Interventions for preschool children at high risk for ADHD: a comparative effectiveness review

Systematic Review and Meta-Analysis: Attention-Deficit/Hyperactivity Disorder Symptoms in Children With Neurofibromatosis Type 1

OBJECTIVE

This meta-analysis aimed to robustly estimate differences in attention-deficit/hyperactivity disorder (ADHD) symptoms between children and adolescents with and without neurofibromatosis type 1 (NF1).

METHOD

Systematic literature searches were conducted in Scopus, PsycINFO, Web of Science, PubMed, and ProQuest in September 2022 with a supplemental search conducted in Google Scholar in February 2023. The searches identified 2153 unique articles. Screening identified 114 academic journal articles that assessed parent/caregiver- or teacher-reported ADHD symptoms for children/adolescents with NF1. Two researchers independently screened articles and extracted data. The primary outcome was group differences in ADHD symptoms between children/adolescents with and without NF1 (Hedges' g). Data were analyzed using robust variance estimation and random-effects models.

RESULTS

The meta-analysis included 70 studies (138 effect sizes), involving 3,653 children/adolescents with NF1 (46% female; Mage = 9.69 years, SD = 2.60 years) and 4,895 children/adolescents without NF1 (48% female; Mage = 10.03 years, SD = 3.10 years). According to parent/caregiver reports, children/adolescents with NF1 exhibited more severe inattentive symptoms (g = 1.20; 95% CI [1.06, 1.35]), hyperactive/impulsive symptoms (g = 0.85; 95% CI [0. 68, 1.03]), and combined ADHD symptoms (g = 1.02; 95% CI [0.87, 1.17]) than unaffected controls. Inattentive ADHD symptoms were more elevated than hyperactivity/impulsivity for children/adolescents with NF1. Larger effect sizes for inattention and hyperactivity/impulsivity were associated with older age, lower intelligence quotient (IQ), and parent/caregiver versus teacher reports.

CONCLUSION

NF1 is a monogenic condition that has strong associations with elevated ADHD symptoms. Findings highlight the importance of early intervention and targeted support for ADHD-related problems in children with NF1.

Electrophysiological functional connectivity and complexity reflecting cognitive processing speed heterogeneity in young children with ADHD

Early intervention is imperative for young children with attention-deficit/hyperactivity disorder (ADHD) who manifest heterogeneous neurocognitive deficits. The study investigated the functional connectivity and complexity of brain activity among young children with ADHD exhibiting a fast cognitive processing speed (ADHD-F, n = 26), with ADHD exhibiting a slow cognitive processing speed (ADHD-S, n = 17), and typically developing children (n = 35) using wireless electroencephalography (EEG) during rest and task conditions. During rest, compared with the typically developing group, the ADHD-F group displayed lower long-range intra-hemispheric connectivity, while the ADHD-S group had lower frontal beta inter-hemispheric connectivity. During task performance, the ADHD-S group displayed lower frontal beta inter-hemispheric connectivity than the typically developing group. The ADHD-S group had lower frontal inter-hemispheric connectivity in broader frequency bands than the ADHD-F group, indicating ADHD heterogeneity in mental processing speed. Regarding complexity, the ADHD-S group tended to show lower frontal entropy estimators than the typically developing group during the task condition. These findings suggest that the EEG profile of brain connectivity and complexity can aid the early clinical diagnosis of ADHD, support subgrouping young children with ADHD based on cognitive processing speed heterogeneity, and may contain specific novel neural biomarkers for early intervention planning.

Behavioral characteristics of toddlers later identified with an autism diagnosis, ADHD symptoms, or combined autism and ADHD symptoms

BACKGROUND

Autism commonly co-occurs with attention-deficit/hyperactivity disorder (ADHD), but less is known regarding how ADHD symptoms impact the early presentation of autism. This study examined early behavioral characteristics of a community sample of toddlers later identified with autism diagnosis, ADHD symptoms, combined autism and ADHD symptoms, or neither condition.

METHODS

Participants were 506 toddlers who were part of a longitudinal study of children's behavioral development. Parents completed questionnaires about their children's behavior at two time points. Four groups were identified based on study measures or medical record: autism diagnosis (n = 45), elevated ADHD symptoms (n = 70), autism and ADHD symptoms (n = 30), or neurotypical development (n = 361). Relationships between early parent report of autism- and ADHD-related behaviors, social-emotional and behavioral functioning, and caregiver experience and subsequent group designation were evaluated with adjusted linear regression models controlling for sex.

RESULTS

Significant group differences were found in measures of autism-related behaviors, ADHD-related behaviors, externalizing and internalizing behaviors, and parent support needs (p < .0001). Pairwise comparisons indicated toddlers later identified with combined autism diagnosis and ADHD symptoms had higher levels of autism-related behaviors, externalizing and internalizing behaviors, and autism-related parent support needs compared to the other groups. Toddlers with subsequent elevated ADHD symptoms or combined autism diagnosis and ADHD symptoms exhibited similar levels of ADHD-related behaviors, while both groups displayed more ADHD-related behaviors than toddlers subsequently identified with autism or those with neither condition.

CONCLUSIONS

In this community sample, toddlers for whom combined autism diagnosis and ADHD symptoms were subsequently identified showed a distinct presentation characterized by higher early autism-related behaviors, broader behavioral concerns, and higher parent support needs. Presence of ADHD symptoms (alone or in combination with autism) was associated with higher parent-reported ADHD-related behaviors during toddlerhood. Results indicate that ADHD-related behaviors are manifest by toddlerhood, supporting screening for both autism and ADHD during early childhood.

Telebehavioral Health for Caregivers of Children With Behavioral Health Needs to Address Caregiver Strain: Cohort Study

BACKGROUND

Behavioral health conditions among children have worsened over the past decade. Caregivers for children with behavioral health conditions are at risk for two types of caregiver strain: (1) an objective strain, that results directly from the child's condition and (2) subjective strain, that arises from the caregiver's feelings regarding these events.

OBJECTIVE

This study aimed to evaluate the impact of a technology-enabled pediatric and family behavioral health service on caregivers' strain among a commercially insured population. We also explore the common symptom clusters of caregiver strain to better understand the caregiver presentation to inform future care planning.

METHODS

We examined changes in caregiver strain using the Caregiver Strain Questionnaire-Short Form 7 over the course of their child's web-based behavioral health care between 2021 and 2023 using a pre-post study design. Common caregiver strain symptom clusters were identified using Ward hierarchical agglomerative clustering.

