Empirically supported psychosocial treatments for attention deficit hyperactivity disorder

Improving the efficacy and effectiveness of evidence-based psychosocial interventions for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and impairing mental health disorder of childhood. Decades of empirical research has established a strong evidence-based intervention armamentarium for ADHD; however, limitations exist in regards to efficacy and effectiveness of these interventions. We provide an overview of select evidence-based interventions for children and adolescents, highlighting potential approaches to further improving the efficacy and effectiveness of these interventions. We conclude with broader recommendations for interventions, including considerations to moderators and under-explored intervention target areas as well as avenues to improve access and availability of evidence-based interventions through leveraging underutilized workforces and leveraging technology.

Reconceptualizing the approach to supporting students with attention-deficit/hyperactivity disorder in school settings

The long-term academic outcomes for many students with attention-deficit/hyperactivity disorder (ADHD) are strikingly poor. It has been decades since students with ADHD were specifically recognized as eligible for special education through the Other Health Impaired category under the Education for all Handicapped Children Act of 1975, and similarly, eligible for academic accommodations through Section 504 of the 1973 Rehabilitation Act. It is time to acknowledge that these school-policies have been insufficient for supporting the academic, social, and behavioral outcomes for students with ADHD. Numerous reasons for the unsuccessful outcomes include a lack of evidence-based interventions embedded into school approaches, minimizing the importance of the general education setting for promoting effective behavioral supports, and an over-reliance on assessment and classification at the expense of intervention. Contemporary behavioral support approaches in schools are situated in multi-tiered systems of support (MTSS); within this article we argue that forward-looking school policies should situate ADHD screening, intervention, and maintenance of interventions within MTSS in general education settings and reserve special education eligibility solely for students who require more intensive intervention. An initial model of intervention is presented for addressing ADHD within schools in a manner that should provide stronger interventions, more quickly, and therefore more effectively.

Incorporating emotion coaching into behavioral parent training program: evaluation of its effectiveness

Disruptive behaviors in childhood yield negative mental health outcomes. Both behavioral management and emotion coaching parenting programs were effective in reducing children's disruptive behaviors. This randomized control trial (RCT) study evaluated the effectiveness of a community clinic-based, parent training program that incorporated emotion coaching into behavioral training (BPEC) for 119 parents who expressed difficulty in handling their elementary school-aged children's disruptive behaviors. These parents were randomly assigned to the treatment group or waitlist control. Pre-tests, post-tests, and 3-month delayed post-tests were administered. Compared to those in the waitlist control group, participants in the BPEC group reported significantly (a) fewer child oppositional behaviors and ADHD symptoms and (b) more positive aspects of the parent-child relationship. Significant short-term effects were maintained after 3-month for parent-reported, child oppositional behaviors. Thus, BPEC effectively reduced the disruptive behaviors of children.

Use of School-Based Interventions for ADHD, Professional Support, and Burnout Symptoms among Teachers in Iceland

OBJECTIVE

Effective school-based interventions for youth with ADHD are critical to their success. We examined whether teacher application of such interventions and perceptions of professional support related to greater well-being, including fewer burnout symptoms.

METHOD

Teachers in primary schools in Iceland were invited to participate in an online survey, including questions about professional support and the Maslach Burnout Inventory (MBI). The sample comprised N = 592 (88.5% female) participants.

RESULTS

Regression analyses indicated that use of recommended ADHD interventions was positively associated with MBI-Personal Achievement (PA). Greater satisfaction with professional support related to lower MBI-Emotional Exhaustion and MBI-Depersonalization, and higher MBI-PA. Level of professional support was positively associated with use of recommended interventions.

CONCLUSION

Effective interventions and support for students with ADHD may enhance teacher well-being. Icelandic teachers require further training and professional support in best practices for ADHD, to help promote teacher and student success.

Single and Combined Effects of Multiple Intensities of Behavioral Modification and Methylphenidate for Children with ADHD in the Home Setting

Behavioral treatment, stimulants, and their combination are the recommended treatments for childhood attention-deficit/hyperactivity disorder (ADHD). The current study utilizes within-subjects manipulations of multiple doses of methylphenidate (placebo, 0.15, 0.30, and 0.60 mg/kg/dose t.i.d.) and intensities of behavioral modification (no, low, and high intensity) in the summer treatment program (STP) and home settings. Outcomes are evaluated in the home setting. Participants were 153 children (ages 5-12) diagnosed with ADHD. In alignment with experimental conditions implemented during the STP day, parents implemented behavioral modification levels in three-week intervals, child medication status varied daily, and the orders were randomized. Parents provided daily reports of child behavior, impairment, and symptoms and self-reported parenting stress and self-efficacy. At the end of the study, parents reported treatment preferences. Stimulant medication led to significant improvements across all outcome variables with higher doses resulting in greater improvement. Behavioral treatment significantly improved child individualized goal attainment, symptoms, and impairment in the home setting and parenting stress and self-efficacy. Effect sizes indicate that behavioral treatment combined with a low-medium dose (0.15 or 0.30 mg/kg/dose) of medication results in equivalent or superior outcomes compared to a higher dose (0.60 mg/kg/dose) of medication alone. This pattern was seen across outcomes. Parents overwhelmingly reported preferring treatment with a behavioral component as a first-choice treatment (99%). Results underscore the need to consider dosing as well as parent preference when utilizing combined treatment approaches. This study provides further evidence that combining behavioral treatment and stimulant medication may reduce the stimulant dose needed for beneficial effects.

