An innovative SMS intervention to improve adherence to stimulants in children with ADHD: Preliminary findings

Medication adherence and persistence in children and adolescents with attention deficit hyperactivity disorder (ADHD): a systematic review and qualitative update

Low medication-adherence and persistence may reduce the effectiveness of ADHD-medication. This preregistered systematic review (PROSPERO CRD42020218654) on medication-adherence and persistence in children and adolescents with ADHD focuses on clinically relevant questions and extends previous reviews by including additional studies. We included a total of n = 66 studies. There was a lack of consistency in the measurement of adherence/persistence between studies. Pooling the medication possession ratios (MPR) and using the most common adherence definition (MPR ≥ 80%) indicated that only 22.9% of participants had good adherence at 12-month follow-up. Treatment persistence on medication measured by treatment duration during a 12-month follow-up averaged 170 days (5.6 months). Our findings indicate that medication-adherence and persistence among youth with ADHD are generally poor and have not changed in recent years. Clinicians need to be aware that various factors may contribute to poor adherence/persistence and that long-acting stimulants and psychoeducational programs may help to improve adherence/persistence. However, the evidence to whether better adherence/persistence contributes to better long-term outcomes is limited and requires further research.

Phase-specific strategies and interventions to enhance medication adherence across different phases in ADHD: a systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis assessed the characteristics, types, and impact of interventions to improve adherence to attention-deficit hyperactivity disorder (ADHD) medications within the context of the three phases of adherence, namely, initiation, implementation, and discontinuation.

METHODS

PubMed, Psychological Information Database, Embase, International Pharmaceutical Abstracts, and Google Scholar were systematically searched for relevant trials using appropriate search terms. Interventions were classified as educational, behavioural, affective, and multifaceted. Data was pooled using odds ratios and proportions.

RESULTS

Seventeen studies were included in this review. In a pooled analysis of four RCTs, interventions did not significantly improve medication adherence (OR = 2.32; 95%-Confidence Interval=CI = 0.91-5.90; p = 0.08). In seven non-randomized trials, a pooled proportion of people who adhered to ADHD medication was considerably higher in the intervention group (85%, 95%CI = 78%-91%) than in the control group (47%, 95%CI = 33%-61%). Interventions varied in terms of study design, methods and their impact on different phases of adherence.

CONCLUSIONS

Despite some promising results, the lack of consideration of phase-specific adherence factors may limit the effectiveness and sustainability of interventions to improve adherence in clinical practice. Future interventions should be phase-specific, guided by factors which are pertinent to each phase. Meanwhile, clinicians should choose or tailor interventions based on individual needs and preferences.

In Memoriam: Professor Joseph Biederman's Contributions to Child and Adolescent Psychiatry

OBJECTIVE

To provide an overview of Joe Biederman's contributions to child and adolescent psychiatry.

METHOD

Nine colleagues described his contributions to: psychopharmacology, comorbidity and genetics, pediatric bipolar disorder, autism spectrum disorders, Tourette's and tic disorders, clinical and neuro biomarkers for pediatric mood disorders, executive functioning, and adult ADHD.

RESULTS

Joe Biederman left us with many concrete indicators of his contributions to child and adolescent psychiatry. He set up the world's first pediatric psychopharmacology clinic and clinical research program in child adolescent psychiatry. As a young faculty member he began a research program that led to many awards and eventual promotion to full professor at Harvard Medical School. He was for many years the most highly cited researcher in ADHD. He achieved this while maintaining a full clinical load and was widely respected for his clinical acumen.

CONCLUSION

The world is a better place because Joe Biederman was here.

Promoting Medication Adherence in Children with Attention Deficit Hyperactivity Disorder: A Mixed-Methods Systematic Review with Meta-analysis and Qualitative Comparative Analysis

OBJECTIVE

To evaluate the efficacy of ADHD medication adherence interventions and explore the pathways to effectiveness.

METHODS

A systematic review was conducted using multiple databases to identify relevant randomized controlled trials (RCTs). Pooled effect sizes were calculated for medication adherence and ADHD symptom outcomes. Qualitative Comparative Analysis (QCA) was used to identify pathways to effectiveness.

RESULTS

Six RCTs were included. The interventions significantly improved medication adherence (OR = 2.39, 95% CI [1.19, 4.79]) and ADHD symptoms (Hedges' g = -0.96, 95% CI [-1.38, -0.54]). Multi-regression analysis showed a positive relationship between medication adherence and ADHD symptom reduction. QCA revealed two paths for effectiveness: (1) Presence of ADHD drug education and absence of reminder and (2) Presence of tracking and absence of reminder.