RESULTS

The majority of children were White 60.8% (1002/1647), female 53.6% (882/1647), and aged between 5 and 9 years (33.7%, 555/1647). Families fall broadly into 4 groups based on what drives caregiver strain the most, namely those experiencing (1) disrupted family relationships and time interruption, (2) missed work, (3) worried about their child's future and feeling tired and sad, and (4) financial strain. Caregiver strain, which was associated with the child's disease severity (P<.001), decreased significantly in all therapeutic groups.

CONCLUSIONS

Web-based family-oriented behavioral health care can improve caregiver strain and reduce family and time disruptions, missed work, and financial strain. Sources of caregiver strain vary and may be overlooked when relying on the conventional scoring of the Caregiver Strain Questionnaire-Short Form 7.

The Utility of a Novel Neuropsychological Measurement to Analyze Event-Related Attentional Behaviors among Young Children with Attention Deficit Hyperactivity Disorder-a Pilot Study

OBJECTIVE

The identification and diagnosis of children with attention deficit hyperactivity disorder (ADHD) traits is challenging during the preschool stage. Neuropsychological measures may be useful in early assessments. Furthermore, analysis of event-related behavior appears to be an unmet need for clinical treatment planning. Conners' Kiddie Continuous Performance Test (K-CPT) is the most popular well-established neuropsychological measurement but lacks event markers to clarify the heterogeneous behaviors among children. This study utilized a novel commercially available neuropsychological measure, the ΣCOG, which was more game-like and provided definite event markers of individual trial in the test.

METHODS

Thirty-three older preschool children (14 were diagnosed with ADHD, mean age: 66.21 ± 5.48 months; 19 demonstrated typical development, mean age: 61.16 ± 8.11 months) were enrolled and underwent comprehensive medical and developmental evaluations. All participants underwent 2 versions of neuropsychological measures, including the K-CPT, Second Edition (K-CPT 2) and the ΣCOG, within a short interval.

RESULTS

The study indicated the omissions and response time scores measured in this novel system correlated with clinical measurement of the behavioral scales in all participants and in the group with ADHD; additionally, associations with the traditional K-CPT 2 were observed in commissions and response time scores. Furthermore, this system provided a within-task behavioral analysis that identified the group differences in the specific trial regarding omission and commission errors.

CONCLUSIONS

This innovative system is clinically feasible and can be further used as an alternative to the K-CPT 2 especially in research by revealing within-task event-related information analysis.

Measuring quality-of-care in treatment of young children with attention-deficit/hyperactivity disorder using pre-trained language models

OBJECTIVE

To measure pediatrician adherence to evidence-based guidelines in the treatment of young children with attention-deficit/hyperactivity disorder (ADHD) in a diverse healthcare system using natural language processing (NLP) techniques.

MATERIALS AND METHODS

We extracted structured and free-text data from electronic health records (EHRs) of all office visits (2015-2019) of children aged 4-6 years in a community-based primary healthcare network in California, who had ≥1 visits with an ICD-10 diagnosis of ADHD. Two pediatricians annotated clinical notes of the first ADHD visit for 423 patients. Inter-annotator agreement (IAA) was assessed for the recommendation for the first-line behavioral treatment (F-measure = 0.89). Four pre-trained language models, including BioClinical Bidirectional Encoder Representations from Transformers (BioClinicalBERT), were used to identify behavioral treatment recommendations using a 70/30 train/test split. For temporal validation, we deployed BioClinicalBERT on 1,020 unannotated notes from other ADHD visits and well-care visits; all positively classified notes (n = 53) and 5% of negatively classified notes (n = 50) were manually reviewed.

RESULTS

Of 423 patients, 313 (74%) were male; 298 (70%) were privately insured; 138 (33%) were White; 61 (14%) were Hispanic. The BioClinicalBERT model trained on the first ADHD visits achieved F1 = 0.76, precision = 0.81, recall = 0.72, and AUC = 0.81 [0.72-0.89]. Temporal validation achieved F1 = 0.77, precision = 0.68, and recall = 0.88. Fairness analysis revealed low model performance in publicly insured patients (F1 = 0.53).

CONCLUSION

Deploying pre-trained language models on a variable set of clinical notes accurately captured pediatrician adherence to guidelines in the treatment of children with ADHD. Validating this approach in other patient populations is needed to achieve equitable measurement of quality of care at scale and improve clinical care for mental health conditions.

Is prevention of ADHD and comorbid conditions in adolescents possible?

OBJECTIVES

To examine how the concept of prevention is applicable to adolescent ADHD, which preventive interventions may be feasible, and which methods can be used to evaluate effectiveness.

METHOD

Following a literature search for prevention clinical trials relevant to adolescent ADHD, selected studies are critically reviewed to identify suitable targets and promising interventions.

RESULTS

There is some evidence from controlled studies that interventions delivered to prepubertal children at high risk for ADHD or diagnosed with ADHD may decrease the incidence or persistence of ADHD in adolescence. Uncontrolled follow-up of clinical samples and population studies suggest that treatment of adolescents with ADHD can decrease the risk for several negative functional outcomes in youth. A controlled trial found a specific cognitive training intervention to decrease risky driving.

CONCLUSIONS

Prevention of ADHD and associated negative outcomes is possible and of high clinical relevance. Assessing prevention effects is methodologically challenging, but feasible.

Comparison of brief group behavioural parent training with individual parent training for preschool children with attention deficit hyperactivity disorder: A randomized feasibility study

BACKGROUND

Behaviour parent training (BPT) is first-line treatment for preschool attention deficit hyperactivity disorder (ADHD). BPT in a group format can be a cost- and time-effective alternative in low and middle-income countries (LMIC) settings with limited resources. We conducted a randomized controlled trial to compare the feasibility and efficacy of group BPT with individual BPT in improving ADHD severity in the preschool age group over 12 weeks.

METHODS

After approval by the ethical committee, the study was conducted in the child guidance clinic, JIPMER. Fifty-six children aged 2.5 to 6 years diagnosed with ADHD according to DSM5 were recruited. Children with autism spectrum disorder and a social quotient less than 50 were excluded. Block randomization parallel design was done. Group interventions were delivered with 4-8 parents per group, focusing on psychoeducation, structuring of routine, attention enhancing tasks, behavioural parenting techniques, and TAU. ADHD severity was assessed using Conner's abbreviated behaviour rating scale at baseline, 4, 8, and 12 weeks. Parental stress was estimated by FISC-MR adapted for ADHD. Statistical analysis included repeated measures ANOVA.

RESULTS

Significant improvement was noticed for both groups (F = 20.261, p < .001, ES (η2 ) = 0.539). Group intervention was not inferior to individual BPT in reducing ADHD severity (F = 0.860, p = .468, ES (η2 ) = 0.047). There was a statistically significant difference from baseline to 12 weeks of intervention in the reduction of parental stress (F = 20.80, p < .001, ES (η2 ) = 0.278) and enhancement of the coping strategies (F = 64.4, (p < .001), ES (η2 ) = 0.78). The intervention had high attendance and fidelity rates.