Psychological Treatments for Hyperactivity and Impulsivity in Children with ADHD: A Narrative Review

Treatment of the ADHD types (hyperactive-impulsive, inattentive, and combined) in children has rarely been studied separately, although their prognostic courses differ widely. In addition, data show that improvements in hyperactivity/impulsivity are hard to achieve. Thus, we focused on treatments tailored to hyperactivity/impulsivity. We examined meta-analyses and systematic reviews within the inter- and intra-individual treatments and found that psychoeducation and training for parents, school-based interventions, reinforcement strategies, and neurofeedback consistently showed small to moderate effect sizes in reducing hyperactivity/impulsivity in children. Conversely, emotional self-regulation, social skills, and cognitive trainings showed unsatisfactory results. In summary, we found that the quality of usual care can be surpassed when the designated interventions are purposefully combined into a multimodal treatment program.

The Efficacy of Visual Activity Schedule Intervention in Reducing Problem Behaviors in Children With Attention-Deficit/Hyperactivity Disorder Between the Age of 5 and 12 Years: A Systematic Review

Objectives

Children with attention-deficit/hyperactivity disorder (ADHD) tend to be noisy and violate rules with their disruptive behaviors, resulting in greater difficulties with off-task behaviors and being at risk for social refusal. The visual activity schedule (VAS) intervention program is a frequently used method to teach multiple skills involving on-task, use of schedules, transition behaviors, social initiation, independent play skills, classroom skills, and academic skills. The current systematic review aimed to examine the efficacy of using VAS intervention in reducing problem behaviors in children with ADHD between 5 and 12 years of age.

Methods

Systematic searches were conducted using two electronic databases (PubMed and Scopus) to identify relevant studies published in English between 2010 and 2020. Four studies met the inclusion criteria: two studies examined the effect of schedule-based tasks and the use of an iPad on classroom skills, while the other two examined randomized clinical trials (RCTs) of psychosocial treatment for ADHD inattentive type and a cross-sectional study examined the impact of the group size on task behavior and work productivity in children with ADHD.

Results

The findings indicate that the interventions used in all four studies could lead to increased satisfaction among participants and parents, as well as a reduction in problem behavior. In terms of the research indicators, the RCT had low quality, while the others were of high quality.

Conclusion

A larger number of studies and the ADHD clinical population would help to increase the generalizability of future reviews of treatments in this context.

Developing the Evidence-Grading Tools and Process for the Complex Attention-Deficit/Hyperactivity Disorder Guideline

Clinical practice guidelines (CPGs) rely on a robust assessment of the quality of evidence supporting guideline recommendations. For the Society for Developmental and Behavioral Pediatrics (SDBP) CPG for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit Hyperactivity Disorder (ADHD), the nature of the evidence and resource constraints led the guideline panel to develop an innovative, yet rigorous, approach to evidence grading. This study will (1) describe the challenges of evidence grading for the SDBP Complex ADHD Guideline; (2) discuss the rationale, process, and tools developed to conduct evidence grading; and (3) report on the experiences and readiness of the volunteer reviewers with diverse background in research methodology to conduct evidence grading. This evidence review process may serve as an example of approaches that can be used by other groups tasked with evaluating the evidence in support of new CPGs.

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

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

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.

Outcomes of School-Home Intervention for Attention and Behavior Problems: Teacher Adherence Matters

This study evaluated the effects of teacher adherence to behavioral treatment on student outcomes. Eighty-four children (ages 7-11) completed a 12-week, collaborative school-home behavioral intervention designed for youth with significant attention-deficit/hyperactivity disorder symptoms and impairment. Teacher adherence was assessed via school mental health provider (SMHP) ratings and Daily Report Card (DRC) implementation. Pre- and post-treatment outcomes included parent and teacher ratings of organizational skills and problem behaviors, observational measures of classroom task engagement and off task behaviors and report card standard grades. Using multi-level models to account for clustering by school, teacher adherence rated by SMHPs predicted improvement across teacher- and parent-rated organizational skills, parent-rated problem behaviors, and classroom observations of task engagement and off-task behavior. Higher rates of DRC implementation only predicted improvements in parent-rated organizational skills; percentage of days parents signed the DRC only predicted teacher-rated improvement in organizational skills. Post-hoc analyses indicated that teacher adherence and child success with academic targets on the DRC during the first month predicted parent-rated improvement in organizational skills. These results suggest that teacher adherence, particularly when rated by SMHPs, is an important predictor of positive treatment outcomes across both school and home settings. Future research is needed to better understand methods for measuring and optimizing teacher adherence to classroom behavioral interventions.

Impulsive and Omission Errors: Potential Temporal Processing Endophenotypes in ADHD

Temporal processing (TP) is associated with functions such as perception, verbal skills, temporal perspective, and future planning, and is intercorrelated with working memory, attention, and inhibitory control, which are highly impaired in individuals with attention deficit hyperactivity disorder (ADHD). Here we evaluate TP measures as potential endophenotypes in Caribbean families ascertained from probands affected by ADHD. A total of 232 individuals were recruited and clinically evaluated using an extensive battery of neuropsychological tasks and reaction time (RT)-based task paradigms. Further, the heritability (genetic variance underpinning phenotype) was estimated as a measure of the genetics apportionment. A predictive framework for ADHD diagnosis was derived using these tasks. We found that individuals with ADHD differed from controls in neuropsychological tasks assessing mental control, visual-verbal memory, verbal fluency, verbal, and semantic fluency. In addition, TP measures such as RT, errors, and variability were also affected in individuals with ADHD. Moreover, we determined that only omission and commission errors had significant heritability. In conclusion, we have disentangled omission and commission errors as possible TP endophenotypes in ADHD, which can be suitable to assess the neurobiological and genetic basis of ADHD. A predictive model using these endophenotypes led to remarkable sensitivity, specificity, precision and classification rate for ADHD diagnosis, and may be a useful tool for patients' diagnosis, follow-up, and longitudinal assessment in the clinical setting.