CONCLUSION

ADHD medication adherence interventions have a positive impact on both medication adherence and ADHD symptoms. Interventions should consider including ADHD drug education or tracking to maximize effectiveness.

Effectiveness of Technology-Based Interventions for School-Age Children With Attention-Deficit/Hyperactivity Disorder: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is relatively common among school-age children. Technology-based interventions, such as computer-assisted training programs, neurofeedback training, and virtual reality, show promise in regulating the behaviors and cognitive functions of children with ADHD. An increasing number of randomized controlled trials have been conducted to evaluate the effectiveness of these technologies in improving the conditions of children with ADHD.

OBJECTIVE

This study aims to conduct a systematic review of technological interventions for school-age children with ADHD and perform a meta-analysis of the outcomes of technology-based interventions.

METHODS

A total of 19 randomized controlled studies involving 1843 participants were selected from a pool of 2404 articles across 7 electronic databases spanning from their inception to April 2022. ADHD behaviors, cognitive functions, learning ability, and quality of life were addressed in this study.

RESULTS

Random effects meta-analyses found that children with ADHD receiving technology-based intervention showed small and significant effect sizes in computer-rated inattention (standardized mean difference [SMD] -0.35; P<.04), parent-rated overall executive function measured by the Behavior Rating Inventory of Executive Function (SMD -0.35; P<.04), parent-rated disruptive behavior disorder measured by the Child Behavior Checklist (SMD -0.50; P<.001) and Disruptive Behavior Disorder Rating Scale (SMD -0.31; P<.02), and computer-rated visual attention measured by the Continuous Performance Test (SMD -0.42; P<.001) and Reaction Time (SMD -0.43; P<.02).

CONCLUSIONS

Technology-based interventions are promising treatments for improving certain ADHD behaviors and cognitive functions among school-age children with ADHD.

TRIAL REGISTRATION

PROSPERO CRD42023446924; https://tinyurl.com/7ee5t24n.

Transcranial Direct Current Stimulation vs Sham for the Treatment of Inattention in Adults With Attention-Deficit/Hyperactivity Disorder: The TUNED Randomized Clinical Trial

IMPORTANCE

Transcranial direct current stimulation (tDCS) may improve symptoms of inattention in adults with attention-deficit/hyperactivity disorder (ADHD). However, previous trials are characterized by small sample sizes, heterogeneous methodologies, and short treatment periods using clinic-based tDCS.

OBJECTIVE

To determine the efficacy and safety of home-based tDCS in treating inattention symptoms in adult patients with ADHD.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, parallel, sham-controlled clinical trial (tDCS for the Treatment of Inattention Symptoms in Adult Patients With ADHD [TUNED]), conducted from July 2019 through July 2021 in a single-center outpatient academic setting. Of 277 potential participants screened by phone, 150 were assessed for eligibility on site, and 64 were included. Participants were adults with ADHD, inattentive or combined subtype. Exclusion criteria included current stimulant drug treatment, current moderate to severe symptoms of depression or anxiety, diagnosis of bipolar disorder with a manic or depressive episode in the last year, diagnosis of schizophrenia or another psychotic disorder, and diagnosis of autism spectrum disorder; 55 of participants completed follow-up after 4 weeks.

INTERVENTIONS

Thirty-minute daily sessions of home-based tDCS for 4 weeks, 2 mA anodal-right and cathodal-left prefrontal stimulation with 35-cm2 carbon electrodes.

MAIN OUTCOMES AND MEASURES

Inattentive scores in the clinician-administered version of the Adult ADHD Self-report Scale version 1.1 (CASRS-I).

RESULTS

Included in this trial were 64 participants with ADHD (31 [48%] inattentive presentation and 33 [52%] combined presentation), with a mean (SD) age of 38.3 (9.6) years. Thirty participants (47%) were women and 34 (53%) were men. Fifty-five finished the trial. At week 4, the mean (SD) inattention score, as measured with CASRS-I, was 18.88 (5.79) in the active tDCS group and 23.63 (3.97) in the sham tDCS group. Linear mixed-effects models revealed a statistically significant treatment by time interaction for CASRS-I (βinteraction = -3.18; 95% CI, -4.60 to -1.75; P < .001), showing decreased symptoms of inattention in the active tDCS group over the 3 assessments compared to the sham tDCS group. Mild adverse events were more frequent in the active tDCS group, particularly skin redness, headache, and scalp burn.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, daily treatment with a home-based tDCS device over 4 weeks improved attention in adult patients with ADHD who were not taking stimulant medication. Home-based tDCS could be a nonpharmacological alternative for patients with ADHD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04003740.