CONCLUSION

Group BPT was promising in treating ADHD in low-resource settings.

Factors Influencing Long-Term Behavioral Intervention Outcomes in Preschool Children with Attention-Deficit Hyperactivity Disorder in Southeast China

Introduction

Previous studies have demonstrated the long-term effectiveness of behavioral interventions for attention-deficit hyperactivity disorder (ADHD) in preschool children. We continue to design a case‒control study to further investigate the factors influencing the long-term effect of behavioral intervention.

Methods

From May 2020 to August 2021, children who were newly diagnosed with ADHD and not receiving any treatment received a one-year behavioral intervention. A total of 86 children completed the behavioral intervention and assessment.

Results

50 children (58.140%) were in the effective group, and 36 children (41.860%) were in the ineffective group. Attention retention time (OR=0.559, 0.322-0.969), Swanson, Nolan, and Pelham total score (OR=1.186, 1.024-1.374) at baseline, performance score for parents (OR=0.631, 0.463-0.859), and teacher coordination (OR=0.032, 0.002-0.413) were the influencing factors of behavioral intervention effects. The area under the receiver operating curve was 0.979 (p<0.001). The comprehensive nomogram model showed that the discrimination and mean absolute error were 0.979 and 0.023, respectively.

Discussion

During behavioral intervention, the implementation skills of parents should be evaluated in a timely manner. The behavioral intervention effect can be predicted based on a child's attention retention time at baseline, teacher involvement, behavioral scale score, and performance score for parents, which can guide clinicians in adjusting personalized treatment plans and provide a basis for clinical decision-making. The treatment of ADHD in preschool children requires a systematic framework that integrates family, school, and society.

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015.

OBJECTIVES

To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate.

SELECTION CRITERIA

We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non-serious, general behaviour, and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel-group trials and first-period data from cross-over trials formed the basis of our primary analyses. We undertook separate analyses using end-of-last period data from cross-over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach.

MAIN RESULTS

We included 212 trials (16,302 participants randomised); 55 parallel-group trials (8104 participants randomised), and 156 cross-over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross-over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male-female ratio was 3:1. Most trials were carried out in high-income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias.

PRIMARY OUTCOMES

methylphenidate versus placebo or no intervention may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -0.88 to -0.61; I² = 38%; 21 trials; 1728 participants; very low-certainty evidence). This corresponds to a mean difference (MD) of -10.58 (95% CI -12.58 to -8.72) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD-RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68).

SECONDARY OUTCOMES

methylphenidate may cause more adverse events considered non-serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher-rated general behaviour versus placebo (SMD -0.62, 95% CI -0.91 to -0.33; I² = 68%; 7 trials 792 participants; very low-certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI -0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The majority of our conclusions from the 2015 version of this review still apply. Our updated meta-analyses suggest that methylphenidate versus placebo or no-intervention may improve teacher-rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non-serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non-serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes.

Efficacy and tolerability of psychostimulants for symptoms of attention-deficit hyperactivity disorder in preschool children: A systematic review and meta-analysis

BACKGROUND

There was no previous meta-analysis investigating the efficacy/tolerability of psychostimulants for symptoms of attention-deficit hyperactivity disorder (ADHD) in preschool children.

METHODS

Databases including PubMed, the Cochrane Library, EMBASE, ScienceDirect, and ClinicalTrials.gov were searched from inception to March 2022 for randomized controlled trials (RCTs) on therapeutic efficacy of psychostimulants against ADHD symptoms in preschool children (age ≤6 years) compared with placebos. Primary outcomes were (a) changes in ADHD symptoms evaluated by validated rating scales from parents'/teacher's observation, or (b) post-intervention improvements in neuropsychological performance. Secondary outcomes were risks of adverse events.

RESULTS

Meta-analysis of nine eligible trials including 544 preschool children (mean age=4.86 years, female=11.98%, median treatment duration=4.33 weeks) supported the efficacy of psychostimulants against global symptoms from observations of parents (Hedges' g=0.6152, p<0.0001) and teachers (Hedges' g=0.6563, p=0.0039). Efficacy of psychostimulants was also noted against symptoms of inattention and hyperactivity/impulsivity, especially the latter (i.e., main symptoms in preschool children). Moreover, male gender, older age, and longer treatment duration were associated with better efficacy. Regarding adverse events, only the risk of poor appetite was higher in the psychostimulant group (odds ratio [OR]=2.39). However, the qualities of evidence were low to very low, indicating potential discrepancy between the true and estimated effect.

CONCLUSIONS

Our results showed that psychostimulants might be beneficial for preschool children with ADHD, especially hyperactivity/impulsivity from teachers' observation, with tolerable side effects. Nevertheless, the true magnitude of the effect needs to be confirmed with more research due to low to very low certainty of the evidence.

Editorial: Treating Attention-Deficit/Hyperactivity Disorder in Preschool-Age Children With Stimulants: Modest Effects in Young Children With Big Problems

Poor school readiness and high rates of expulsion from preschool or day care are common in very young children with attention-deficit/hyperactivity disorder (ADHD), while in cases of severe impulsivity and inadequate monitoring there is real danger of injury to the child and others. Compared to older children, preschool-age children with ADHD have more frequent and often severe ADHD symptoms and high rates of psychiatric and developmental comorbidity.¹ As pediatricians are now routinely screening for ADHD in children as young as 4 years of age,² identification will likely increase. However, once identified, far less is known about treating ADHD.³.

Incremental Validity of Multi-Method and Multi-Informant Evaluations in the Clinical Diagnosis of Preschool ADHD

OBJECTIVES

This study investigated the discriminative validity of various single or combined measurements of electroencephalogram (EEG) data, Conners' Kiddie Continuous Performance Test (K-CPT), and Disruptive Behavior Disorder Rating Scale (DBDRS) to differentiate preschool children with ADHD from those with typical development (TD).

METHOD

We recruited 70 preschoolers, of whom 38 were diagnosed with ADHD and 32 exhibited TD; all participants underwent the K-CPT and wireless EEG recording in different conditions (rest, slow-rate, and fast-rate task).

RESULTS

Slow-rate task-related central parietal delta (1-4 Hz) and central alpha (8-13 Hz) and beta (13-30 Hz) powers between groups with ADHD and TD were significantly distinct (p < .05). A combination of DBDRS, K-CPT, and specific EEG data provided the best probability scores (area under curve = 0.926, p < .001) and discriminative validity to identify preschool children with ADHD (overall correct classification rate = 85.71%).

CONCLUSIONS

Multi-method and multi-informant evaluations should be emphasized in clinical diagnosis of preschool ADHD.