Knowledge and attitude of Attention-Deficit and Hyperactivity Disorder (ADHD) among male primary school teachers, in Riyadh City, Saudi Arabia

Objective:

The aim of this study was to explore teachers' knowledge about the ADHD, its origin, causes, and identify the main demographic variables affecting their knowledge.

Methods:

The study was conducted among male school teachers of ten government primary schools that are found in different regions of Riyadh city, the Kingdom of Saudi Arabia. We used a stratified random sampling technique to collect our sample with inclusion criteria of being male teachers who currently working in male government primary school and are directly involved on teaching of students. Data analysis was performed using SPSS software statistical program version 21.

Results:

We received 400 response for our questionnaire, mostly younger than 40 years old. Most of teachers in this sample had a bachelor's degree, only 6% had diploma while 8% had a higher degree, while most of them had experience more than 5 years in teaching (74.2%). only 8%of teachers admitted that they had not heard about ADHD before. 78% of teachers had read about ADHD at least once before. This knowledge was more from reading books (32.8%) followed by reading internet websites (28.7%), TV/Media (14.6%) while magazine and social media represent (23.9%). Most of the teachers showed that they had attended courses/training about ADHD (76.7%) however only 40.4% of them thought that they had the enough information about the disease. 51.5% of teachers showed that they had already asked before to assess a child who was suspected to have ADHD and 65.3% had taught a child with the disease.

Conclusion:

From the results of this study, it is concluded that the knowledge regarding ADHD among elementary school teachers is suboptimal. Some teachers had misunderstanding about ADHD symptoms and general information, which indicated the further needing for courses to enhance this knowledge.

Do Athletes Have More of a Cognitive Profile with ADHD Criteria than Non-Athletes?

The current study investigates the possibility that athletes have more parallel ADHD symptoms than non-athletes. High-level youth sport athletes were compared with non-athletes in leisure time (i.e., sport) and in the school in ADHD symptoms. Athletes and students were evaluated by a trained psychotherapist using Adult ADHD Self-Report Scale (ASRS) on activities at school and during activities in leisure/sports time. They also filled in the Autism Spectrum Questionnaire (AQ) as a self-report assessment. Results showed significant differences in ASRS-scores for athletes in school and in their sport, with high scores in school and low scores in sport. No differences were found in AQ between the groups. The findings indicate that many athletes might display a cognitive profile of parallel of ADHD criteria. Future research needs to further investigate potential benefits of the cognitive profile in athletes and how they handle different contexts including sport and school settings.

Prioritising Targets for School-Based ADHD Interventions: A Delphi Survey

Many studies have investigated the effectiveness of school-based ADHD interventions at modifying different social, emotional and behavioural target outcomes. However, there is a lack of evidence about which targets stakeholders perceive to be most important. This study sought to obtain consensus on which outcomes are perceived to be most important. A total of 114 people with ADHD, educational professionals, parents of children with ADHD, clinicians and researchers participated in a Delphi survey with 3 rounds. The importance of 52 intervention targets was rated on a scale from 0 to 8 (8 being extremely important). Consensus was reached if >70% of a stakeholder group rated a target as between 6–8 and <15% rated it as 0–2. Targets were dropped from subsequent rounds if more than 50% of stakeholder groups rated it as 0–5. Targets that all four stakeholder groups reached consensus on in any round were automatically included in our final outcome set. Comments were analysed using Thematic Analysis. All four stakeholder groups reached consensus on the importance of seven targets: ability to pay attention, conflict with teachers and peers, executive functioning, global functioning and quality of life, inattention symptoms, organisation skills and self-esteem. Four overarching themes were identified: Complexity of ADHD, Relationships, School Context, and What ADHD means to me. School-based ADHD interventions should target outcomes identified as most important to those who stand to benefit from such interventions. Some outcomes prioritised by our participants have not yet been targeted in school-based ADHD interventions. Implications of our findings for intervention and research design are discussed.

The Effectiveness of Daily Behavior Report Cards for Children With ADHD: A Meta-Analysis

