermestad
- Department of Psychology, University of Oslo, Norway; Frambu Resource Centre for Rare Disorders, Siggerud, Norway
| | | | - Merete Glenne Øie
- Department of Psychology, University of Oslo, Norway; Innlandet Hospital Trust, Norway
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Roberti E, Scarpellini F, Campi R, Giardino M, Clavenna A, Bonati M. Transitioning to adult mental health services for young people with ADHD: an Italian-based survey on practices for pediatric and adult services. Child Adolesc Psychiatry Ment Health 2023; 17:131. [PMID: 38017552 PMCID: PMC10685479 DOI: 10.1186/s13034-023-00678-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/20/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Supporting young ADHD patients in transition to adult services is essential. Yet, the low percentages of successful referrals and the issues reported by patients and clinicians stress the need for further attention to transitioning practices. The present study assessed the transitioning process of Attention-Deficit/Hyperactivity Disorder (ADHD) patients in Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) in the Italian territory. We asked child and adult psychiatrists to report the current state of services and their observations on limitations and possible future matters that must be addressed. METHOD Seventy-seven centers (42 CAMHS, 35 AMHS) filled in a web-based survey in which they reported the number of ADHD patients, how many transitioning patients they had within the past year, and how they structured transition. RESULTS A fragmented picture emerged from the survey. Lack of resources, training, and communication between services hinder the transition process, and many adult patients remain under CAMHS' care. While some services have a protocol, there is no structured guidance that can help improve integration and continuity of treatment. CONCLUSION The observed situation reflects a need for improvement and standard guidelines to enable a successful transition process, considering clinicians' and patients' necessities.
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Affiliation(s)
- Elisa Roberti
- Laboratory of Epidemiology of Developing Age, Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
| | - Francesca Scarpellini
- Laboratory of Epidemiology of Developing Age, Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
| | - Rita Campi
- Laboratory of Epidemiology of Developing Age, Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
| | - Michele Giardino
- Information Science for Clinical Knowledge Sharing Unit, Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Antonio Clavenna
- Laboratory of Epidemiology of Developing Age, Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
| | - Maurizio Bonati
- Laboratory of Epidemiology of Developing Age, Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy.
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Quintero J, Rodríguez-Quiroga A, Álvarez-Mon MÁ, Mora F, Rostain AL. Addressing the Treatment and Service Needs of Young Adults with Attention Deficit Hyperactivity Disorder. Child Adolesc Psychiatr Clin N Am 2022; 31:531-551. [PMID: 35697400 DOI: 10.1016/j.chc.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The transition from adolescence to adulthood is a complex period in which multiple changes take place (education, work, independent living, and social relations). This stage is especially difficult for adolescents suffering from attention deficit hyperactivity disorder (ADHD), who have to move on from child and adolescent mental health services to adult mental health services. This review analyzes developmental and environmental risk and protective factors as well as critical variables such as executive functioning and self-monitoring that influence the course of ADHD in transitional age youth and guide the priorities for an optimal transition of care. The influence of the COVID-19 pandemic is also discussed. We reflect on the unmet needs for an optimal transition of care and propose practice and policy recommendations to achieve this goal.
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Affiliation(s)
- Javier Quintero
- Psychiatry and Mental Health Department, Hospital Universitario Infanta Leonor, Avenida de la Gran Vía del Este 80, Madrid 20830, Spain; Department of Legal Medicine & Psychiatry, Complutense University, Spain.
| | - Alberto Rodríguez-Quiroga
- Psychiatry and Mental Health Department, Hospital Universitario Infanta Leonor, Avenida de la Gran Vía del Este 80, Madrid 20830, Spain; Department of Legal Medicine & Psychiatry, Complutense University, Spain
| | - Miguel Ángel Álvarez-Mon
- Psychiatry and Mental Health Department, Hospital Universitario Infanta Leonor, Avenida de la Gran Vía del Este 80, Madrid 20830, Spain; Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcala, 28801 Alcala de Henares, Spain; Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Fernando Mora
- Psychiatry and Mental Health Department, Hospital Universitario Infanta Leonor, Avenida de la Gran Vía del Este 80, Madrid 20830, Spain; Department of Legal Medicine & Psychiatry, Complutense University, Spain
| | - Anthony L Rostain
- Department of Psychiatry, Cooper Medical School of Rowan University, 401 Broadway, Camden, NJ 08103, USA
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