Attention Deficit Hyperactivity Disorder Medications and Sleep

Sleep problems are common and often increase when initiating pharmacotherapy for ADHD. Stimulants are commonly associated with delayed sleep onset/insomnia although nonstimulants can be associated with daytime sleepiness. There is a wide variability in severity and duration of sleep effects, but most effects are mild and improve over time. Although sleep problems occur in all age groups, preschoolers and adolescents appear to be more vulnerable to adverse effects on sleep than adults and children. Interventions to improve sleep include behavioral therapy, changing dose schedules or formulations, and adding a sleep-promoting agent such as melatonin.

Task-Rate-Related Neural Dynamics Using Wireless EEG to Assist Diagnosis and Intervention Planning for Preschoolers with ADHD Exhibiting Heterogeneous Cognitive Proficiency

This study used a wireless EEG system to investigate neural dynamics in preschoolers with ADHD who exhibited varying cognitive proficiency pertaining to working memory and processing speed abilities. Preschoolers with ADHD exhibiting high cognitive proficiency (ADHD-H, n = 24), those with ADHD exhibiting low cognitive proficiency (ADHD-L, n = 18), and preschoolers with typical development (TD, n = 31) underwent the Conners’ Kiddie Continuous Performance Test and wireless EEG recording under different conditions (rest, slow-rate, and fast-rate task). In the slow-rate task condition, compared with the TD group, the ADHD-H group manifested higher delta and lower beta power in the central region, while the ADHD-L group manifested higher parietal delta power. In the fast-rate task condition, in the parietal region, ADHD-L manifested higher delta power than those in the other two groups (ADHD-H and TD); additionally, ADHD-L manifested higher theta as well as lower alpha and beta power than those with ADHD-H. Unlike those in the TD group, the delta power of both ADHD groups was enhanced in shifting from rest to task conditions. These findings suggest that task-rate-related neural dynamics contain specific neural biomarkers to assist clinical planning for ADHD in preschoolers with heterogeneous cognitive proficiency. The novel wireless EEG system used was convenient and highly suitable for clinical application.

Neurofeedback Training Versus Perceptual-motor Exercises Interventions in Visual Attention for Children With Attention-Deficit/Hyperactivity Disorder: A Randomized Controlled Trial

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood psychiatric disorders characterized by poor attention and subsequently lower learning abilities than normal children. This study aimed to compare the effectiveness of neurofeedback and perceptual-motor exercises as two common nonpharmacological treatments for visual attention.

METHODS

A total of 40 combined medicated ADHD children (aged 5-12 years) were randomly allocated into two groups: neurofeedback training and perceptual-motor exercises. Visual attention and motor proficiency were assessed before and after the treatment by continuous performance test (CPT) and Bruininks-Oseretsky Test (BOT), respectively.

RESULTS

According to repeated measures analysis of variance (ANOVA), both groups showed significant improvement in three attention-related areas of CPT, including reaction time, omission, and commission errors (P<0.001), while the difference between the two groups was not significant (P>0.05). However, in the perceptual-motor exercises group, motor proficiency improved significantly (P<0.01).

CONCLUSION

Neurofeedback training intervention, as well as perceptual-motor exercises, are effective in improving ADHD symptoms, and given the similar effect of both interventions and their lack of side effects, perceptual-motor exercises appear to be the more appropriate option for reducing symptoms of ADHD, because of its additional effect on motor proficiency, rich content of purposeful activities, and social interactions.

HIGHLIGHTS

Neurofeedback training intervention promote attention in ADHD;Perceptual-motor exercises improve ADHD symptoms;Perceptual-motor exercises has an additional effect on motor proficiency.

PLAIN LANGUAGE SUMMARY

The effectiveness and cost of interventions is an important issue. The result of this study revealed although neuro-feedback training intervention as well as perceptual-motor exercises are effective in improving ADHD symptoms, perceptual-motor exercises seem more appropriate option for reducing symptoms of ADHD, due to its additional effect on motor proficiency.

The Role of the Maternal and Child Health Handbook in Developmental Surveillance: The Exploration of Milestone Attainment Trajectories

Despite the pivotal role of developmental surveillance in pediatric practice for the early detection of neurodevelopmental disorders (NDDs), there are several barriers, including scarcity of time and staff availability, to its implementation. Additionally, inadequate parental knowledge on what to expect about their child's development contributes to potential delays in the early identification of NDDs. Home-based records (HBRs) are widely used in both high-income and low- and middle-income countries, allowing caregivers to prospectively chart the child's development, including milestone attainment, and thus can be a useful tool for developmental surveillance. Therefore, we analyzed data on milestone attainment from birth to 5 years of age obtained through the home-based records (the Maternal Child Health Handbook: MCHH) in 720 children who attended the Hirosaki Five-year-old children Developmental Health Check-up Study in Hirosaki, Japan to identify trajectory patterns of milestone attainment. Parallel process latent class growth analysis on four milestone domains (motor, social interaction, communication, and self-care) revealed three different trajectories (Class 1: "Consistent milestone attainment" group; 42%, Class 2: "subtle initial delay and catch-up" group; 45%, Class 3: "Consistent failure to attain expected milestones" group; 13%). In Class 3, 90% of children were diagnosed with at least one NDDs at age 5 and approximately 65% of children had autism spectrum disorder and/or intellectual disability, the rate of which was higher than that in the other two classes. Boys and preterm-born children were more likely to be assigned to classes with less favorable trajectories of milestone attainment. Although the use of the MCHH alone does not substitute diagnostic evaluation for NDDs, our study findings suggest the potential utility of the MCHH as a tool to educate parents on what longitudinal patterns of milestone attainment are concerning and require prompt visits to professionals.

Self-Reported Maternal Parenting Stress From 9 m Is Longitudinally Associated With Child ADHD Symptoms at Age 12: Findings From a Population-Based Birth Cohort Study

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) develops in early childhood and carries lifelong impact, but early identification and intervention ensure optimal clinical outcomes. Prolonged or excessive parenting stress may be a response to infant behavioral differences antecedent to developmental disorders such as ADHD, and therefore represents a potentially valuable inclusion in routine early-life assessment. To investigate the feasibility of using routinely-collected self-reported maternal parenting stress as a risk marker for child ADHD, this study investigated the longitudinal association between maternal parenting stress from 1 to 36 months after childbirth and child ADHD in early adolescence.

METHODS

The sample comprised 2,638 children (1,253 girls) from the Tokyo Teen Cohort population-based birth cohort study. Mothers recorded parenting stress five times from 1 to 36 months following childbirth in the Maternal and Child Health Handbook, a tool used for routine early-life assessment in Japan. Nine years later, mothers evaluated their child's ADHD symptoms at 12 y using the hyperactivity/inattention subscale from the Strength and Difficulties Questionnaire.