Objective: This meta-analysis examined group-design studies investigating the effectiveness of Daily Behavior Report Cards (DBRC) as a school-based intervention to manage the classroom behavior of students with ADHD. Methods: A search of three article databases (PsycINFO, ERIC and Medline) identified seven group design evaluations of DBRC interventions. This meta-analysis included a total of 272 participants, with an average age of 7.9 years old. Three of the studies compared a control group to a treatment group with randomized group assignment, one study compared a control group to three treatment groups, two studies compared pre-and post-treatment scores in the same group, and one study compared pre-and post-treatment results of two intervention groups without random assignment. Dependent measures for these studies were teacher ratings (n = 5) and systematic direct observation of student academic and social behaviour (n = 2). Standardized mean differences (Hedge's g) were calculated to obtain a pooled effect size using fixed effects. Results: DBRCs were associated with reductions teacher-rated ADHD symptoms, with a Hedge's g of 0.36 (95% CI: 0.12-0.60, z=2.93, p ≤ .005) with low heterogeneity (Q-value: 2.40, I² = 0.00). This result excluded two studies that used observational coding instead of standardized tests to evaluate the effects of the intervention. A moderator analysis indicated that the effect size for systematic direct observation was large (Hedge's G = 1.05[95% CI: 0.66-1.44, z=5.25, p ≤ .00]), with very high heterogeneity (Q-value: 46.34, I²: 93.53). A second moderator analysis found differences in the effects of DBRCs for comorbid externalizing symptoms with an overall effect size of 0.34 (95%CI: -0.04-0.72, z=1.76 p =0.08) with high heterogeneity (Q-value: 3.98, I²: 74.85). Conclusions: DBRCs effectively reduce the frequency and severity of ADHD symptoms in classroom settings. Additionally, they have a significant effect on co-occuring externalizing behaviors. It appears that systematic direct observation may be a more sensitive measure of treatment effects compared to teacher ratings of ADHD symptoms.

A Preliminary Evaluation of the Utility of Sluggish Cognitive Tempo Symptoms in Predicting Behavioral Treatment Response in Children with Behavioral Difficulties

Interest in symptoms of sluggish cognitive tempo (SCT) has led to a number of studies evaluating how these symptoms respond to treatment commonly utilized in youths with symptoms of ADHD. No study to date, however, has examined the extent to which symptoms of SCT predict behavioral treatment response in youths across multiple domains of functioning. The current preliminary investigation integrates a number of methodological (e.g., direct observations) and analytic (e.g., Poisson regression) refinements to evaluate the extent to which symptoms of SCT predict treatment responses across multiple domains including behavioral (e.g., interruptions, rule violations), social (e.g., social skills, negative verbalizations), and severe behavioral difficulties (e.g., intentional aggression) above and beyond other demographic characteristics (e.g., symptom severity, Full Scale Intelligence Quotient [FSIQ]). A relatively small sample of 37 children, aged six to 12 years (M = 8.03, SD = 1.83, 35 males: 2 females) attending an eight week multi-component intensive behavioral treatment program for youths with behavioral difficulties participated in the current study. Baseline parental perceptions of SCT were collected prior to the initiation of treatment. Results from this preliminary investigation revealed that pre-treatment SCT symptoms only predicted a less robust treatment response to time out which was associated also with parent's perceptions of underlying working memory problems. Results revealed also that pre-treatment SCT symptoms failed to predict paraprofessional counselor's and teacher's improvement ratings of both rule following and social skills following treatment. Notably, other potential predictors (e.g., symptom severity, FSIQ) also largely failed to predict behavioral treatment response.

The Transition of Youth with ADHD into the Workforce: Review and Future Directions

Previous research suggests that a majority of children with attention-deficit/hyperactivity disorder (ADHD) continue to experience increased impairment across multiple life domains into adulthood. A systematic review of the occupational impairments, and associated educational and financial difficulties, faced by individuals with childhood ADHD was conducted. Systematic searches from PsycINFO and PubMed databases and other sources (i.e., books and consultants with experts) yielded 35 relevant articles that described 19 longitudinal studies on adults with a history of ADHD or related symptoms. Multiple studies indicated that those with a history of ADHD had more educational impairment and were less likely to graduate from high school and college than their peers without a history of ADHD. Subsequently, they faced lower occupational attainment, had more job instability, and demonstrated more impaired job performance, and these outcomes were largely consistent regardless of sex, medication history, or symptom persistence. Similar results were found in clinical and representative national studies in both U.S. and abroad, although older studies tended to indicate less occupational impairment. In addition, ADHD was associated with a number of financial challenges, including lower annual income, more reliance on public aid, and increased risk for homelessness. Future research should use more varied informant sources and utilize innovative measures of occupational impairment at both a macro- and micro-level of analyses. In addition, studies of effective supports and interventions in occupational settings for individuals with ADHD are needed.

A Randomized Controlled Trial of an Integrated Brain, Body, and Social Intervention for Children With ADHD

Objective: This study evaluated the efficacy of an Integrated Brain, Body, and Social (IBBS) intervention for children with ADHD. Treatment consisted of computerized cognitive remediation training, physical exercises, and a behavior management strategy. Method: Ninety-two children aged 5 to 9 years with ADHD were randomly assigned to 15 weeks of IBBS or to treatment-as-usual. Primary outcome measures included blinded clinician ratings of ADHD symptoms and global clinical functioning. Secondary outcome measures consisted of parent and teacher ratings of ADHD and neurocognitive tests. Results: No significant treatment effects were found on any of our primary outcome measures. In terms of secondary outcome measures, the IBBS group showed significant improvement on a verbal working memory task; however, this result did not survive correction for multiple group comparisons. Conclusion: These results suggest that expanding cognitive training to multiple domains by means of two training modalities does not lead to generalized improvement of ADHD symptomatology.

Non-pharmacologic management of attention-deficit/hyperactivity disorder in children and adolescents: a review

Attention-deficit/hyperactivity disorder (ADHD) is a very common neurobehavioral disorder that affects children and adolescents with impact that persists beyond adolescence into adulthood. Medication and non-pharmacological treatments are evidence-based interventions for ADHD in various age groups, and this article will elaborate on the psychosocial, physical and integrative medicine interventions that have been studied in ADHD.