A systematic review of interventions to enhance adherence and persistence with ADHD pharmacotherapy

Although high rates of poor adherence/persistence have been documented in ADHD, there is limited research targeting the problem. This systematic review evaluated interventions to address poor adherence/persistence to ADHD pharmacotherapy, with the aim of guiding the development of future interventions. An extensive search was conducted from January 1980 until January 2021. Thirteen studies were identified involving interventions based on psychoeducation, behavioural therapy, combined psychoeducation/behavioural therapy, technology-based interventions, written informed consent and a nursing support line. All 13 studies (including five RCTs) reported improvement in adherence/persistence and five studies (including four RCTs) also reported improvement in ADHD symptomatology. Almost all studies involved interventions utilising some form of education. Three RCTs of psychoeducation alone were included, with two of the three studies reporting adherence benefits at three and 12 months respectively. The third RCT was terminated early due to poor recruitment. A behavioural intervention RCT reported improved adherence six months post intervention (but not at 12 months), although a substantial drop-out rate was observed. A final included RCT used a Smartphone Application and reported a short term increase in adherence. The authors of the studies in this review make salient attempts at improving adherence and provide insight for future intervention development. We believe future interventions should involve combinations of strategies, have a theoretical framework and target the most common reasons for non-adherence. Interventions should also be integratable into routine care and include patient input to maximise sustainability.

Clinical Efficacy Evaluation of Psychological Nursing Intervention Combined with Drugs Treatment of Children with ADHD under Artificial Intelligence

ADHD in children is one of the most common neurodevelopmental disorders. It is manifested as inattention, hyperactivity, impulsiveness, and other symptoms that are inconsistent with the developmental level in different occasions, accompanied by functional impairment in social, academic, and occupational aspects. At present, the treatment for children with ADHD is mainly based on psychological nursing intervention combined with drug therapy. Therefore, the actual efficacy evaluation of this treatment regimen is very important. Neural networks are widely used in smart medical care. This work combines artificial intelligence with the evaluation of clinical treatment effects of ADHD children and designs an intelligent model based on neural networks for evaluating the clinical efficacy of psychological nursing intervention combined with drug treatment of children with ADHD. The main research is that, for the evaluation of clinical treatment effect of ADHD in children, this paper proposes a 1D Parallel Multichannel Network (1DPMN), which is a convolutional neural network. The results show that network models can extract different data features through different channels and can achieve high accuracy evaluation of clinical efficacy of ADHD in children. On the basis of the model, performance is improved through the study of Adam optimizer to speed up the model convergence, adopts batch normalization algorithm to improve stability, and uses Dropout to improve the generalization ability of the network. Aiming at the problem of too many parameters, the 1DPMN is optimized through the principle of local sparseness, and the model parameters are greatly reduced.

Digital Health Applications for Pharmacogenetic Clinical Trials

Digital health (DH) is the use of digital technologies and data analytics to understand health-related behaviors and enhance personalized clinical care. DH is increasingly being used in clinical trials, and an important field that could potentially benefit from incorporating DH into trial design is pharmacogenetics. Prospective pharmacogenetic trials typically compare a standard care arm to a pharmacogenetic-guided therapeutic arm. These trials often require large sample sizes, are challenging to recruit into, lack patient diversity, and can have complicated workflows to deliver therapeutic interventions to both investigators and patients. Importantly, the use of DH technologies could mitigate these challenges and improve pharmacogenetic trial design and operation. Some DH use cases include (1) automatic electronic health record-based patient screening and recruitment; (2) interactive websites for participant engagement; (3) home- and tele-health visits for patient convenience (e.g., samples for lab tests, physical exams, medication administration); (4) healthcare apps to collect patient-reported outcomes, adverse events and concomitant medications, and to deliver therapeutic information to patients; and (5) wearable devices to collect vital signs, electrocardiograms, sleep quality, and other discrete clinical variables. Given that pharmacogenetic trials are inherently challenging to conduct, future pharmacogenetic utility studies should consider implementing DH technologies and trial methodologies into their design and operation.