RESULTS

Approximately 7.5% of parents reported that they had parenting stress at 36 m after childbirth. 6.2% of children were evaluated as above the cut-off for ADHD symptoms at 12 y. Parenting stress at 1 and 3-4 m was not associated with child ADHD symptoms at 12 y. However, child ADHD symptoms at 12 y was significantly associated with parenting stress at 9-10 m (unadjusted OR = 1.42, p =.047, 95% CI [1.00, 2/00]), 18 m (unadjusted OR = 1.57, p =.007, 95% CI [1.13, 2.19]) and 36 m (unadjusted OR = 1.67, p =.002, 95% CI [1.20, 2.31]). These associations remained after adjustment for child's sex, age in months and family income.

CONCLUSIONS

We identified associations between parenting stress at 9-10, 18 and 36 m after childbirth and child ADHD symptoms at 12 years old. Self-reported parenting stress data may have utility as an early indicator for ADHD risk. Participation in early-life health checks, assessment of parenting stress, and tailoring support to family needs should be promoted for early identification and intervention for ADHD.

Rate of Pediatrician Recommendations for Behavioral Treatment for Preschoolers With Attention-Deficit/Hyperactivity Disorder Diagnosis or Related Symptoms

This cohort study investigates the rate of pediatrician recommendations for behavioral treatment for preschoolers with an attention-deficit/hyperactivity disorder diagnosis or symptoms.

Effects of Parent-Teacher Training on Academic Performance and Parental Anxiety in School-Aged Children With Attention-Deficit/Hyperactivity Disorder: A Cluster Randomized Controlled Trial in Shanghai, China

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common chronic neurodevelopmental disorder in childhood, placing a heavy burden on family and society. The treatment of school-aged children with ADHD emphasizes multimodal interventions, but most current research focuses solely on parent training and family functioning. The aim of this study was to examine the effect of parent-teacher training on academic performance and parental anxiety. In an open-label cluster randomized controlled trial from January 2018 to January 2019, 14 primary schools in Shanghai were randomly assigned into the intervention group and the control group, and ADHD screening was conducted for students from grades one to five. Children in both groups received medication as prescribe by their pediatricians. In the intervention group, families and teachers also received parent-teacher training. The training included ADHD behavioral interventions for parents, as well as classroom management skills for teachers. This study screened 9,295 students, 99 children in the control group and 105 children in the intervention group were included in the analysis. The intervention group demonstrated significant improvement in ADHD symptoms and academic performance and decreases in parent stress compared to that in the control group (P < 0.05). This training improved the parents' perception of ADHD knowledge, treatment options, and drug side effects awareness (P < 0.05). Our study aims to underscore the suitability of such programs in the local nuances of the Chinese context, show application feasibility to pediatricians and psychiatrists, and provide supporting evidence for their utilization within the country's health and educational systems.

Neurodevelopmental Outcome of Children with Congenital Heart Disease: A Cohort Study from Infancy to Preschool Age

OBJECTIVE

To characterize the neuropsychological outcome of children with congenital heart disease (CHD) at age 5 years; the stability of cognitive and language abilities across childhood; and to identify early neurodevelopmental markers of neuropsychological outcomes in these children.

STUDY DESIGN

Five-year-old children (n = 55) with complex CHD were assessed using standardized and comprehensive neuropsychological measures. Stability of language and cognitive performance was assessed by comparing standardized scores between ages 1, 2, and 5 years old. Association between 5-year-old skills and scores obtained in early childhood was studied to identify potential early markers of preschool performance. Receiver operating characteristic curves were used to evaluate the classification accuracy of Bayley Scales of Infant Development, Third Edition scales in identifying later impairments.

RESULTS

At age 5 years, our cohort obtained scores significantly below the norms on most developmental domains, with 35% to 65% of participants showing impaired short-term/working memory, attention, and preacademic skills. Developmental patterns measured between ages 1 and 5 years were different for cognitive and language domains, with a decline with age for cognitive functioning and stable results for expressive language. The Bayley Scales of Infant Development, Third Edition language scores at age 2 years provided a good predictive value in identifying children with impaired language at age 5 years.

CONCLUSIONS

In our cohort, we found a high prevalence of impairments affecting higher-order cognitive domains. Although language difficulties can be detected as early as 2 years of age, other neuropsychological impairments, such as attention and pre-academic skills, only appear later during development, which reinforces the need for long-term monitoring and systematic assessment before school entry.

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.

Practitioner's review: medication for children and adolescents with autism spectrum disorder (ASD) and comorbid conditions

Alleviating the multiple problems of children with autism spectrum disorder (ASD) and its comorbid conditions presents major challenges for the affected children, parents, and therapists. Because of a complex psychopathology, structured therapy and parent training are not always sufficient, especially for those patients with intellectual disability (ID) and multiple comorbidities. Moreover, structured therapy is not available for a large number of patients, and pharmacological support is often needed, especially in those children with additional attention deficit/hyperactivity and oppositional defiant, conduct, and sleep disorders.

Neural Dynamics for Facilitating ADHD Diagnosis in Preschoolers: Central and Parietal Delta Synchronization in the Kiddie Continuous Performance Test

The present study aimed to characterize children at risk of attention-deficit/hyperactivity disorder (ADHD) during preschool age and provide early intervention. The continuous performance test (CPT) and electroencephalography (EEG) can contribute additional valuable information to facilitate diagnosis. This study measured brain dynamics at slow and fast task rates in the CPT using a wireless wearable EEG and identified correlations between the EEG and CPT data in preschool children with ADHD. Forty-nine preschool children participated in this study, of which 29 were diagnosed with ADHD and 20 exhibited typical development (TD). The Conners Kiddie Continuous Performance Test (K-CPT) and wireless wearable EEG recordings were employed simultaneously. Significant differences were observed between the groups with ADHD and TD in task-related EEG spectral powers (central as well as parietal delta, P < 0.01), which were distinct only in the slow-rate task condition. A shift from resting to the CPT task condition induced overall alpha powers decrease in the ADHD group. In the task condition, the delta powers were positively correlated with the CPT perseveration scores, whereas the alpha powers were negatively correlated with specific CPT scores mainly on perseveration and detectability (P < 0.05). These results, which complement the findings of other sparse studies that have investigated within-task-related brain dynamics, particularly in preschool children, can assist specialists working in early intervention to plan training and educational programs for preschoolers with ADHD.