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.

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Attention-deficit/hyperactivity disorder (ADHD) is 1 of the most common neurobehavioral disorders of childhood and can profoundly affect children's academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for evaluation and diagnosis of pediatric ADHD in 2000; recommendations for treatment followed in 2001. The guidelines were revised in 2011 and published with an accompanying process of care algorithm (PoCA) providing discrete and manageable steps by which clinicians could fulfill the clinical guideline's recommendations. Since the release of the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders has been revised to the fifth edition, and new ADHD-related research has been published. These publications do not support dramatic changes to the previous recommendations. Therefore, only incremental updates have been made in this guideline revision, including the addition of a key action statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying process of care algorithm has also been updated to assist in implementing the guideline recommendations. Throughout the process of revising the guideline and algorithm, numerous systemic barriers were identified that restrict and/or hamper pediatric clinicians' ability to adopt their recommendations. Therefore, the subcommittee created a companion article (available in the Supplemental Information) on systemic barriers to the care of children and adolescents with ADHD, which identifies the major systemic-level barriers and presents recommendations to address those barriers; in this article, we support the recommendations of the clinical practice guideline and accompanying process of care algorithm.

Efficacy of behavioral classroom programs in primary school. A meta-analysis focusing on randomized controlled trials

OBJECTIVE

This meta-analysis evaluated the efficacy of behavioral classroom programs on symptoms of Attention-deficit Hyperactivity Disorder or Oppositional Defiant and/or Conduct Disorder in primary school children.

METHOD

Online database searches (in PubMed, Embase, Psycinfo, and Eric) yielded nineteen randomized controlled trials (N = 18,094), comparing behavioral classroom programs (including multimodal programs involving a classroom program) to no treatment/treatment as usual. Random-effects meta-analyses were conducted for teacher-rated and classroom-observed disruptive classroom behavior and for classroom-observed on-task behavior. Post-hoc analyses investigated whether effects depended on type and severity of problem behavior. Meta-regressions studied the moderating effects of age, gender, and intervention duration.

RESULTS

Small positive effects were found on teacher-rated disruptive behavior (d = -0.20) and classroom-observed on-task behavior (d = 0.39). Program effects on teacher-rated disruptive behavior were unrelated to age, gender, type and severity, but negatively associated with intervention duration (R2 = 0.43).

CONCLUSION

Behavioral classroom programs have small beneficial effects on disruptive behavior and on-task behavior. Results advocate universal programs for entire classrooms to prevent and reduce disruptive classroom behavior.

Functional Impairment Variability in Children With ADHD Due to Emotional Impulsivity

OBJECTIVE

The present study utilized ecological momentary assessment (EMA) to examine the effects of emotional impulsivity on overall functional impairment and functional impairment variability (FIV) of children with and without ADHD.

METHOD

Parents of 74 children, 8- to 12-year-olds (42 with ADHD, 32 without ADHD), completed EMA assessment protocol ratings of their child's mood (3 times daily) and functional impairment (1 time daily) over the course of 28 days.

RESULTS

Hierarchical regression analyses supported the interaction of ADHD diagnostic status and greater EMA-derived emotional impulsivity in the estimation of total functional impairment (Total FI) and FIV. Thus, greater emotional impulsivity was found to be related to greater Total FI and FIV among children with ADHD but not among children without ADHD.

CONCLUSION

This study suggests that children with ADHD and greater emotional impulsivity demonstrate greater overall levels of functional impairment, with the severity of their impairment varying significantly over time.

Development and Validation of a Functional Behavioural Assessment Ontology to Support Behavioural Health Interventions

Background

In the cognitive-behavioral approach, Functional Behavioural Assessment is one of the most effective methods to identify the variables that determine a problem behavior. In this context, the use of modern technologies can encourage the collection and sharing of behavioral patterns, effective intervention strategies, and statistical evidence about antecedents and consequences of clusters of problem behaviors, encouraging the designing of function-based interventions.

Objective

The paper describes the development and validation process used to design a specific Functional Behavioural Assessment Ontology (FBA-Ontology). The FBA-Ontology is a semantic representation of the variables that intervene in a behavioral observation process, facilitating the systematic collection of behavioral data, the consequential planning of treatment strategies and, indirectly, the scientific advancement in this field of study.

Methods

The ontology has been developed deducing concepts and relationships of the ontology from a gold standard and then performing a machine-based validation and a human-based assessment to validate the Functional Behavioural Assessment Ontology. These validation and verification processes were aimed to verify how much the ontology is conceptually well founded and semantically and syntactically correct.

Results

The Pellet reasoner checked the logical consistency and the integrity of classes and properties defined in the ontology, not detecting any violation of constraints in the ontology definition. To assess whether the ontology definition is coherent with the knowledge domain, human evaluation of the ontology was performed asking 84 people to fill in a questionnaire composed by 13 questions assessing concepts, relations between concepts, and concepts’ attributes. The response rate for the survey was 29/84 (34.52%). The domain experts confirmed that the concepts, the attributes, and the relationships between concepts defined in the FBA-Ontology are valid and well represent the Functional Behavioural Assessment process.

Conclusions

The new ontology developed could be a useful tool to design new evidence-based systems in the Behavioral Interventions practices, encouraging the link with other Linked Open Data datasets and repositories to provide users with new models of eHealth focused on the management of problem behaviors. Therefore, new research is needed to develop and implement innovative strategies to improve the poor reproducibility and translatability of basic research findings in the field of behavioral assessment.