Exploring the Effects of Pharmacological, Psychosocial, and Alternative/Complementary Interventions in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder: Meta-Regression Approach

BACKGROUND

There have been various therapies for attention-deficit/hyperactivity disorder (ADHD), but the previous meta-analysis of ADHD efficacy remains unclear. This study aims to systemically meta-regress the effect sizes (ES) of psychostimulant pharmacotherapy (methylphenidate and lisdexamfetamine), non-stimulant pharmacotherapy (atomoxetine and alpha-2 agonists), psychosocial therapy (parental behavioral therapy [PBT]), combination therapy (psychostimulant plus PBT), and alternative/complementary interventions to determine the right treatment for ADHD.

METHODS

We searched various ADHD interventions from the MEDLINE and PubMed databases (National Center for Biotechnology Information) between January 1, 1980, and July 30, 2018. Following the meta-analysis of random effects, the meta-regression analyses were used to explore factors potentially influencing treatment efficacy. The confounding variables included type of treatment, type of study, age, type of symptom scale used, and year of publication.

RESULTS

A total of 107 trials (n = 9883 participants) were included. After adjustment, compared with the psychostimulant therapy (28 trial, 2134 participants), non-stimulant pharmacotherapy (28 trials, 4991 participants) and alternative/complement intervention (25 trials, 1195 participants) were less effective by the ES of -0.384 (P = .004) and -0.419 (P = .028), respectively. However, compared with psychostimulant, PBT (19 trials, 1122 participants; ES = -0.308, P = .095) and the combination of psychostimulant and PBT (7 trials, 441participants; ES = -0.196, P = .209) did not differ significantly.

CONCLUSIONS

Psychostimulant therapy surpassed non-stimulant pharmacotherapy and alternative/complement intervention. Psychostimulant therapy, PBT, and the combination of psychostimulant therapy and PBT appear to be similar in efficacy according to this meta-regression.

Individualization of attention-deficit/hyperactivity disorder treatment: pharmacotherapy considerations by age and co-occurring conditions

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in childhood and can persist into adolescence and adulthood. Impairments associated with ADHD can impact quality of life, social interactions, and increase the risk of morbidity and mortality; however, for many patients, effective treatment can lessen these effects. Pharmacotherapy with stimulants or nonstimulants is recommended in conjunction with psychosocial therapy for most patients. Determining the optimal pharmacotherapy can be complex, and the clinician needs to consider many factors such as the patient's age, comorbidities, and lifestyle. Furthermore, the needs of the patient with ADHD will change over time, with specific challenges to consider at each stage of life. A variety of Food and Drug Administration (FDA)-approved stimulant and nonstimulant formulations are available with different modes of delivery and durations of effect. This armamentarium of ADHD medications can be used to individualize ADHD treatment for each patient's needs. This article combines current information from the literature and the first-hand experience of the authors to provide guidance on ADHD treatment options for patients of different ages and for some of the more common comorbidities.

Screen Time Exposure in Preschool Children with ADHD: A Cross-Sectional Exploratory Study from South India

BACKGROUND

Concern is mounting regarding screen exposure among young children and its association with mental health. Children with attention deficit hyperactivity disorder (ADHD) may be more vulnerable to its effects such as increased externalizing behaviors and problems with language and cognitive development and biological functions such as sleep. We aimed to assess screen exposure in preschool children with ADHD and to study the correlation of screen time with the severity of ADHD and parental stress levels.

METHODS

Children of age 2.5-6 years, diagnosed with ADHD (n = 56) were included, and details of the total duration of screen exposure, maximum continuous screen exposure time, and types of screen-based devices used, reasons for screen exposure were collected from primary caregivers. ADHD symptom severity was assessed on Conner's Abbreviated Rating Scale. Family interview for stress and coping, adapted for ADHD, was used to measure parental stress.

RESULTS

Total screen exposure time in preschool children with ADHD was more than the recommended standards in 80.4% of children, with a median of 140.00 minutes (range: 20-500 minutes). The most commonly used modality was television (98.2%), followed by mobile phones (87.3%), tablets (17.9%), and laptops (10.7%). The severity of ADHD (r = 0.29, P = 0.02) and parent stress levels (r = 0.29, P = 0.03) were positively correlated to increased screen time exposure in the child.

CONCLUSIONS

Preschool children with ADHD have screen exposure above the recommended duration of one hour/day. Structured parent training programs for children with preschool ADHD and providing developmentally appropriate interventions are essential in curtailing screen time exposure and also to address parental stress.

Digital health interventions (DHI) for the treatment of attention deficit hyperactivity disorder (ADHD) in children - a comparative review of literature among various treatment and DHI

The objective of this study is to compare game-based digital therapeutic device and other DHI like (smartphone apps, wearable technologies) for ADHD with the current pharmacological and behavior therapy. The FDA has approved a game-based digital therapeutic device - EndeavorRx, for the treatment of ADHD in pediatric patients belonging to the age group of 8-12 years old. This has been primarily recommended for the treatment of inattentive or combined-type ADHD who have demonstrated an attention issue. This is the first game-based therapeutic device to be approved by the FDA for any type of condition. According to the FDA, this has been shown to improve attention which is measured by computer-based testing. Objective: The objective of this study is to compare a game-based digital therapeutic device and other DHI (smartphone apps, wearable technologies) with the current pharmacological and behavior therapy used in the treatment of ADHD.

Attention-Deficit/Hyperactivity Disorder in 2- to 5-Year-Olds: A Primary Care Network Experience

OBJECTIVE

To assess 1) rates of primary care provider (PCP) diagnosis of attention-deficit/hyperactivity disorder (ADHD) in young children, 2) documented PCP adherence to ADHD clinical practice guidelines, and 3) patient factors influencing PCP variation in diagnosis and management.

METHODS

Retrospective cohort study of electronic health records from all office visits of children aged 2 to 5 years, seen ≥2 times between 2015 and 2019, in 10 practices of a community-based primary health care network. Outcomes included ADHD diagnosis (symptom or disorder), and adherence to guidelines in 1) comorbidity documentation at or after ADHD diagnosis, 2) ADHD medication choice, and 3) follow-up of medicated patients. Logistic regressions assessed associations between outcomes and patient characteristics.

RESULTS

Of 29,408 eligible children, 195 (0.7%) had ADHD diagnoses. Of those, 56% had solely symptom-level diagnoses (eg, hyperactivity); 54% had documented comorbidities. ADHD medications were prescribed only to 4- to 5-year olds (40 of 195 [21%]); 85% received stimulants as first-line medication; 48% had follow-up visits within 2 months. Likelihood of ADHD diagnosis was higher for children with public or military insurance (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.40-2.66; OR 3.17; 95% CI 1.93-4.96). Likelihood of comorbidity documentation was lower for older ADHD patients (OR 0.48; 95% CI 0.32-0.71) and higher for those with military insurance (OR 3.11; 95% CI 1.13-9.58).