Social Skills Training and ADHD-What Works?

PURPOSE OF REVIEW

Many children and adolescents with attention-deficit/hyperactivity disorder (ADHD) have difficulties in their social skills and peer relationships. Because social problems exacerbate later maladjustment in ADHD populations, it is important to address this serious impairment. Although social skills training (SST) is a common intervention approach, evidence to date suggests that SST has limited efficacy, at least when provided in traditional, clinic-based settings. The current review summarizes recent advances to traditional SST approaches that may potentially enhance their efficacy.

RECENT FINDINGS

We identify two promising directions in which SST may be modified to make it more efficacious for ADHD populations. The first direction involves providing increased reinforcement and reminders of appropriate social behavior at the point of performance to youth with ADHD (e.g., in vivo, in real life peer situations as opposed to in the clinic). We note the importance of ensuring that youth with ADHD are receptive to such reminders. The second direction involves encouraging peers to be more socially accepting and inclusive of youth with ADHD. This avenue has been understudied in the literature to date. SST for children and adolescents with ADHD may be enhanced by providing more in vivo reminders and feedback at the point of performance and by making efforts to alter peers' impressions about youth with ADHD.

Relationship between parenting stress and informant discrepancies on symptoms of ADHD/ODD and internalizing behaviors in preschool children

Parent and teacher ratings of child behaviors are often discrepant, and these discrepancies may be correlated with parenting stress. The present study explored whether various parenting stress factors are associated with discrepancies between parent and teacher ratings of attention-deficit/hyperactivity disorder and oppositional defiant disorder (ODD) as well as internalizing symptoms in preschool children. We recruited 299 Taiwanese preschool children (aged 4-6 years) from the community or via clinical referrals. A structural equation modeling was used to analyze the relationships among three factors derived from the Parenting Stress Index-Short Form and informant discrepancies on symptoms of inattention, hyperactivity/impulsivity, ODD, and internalizing behaviors. Scores reported by parents were higher for each of the symptoms examined than those reported by teachers, and the degree of agreement between informants ranged from low to moderate. The parental distress factor of parenting stress was associated only with parent ratings, whereas other factors of parenting stress-parent-child dysfunctional interaction and parents' stress resulted from their child's temperament-were correlated with both parent and teacher ratings. Only parental distress factor predicted informant discrepancies for all behavioral symptoms assessed. Our findings suggest that parental distress should be considered when parent rating scores show significant discrepancies from that of teacher rating scores.

The Zappel-Philipp a historical example of ADHD Clinics

In his book "Die Geschichte von dem Zappel-Philipp," the German psychiatrist Heinrich Hoffmann (1809-1894) offers a clinical vignette which raises the question of the description of a disobedient child or presenting hyperactivity symptoms. This article describes the historical context and the biographical aspects related to this interesting approach to describing a psychiatric syndrome to children and adults. It also underlines the importance of a global approach of ADHD that considers the familial environment and situational context of symptoms.

The Children's Attention-Deficit Hyperactivity Disorder Telemental Health Treatment Study: Caregiver Outcomes

The Children's Attention-deficit Hyperactivity Disorder (ADHD) Telemental Health Treatment Study (CATTS) tested the hypotheses that children and caregivers who received guideline-based treatment delivered through a hybrid telehealth service delivery model would experience greater improvements in outcomes than children and caregivers receiving treatment via a comparison delivery model. Here, we present caregiver outcomes. 88 primary care providers (PCPs) in seven geographically underserved communities referred 223 children (ages 5.5 - 12.9 years) to the randomized controlled trial. Over 22 weeks, children randomized to the CATTS service delivery model received six sessions of telepsychiatry and six sessions of caregiver behavior management training provided in person by community therapists who were trained and supervised remotely. Children randomized to the comparison Augmented Primary Care (APC) service model received management in primary care augmented by a single telepsychiatry consultation. Caregiver outcomes included changes in distress, as measured by the Patient Health Questionnaire (PHQ-9), Parenting Stress Index (PSI), Caregiver Strain Questionnaire (CSQ) and Family Empowerment Scale (FES). Caregivers completed five assessments. Multilevel mixed effects regression modeling tested for differences between the two service delivery models in caregiver outcomes from baseline to 25 weeks. Compared to caregivers of children in the APC model, caregivers of children in the CATTS service model showed statistically significantly greater improvements on the PHQ-9 (β = -1.41, 95 % CI = [-2.74, -0.08], p < .05), PSI (β = -4.59, 95 % CI = [-7.87, - 1.31], p < .001), CSQ (β = -5.41, 95 % CI = [- 8.58, -2.24], p < .001) and FES (β = 6.69, 95 % CI = [2.32, 11.06], p < .01). Improvement in child ADHD symptoms mediated improved caregiver scores on the PSI and CSQ. Improvement in child ODD behaviors mediated caregiver CSQ scores. The CATTS trial supports the effectiveness of a hybrid telehealth service delivery model for reducing distress in caregivers of children with ADHD and suggests a mechanism through which the service model affected caregiver distress.

Racial and Ethnic Differences in ADHD Treatment Quality Among Medicaid-Enrolled Youth

OBJECTIVES

We estimated racial/ethnic differences in attention-deficit/hyperactivity disorder (ADHD) care quality and treatment continuity among Medicaid-enrolled children.