CONCLUSION

PCPs in this network frequently used symptom-level ADHD diagnoses in 2- to 5-year olds; ADHD diagnosis rates were below estimated population prevalence, with evidence for sociodemographic disparities. PCP comorbidity documentation and choice of stimulant medications were consistent with guidelines. Rates of timely follow-up were low.

Immediate-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is characterized by symptoms of inattention or impulsivity or both, and hyperactivity, which affect children, adolescents, and adults. In some countries, methylphenidate is the first option to treat adults with moderate or severe ADHD. However, evidence on the efficacy and adverse events of immediate-release (IR) methylphenidate in the treatment of ADHD in adults is limited and controversial.

OBJECTIVES

To evaluate the efficacy and harms (adverse events) of IR methylphenidate for treating ADHD in adults.

SEARCH METHODS

In January 2020, we searched CENTRAL, MEDLINE, Embase, eight additional databases and three trial registers. We also searched internal reports on the European Medicines Agency and the US Food and Drug Administration websites. We checked citations of included trials to identify additional trials not captured by the electronic searches.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing IR methylphenidate, at any dose, with placebo or other pharmacological interventions (including extended-release formulations of methylphenidate) for ADHD in adults. Primary outcomes comprised changes in the symptoms of ADHD (efficacy) and harms. Secondary outcomes included changes in the clinical impression of severity and improvement, level of functioning, depression, anxiety and quality of life. Outcomes could have been rated by investigators or participants.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently on the characteristics of the trials, participants, interventions; outcomes and financial conflict of interests. We resolved disagreements by discussion or consulting a third review author. We obtained additional, unpublished information from the authors of one included trial that had reported efficacy data in a graph. We calculated mean differences (MDs) or standardized MDs (SMDs) with 95% confidence intervals (CIs) for continuous data reported on the same or different scales, respectively. We summarized dichotomous variables as risk ratios (RRs) with 95% CI.

MAIN RESULTS

We included 10 trials published between 2001 and 2016 involving 497 adults with ADHD. Three trials were conducted in Europe and one in Argentina; the remaining trials did not report their location. The RCTs compared IR methylphenidate with placebo, an osmotic-release oral system (OROS) of methylphenidate (an extended-release formulation), an extended-release formulation of bupropion, lithium, and Pycnogenol® (maritime pine bark extract). Participants comprised outpatients, inpatients in addiction treatment, and adults willing to attend an intensive outpatient program for cocaine dependence. The duration of the follow-up ranged from 6 to 18 weeks. IR methylphenidate versus placebo We found very low-certainty evidence that, compared with placebo, IR methylphenidate may reduce symptoms of ADHD when measured with investigator-rated scales (MD -20.70, 95% CI -23.97 to -17.43; 1 trial, 146 participants; end scores; Adult ADHD Investigator Symptom Report Scale (AISRS), scored from 0 to 54), but the evidence is uncertain. The effect of IR methylphenidate on ADHD symptoms when measured with participant-rated scales was moderate, but the certainty of the evidence is very low (SMD -0.59, 95% CI -1.25 to 0.06; I² = 69%; 2 trials, 138 participants; end scores). There is very low-certainty evidence that, compared with placebo, IR methylphenidate may reduce the clinical impression of the severity of ADHD symptoms (MD -0.57, 95% CI -0.85 to -0.28; 2 trials, 139 participants; I² = 0%; change and end scores; Clinical Global Impression (CGI)-Severity scale (scored from 1 (very much improved) to 7 (very much worse))). There is low-certainty evidence that, compared with placebo, IR methylphenidate may slightly impact the clinical impression of an improvement in symptoms of ADHD (MD -0.94, 95% CI -1.37 to -0.51; 1 trial, 49 participants; end scores; CGI-Improvement scale (scored from 1 (very much improved) to 7 (very much worse))). There is no clear evidence of an effect on anxiety (MD -0.20, 95% CI -4.84 to 4.44; 1 trial, 19 participants; change scores; Hamilton Anxiety Scale (HAM-A; scored from 0 to 56); very low-certainty evidence) or depression (MD 2.80, 95% CI -0.09 to 5.69; 1 trial, 19 participants; change scores; Hamilton Depression Scale (HAM-D; scored from 0 to 52); very low-certainty evidence) in analyses comparing IR methylphenidate with placebo. IR methylphenidate versus lithium Compared with lithium, it is uncertain whether IR methylphenidate increases or decreases symptoms of ADHD (MD 0.60, 95% CI -3.11 to 4.31; 1 trial, 46 participants; end scores; Conners' Adult ADHD Rating Scale (scored from 0 to 198); very low-certainty evidence); anxiety (MD -0.80, 95% CI -4.49 to 2.89; 1 trial, 46 participants; end scores; HAM-A; very low-certainty evidence); or depression (MD -1.20, 95% CI -3.81 to 1.41, 1 trial, 46 participants; end scores; HAM-D scale; very low-certainty evidence). None of the included trials assessed participant-rated changes in symptoms of ADHD, or clinical impression of severity or improvement in participants treated with IR methylphenidate compared with lithium. Adverse events were poorly assessed and reported. We rated all trials at high risk of bias due to selective outcome reporting of harms and masking of outcome assessors (failure to blind outcome assessor to measure adverse events). Overall, four trials with 203 participants who received IR methylphenidate and 141 participants who received placebo described the occurrence of harms. The use of IR methylphenidate in these trials increased the risk of gastrointestinal complications (RR 1.96, 95% CI 1.13 to 2.95) and loss of appetite (RR 1.77, 95% CI 1.06 to 2.96). Cardiovascular adverse events were reported inconsistently, preventing a comprehensive analysis. One trial comparing IR methylphenidate to lithium reported five and nine adverse events, respectively. We considered four trials to have notable concerns of vested interests influencing the evidence, and authors from two trials omitted information related to the sources of funding and conflicts of interest.

AUTHORS' CONCLUSIONS

We found no certain evidence that IR methylphenidate compared with placebo or lithium can reduce symptoms of ADHD in adults (low- and very low-certainty evidence). Adults treated with IR methylphenidate are at increased risk of gastrointestinal and metabolic-related harms compared with placebo. Clinicians should consider whether it is appropriate to prescribe IR methylphenidate, given its limited efficacy and increased risk of harms. Future RCTs should explore the long-term efficacy and risks of IR methylphenidate, and the influence of conflicts of interest on reported effects.