METHODS

Using Medicaid data from 9 states (2008 to 2011), we identified 172 322 youth (age 6 to 12) initiating ADHD medication. Outcome measures included: (1) adequate follow-up care in the (a) initiation and (b) continuation and maintenance (C&M) treatment phases; (2) combined treatment with medication and psychotherapy (versus medication alone); (3) medication discontinuation; and (4) treatment disengagement (ie, discontinued medication and received no psychotherapy). Logistic regressions controlled for confounding measures.

RESULTS

Among those initiating medication, three-fifths received adequate follow-up care in the initiation and C&M phases, and under two-fifths received combined treatment. Compared with whites, African American youth were less likely to receive adequate follow-up in either phase (P < .05), whereas Hispanic youth were more likely to receive adequate follow-up in the C&M phase (P < .001). African American and Hispanic youth were more likely than whites to receive combined treatment (P < .05). Over three-fifths discontinued medication, and over four-tenths disengaged from treatment. Compared with whites, African American and Hispanic children were 22.4% and 16.7% points more likely to discontinue medication, and 13.1% and 9.4% points more likely to disengage from treatment, respectively (P < .001).

CONCLUSIONS

Care quality for Medicaid-enrolled youth initiating ADHD medication is poor, and racial/ethnic differences in these measures are mixed. The most important disparities occur in the higher rates of medication discontinuation among minorities, which translate into higher rates of treatment disengagement because most youth discontinuing medication receive no psychotherapy.

Preliminary Efficacy of a Behavioral Parent Training Program for Children With ADHD in Pakistan

OBJECTIVE

In an effort to address the lack of evidence-based interventions for ADHD in developing South Asian countries, we examined the preliminary efficacy of a behavioral parent training program in Pakistan.

METHOD

A quasi-experimental design was utilized. Eighty-five 4- to 12-year-old children with clinically significant ADHD symptoms participated: 55 were recruited from hospital clinics (active treatment group) and 30 were recruited from schools (waitlist control group). Parent and teacher ratings of ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms and impairment were collected.

RESULTS

Using intent-to-treat analyses, the treatment group showed significant pre-post improvement on parent-reported ODD symptoms and ADHD-related impairment. Teacher ratings showed no improvement.

CONCLUSION

This study provides preliminary evidence for the feasibility and effectiveness of behavioral parenting training for children with ADHD in Pakistan and represents a critical first step in identifying evidence-based treatments for Pakistani children with ADHD.

Improving homework performance among children with ADHD: A randomized clinical trial

OBJECTIVE

Evidence indicates that children with Attention Deficit Hyperactivity Disorder (ADHD) experience acute and prolonged academic impairment and underachievement including marked difficulty with completing homework. This study is the first to examine the effects of behavioral, psychostimulant, and combined treatments on homework problems, which have been shown to predict academic performance longitudinally.

METHOD

Children with ADHD (ages 5-12, N = 75, 71% male, 83% Hispanic/Latino) and their families were randomly assigned to either behavioral treatment (homework-focused parent training and a daily report card; BPT + DRC) or a waitlist control group. Children also participated in a concurrent psychostimulant crossover trial conducted in a summer treatment program. Children's objective homework completion and accuracy were measured as well as parent-reported child homework behaviors and parenting skills.

RESULTS

BPT + DRC had large effects on objective measures of homework completion and accuracy (Cohen's ds from 1.40 to 2.21, ps < .001). Other findings, including unimodal medication and incremental combined treatment benefits, were not significant.

CONCLUSIONS

Behavioral treatment focused on homework problems results in clear benefits for children's homework completion and accuracy (the difference between passing and failing, on average), whereas long-acting stimulant medication resulted in limited and largely nonsignificant acute effects on homework performance. (PsycINFO Database Record

Practitioner Review: School-based interventions in child mental health

BACKGROUND

School-based interventions (SBIs) are well-established and effective treatments for improving child mental health. Specific school-based topics include prevention (Tier I-III) and interventions (e.g. cognitive-behavioural programmes and daily report cards).

METHODS

We performed a systematic literature search in five commonly used online databases (ERIC, MEDLINE, PsycARTICLES, PsycINFO and PSYNDEX) for English-language articles published between 1993 and 2015. Additional sources included reference lists of relevant articles and book chapters.

RESULTS

We identified a number of successful behavioural or cognitive-behavioural programmes yielding moderate to strong effects for a range of emotional and behavioural problems. The implementation of these programmes and the collaboration of the involved settings (school and home) and persons are important factors for their effectiveness under real-life conditions.

CONCLUSIONS

Effective SBIs are valuable tools for students with mental health problems if evidence-based cognitive-behavioural interventions are applied and rules of translational algorithms and implementation science are respected.

Evidence-Based Considerations and Recommendations for Athletic Trainers Caring for Patients With Attention-Deficit/Hyperactivity Disorder

CONTEXT

Patients with attention-deficit/hyperactivity disorder (ADHD) can be noncompliant, impulsive, and disruptive in an athletic training or physical rehabilitation facility. Athletic trainers (ATs) are valuable and essential health care providers for active patients with ADHD. However, for a patient with ADHD to have a successful outcome in a busy athletic training environment, the AT or health care provider must tailor the treatment setting to the patient's needs.

OBJECTIVE

To educate and raise awareness among ATs about patients with ADHD and to provide ATs with strategies and tools that will allow them to treat patients with ADHD more effectively.

DATA SOURCES

We retrieved and reviewed articles from PubMed, PsychINFO, and Ovid without date restrictions. Search words were attention deficit hyperactivity disorder plus 1 of the following topics or search words: athletic training, athletics, coaching, sport, or sport psychology.

STUDY SELECTION

Any ADHD articles that were not applicable or translatable in good faith to athletic training, physical rehabilitation, or sport and exercise were excluded.

DATA EXTRACTION

Nonpharmacologic interventions were reviewed and amassed into categories from which the recommendations were created. No statistical analyses were conducted for this review.

DATA SYNTHESIS

We identified 1241 articles, and 86 met the inclusion criteria. Five groups of evidence were observed: (1) goal setting and coaching, (2) reinforcements and outcomes, (3) routines and treatment timing, (4) simplified feedback and instructions, and (5) environmental control. Reliable evidence suggests that these techniques can be translated and applied within an athletic training and physical rehabilitation setting.

CONCLUSIONS

Athletic trainers are a vital component in providing health care for patients with ADHD. Using goal contagion creates a structured environment and positive reinforcements that accommodate patients with ADHD. Furthermore, ATs may use the evidence-based recommendations in this review to create a treatment and physical rehabilitation program and space that are tailored to the needs of the ADHD patient to increase the chance of a successful outcome.

The Application of Social Skills Training in the Treatment of a Child With Asperger's Disorder

Asperger's disorder was officially recognized by the American Psychological Association in 1994 with the inclusion of this disorder in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Consequently, it is not surprising that little research has been conducted on appropriate and effective treatments for this unique population. Treatments typically employed with children with Asperger's have been designed for children with autism. However, these populations do not have the same presenting problems, and thus it is necessary for treatments to be designed and empirically tested for children with Asperger's specifically. This case study describes the application of a social skills program to the treatment of a 10-year-old boy with Asperger's. Presenting problems, history, and assessment of the client are reviewed, the treatment program is explained, and the results of the treatment in both the short and long term are described. Finally, an evaluation of the treatment, implications for treatment, and recommendations for practitioners are included.

Comparative Cost Analysis of Sequential, Adaptive, Behavioral, Pharmacological, and Combined Treatments for Childhood ADHD

We conducted a cost analysis of the behavioral, pharmacological, and combined interventions employed in a sequential, multiple assignment, randomized, and adaptive trial investigating the sequencing and enhancement of treatment for children with attention deficit hyperactivity disorder (ADHD; Pelham et al., 201X; N = 146, 76% male, 80% Caucasian). The quantity of resources expended on each child's treatment was determined from records that listed the type, date, location, persons present, and duration of all services provided. The inputs considered were the amount of physician time, clinician time, paraprofessional time, teacher time, parent time, medication, and gasoline. Quantities of these inputs were converted into costs in 2013 USD using national wage estimates from the Bureau of Labor Statistics, the prices of 30-day supplies of prescription drugs from the national Express Scripts service, and mean fuel prices from the Energy Information Administration. Beginning treatment with a low-dose/intensity regimen of behavior modification (large-group parent training) was less costly for a school year of treatment ($961) than beginning treatment with a low dose of stimulant medication ($1,669), regardless of whether the initial treatment was intensified with a higher "dose" or if the other modality was added. Outcome data from the parent study (Pelham et al., 201X) found equivalent or superior outcomes for treatments beginning with low-intensity behavior modification compared to intervention beginning with medication. Combined with the present analyses, these findings suggest that initiating treatment with behavior modification rather than medication is the more cost-effective option for children with ADHD.

Treatment of Attention-Deficit/Hyperactivity Disorder in Preschool-Age Children: Child and Adolescent Psychiatrists' Adherence to Clinical Practice Guidelines

OBJECTIVES

To compare child and adolescent psychiatrists' (CAPs) practices in the treatment of preschool children with attention-deficit/hyperactivity disorder (P-ADHD) with published guidelines, and to determine which clinical factors most influence physicians' decisions to initiate pharmacotherapy for P-ADHD.

METHODS

We developed and mailed the Preschool ADHD Treatment Questionnaire (PATQ) to a randomly selected national sample of ∼2200 CAPs trained in the management of ADHD. The PATQ asked CAPs about their approach to clinical management of children ages 4-5 years with ADHD-specifically, how often they recommend parent training in behavior management, medication as a first- or second-line treatment, and which medication they typically choose first. CAPs also rated the perceived importance of 19 different clinical factors in their decision to initiate pharmacotherapy. These 19 factors reflected five child-centered areas of concern: ADHD risk factors, education concerns, social issues (SI), emotional stress, and physical safety (PS). The physicians were asked to rate each factor on a 4-point Likert scale from "not important" to "very important."

RESULTS

The final sample consisted of 339 board-certified CAPs. When adherence to the Academy of Child and Adolescent Psychiatry (AACAP) guidelines was defined as initial treatment with behavior management (not medication) and pharmacotherapy specifically with methylphenidate as second-line treatment, only 7.4% of CAPs followed clinical guidelines. Most physicians identified PS as an important or very important factor when initiating pharmacotherapy for P-ADHD (93.4%), followed by educational concerns (EC) (79.9%), emotional stress (69.6%), SI (52.8%), and the presence of risk factors for ADHD (32.7%).

CONCLUSIONS

The overwhelming majority of CAPs do not follow current AACAP guidelines for treatment of P-ADHD, especially regarding medication initiation and selection. When deciding whether to prescribe medication for P-ADHD, safety and EC were the most important and historical risk factors for ADHD were the least important clinical factors.