Cognitive behavior therapy for externalizing disorders in children and adolescents in routine clinical care: A systematic review and meta-analysis

Various Cognitive Behavioral Therapy (CBT) programs for externalizing disorders in children and adolescents are supported by a substantial body of empirical evidence. Most of the research evidence comes from efficacy studies conducted in university settings, but there is less knowledge about the effect of these treatments in routine clinical care. The purpose of this meta-analysis was to investigate the effectiveness of CBT in non-university settings for Attention Deficit Hyperactivity Disorder (ADHD), Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD). Embase OVID, Ovid MEDLINE and PsycINFO were systematically searched for eligible studies published up to May 2020. In total, 51 treatment effectiveness studies involving 5295 patients were included. The average within-group effect size at post-treatment was significant (g = 0.91), and there were large effect sizes for both ADHD (g = 0.80) and CD/ODD (g = 0.98). At post treatment, remission rates were 38% for ADHD and 48% for CD/ODD, and the overall attrition rate was 14%. Benchmarking against efficacy studies showed that CBT in routine clinical care yields remission rates, within-group effect sizes and attrition rates that are very similar to those found in university settings. The findings support the transportability of CBT for externalizing disorders from university settings to routine clinical care. PROSPERO registration: CRD42020147524.

Epidemiology of Treatment for Preschoolers on Kentucky Medicaid Diagnosed with Attention-Deficit/Hyperactivity Disorder

Objectives: The National Survey of Children's Health reported a concerning increase in children 2-5 years being diagnosed with attention-deficit/hyperactivity disorder (ADHD) in 2016. Concerns include both the increase in diagnosing and potential deviations from published guidelines for the treatment of ADHD in preschoolers. The present study aims to describe the epidemiology and factors associated with receiving the diagnosis and treatment types for low-income preschoolers. Methods: Using Kentucky Medicaid claims from 2012 to 2017, a retrospective cohort study of children 2-5 years of age (n = 337,631) with a diagnosis of ADHD (n = 11,712) was completed. Trends in demographics, comorbidities, and treatment and provider types are presented. Multinomial logistic regression was used to determine predictors of receipt of the diagnosis and treatment type (a stimulant only, an alpha-2 agonist [A2A] only, both, or neither) based on nonmissing 2017 data (n = 2394). Results: The number of children in the cohort diagnosed with ADHD and receiving a stimulant decreased from 2012 to 2017, but the use of A2As increased. Primary care physicians were the most frequent prescribers of both medications. The adjusted odds ratios (AORs) of receipt of an A2A alone, stimulant alone, or both medications over receiving no ADHD medication were associated with specific demographics and comorbid conditions for each medication regimen. Race/ethnicity is associated with receiving the diagnosis of ADHD and treatment with A2A. Comorbid mental health conditions and provider type are associated with treatment type. Conclusion: Use of stimulants for preschoolers in Kentucky has decreased and A2A use has increased since 2012. Continued vigilance and long-term follow-up of preschoolers with ADHD are warranted. The appropriateness of the diagnosis and treatment type could not be determined.

Welfare consequences for people diagnosed with attention deficit hyperactivity disorder (ADHD): A matched nationwide study in Denmark

There is insufficient data regarding the excess direct and indirect costs associated with attention deficit hyperactivity disorder (ADHD). Using the Danish National Patient Registry (2002-2016), we identified 83,613 people of any age with a diagnosis of ADHD or who were using central-acting medication against ADHD (primarily methylphenidate, with at least two prescriptions) and matched them to 334,446 control individuals. Additionally, 18,959 partners of patients aged ≥18 years with ADHD were identified, and compared with 74,032 control partners. Direct costs were based on data from the Danish Ministry of Health. Information about the use and costs of drugs were obtained from the Danish Medicines Agency. The frequencies of visits and hospitalizations, and costs of general practice were derived from data from the National Health Security. Indirect costs were obtained from Coherent Social Statistics. The average annual health care costs for people with ADHD and their partners were, respectively, €2636 and €477 higher than those of the matched controls. A greater percentage of people with ADHD and their partners compared with respective control subjects received social services (sick pay or disability pension). Those with ADHD had a lower income from employment than did controls for equivalent periods up to five years before the first diagnosis of ADHD. The additional direct and indirect annual costs (for those aged ≥18 years) including transfers of ADHD compared with controls were €23,072 for people with ADHD and €7,997 for their partners. ADHD has substantial socioeconomic consequences for individual patients, their partners and society.

Social Class, Diagnoses of Attention-Deficit/Hyperactivity Disorder, and Child Well-Being

Attention-deficit/hyperactivity disorder (ADHD) is the most commonly diagnosed mental health disorder among U.S. children. Diagnosis can bring positives, like proper treatment, extra testing time, and social support, but may also trigger negatives, like stigmatization. Although rates of diagnosis are high across socioeconomic status (SES) groups, the balance of positive and negative consequences of diagnosis may differ by SES. In high-SES communities, mental health diagnoses are less stigmatized and parents have greater ability to connect children to support resources, suggesting greater positive effects of diagnosis for high-SES children. Alternatively, the greater academic pressure present in high-SES communities may amplify the negative effects of mental health stigma, suggesting larger negative diagnostic effects. Using the Early Childhood Longitudinal Study-Kindergarten Cohort of 1998-1999, I found that diagnosed and medicated high-SES but not low-SES children exhibit significantly poorer future self-competence and teacher-rated school behaviors than undiagnosed matches. Findings suggest that diagnosis may not always be a net positive.

Diagnosis and Treatment Options for Preschoolers with Attention-Deficit/Hyperactivity Disorder

Objective: The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), classifies attention-deficit/hyperactivity disorder (ADHD) as a neurodevelopmental disorder, with symptoms becoming apparent as early as the preschool years. Early recognition can lead to interventions such as parent/teacher-administered behavior therapy, the recommended first-line treatment for preschool patients. There are few data, however, to inform the use of second-line, pharmacotherapy options in this population. In this review, we identified recent literature on the diagnosis and treatment of ADHD in preschool children. Methods: A PubMed and clinicaltrials.gov search was conducted for trials assessing efficacy or safety of ADHD medications in children aged <6 years. Diagnostic methods and criteria focusing on recognition of ADHD in preschool children were also surveyed. Results: The DSM-5 describes different manifestations of ADHD in preschool versus school-aged children, but does not list separate criteria by age group. Importantly, behaviors indicative of ADHD in older children may be developmentally appropriate in preschool children. Several behavioral rating scales have been validated in children younger than 6 years of age for assessing ADHD. The Preschool ADHD Treatment Study (PATS) has provided the most extensive efficacy and safety data on methylphenidate (MPH) for ADHD in preschoolers to date, with significant improvement in ADHD symptoms observed with MPH compared with placebo, although adverse event-related discontinuation was higher in PATS compared with studies of MPH for ADHD in school-aged children. Since PATS was conducted, few studies designed to assess ADHD medication effectiveness in preschool children have been published. One article reported significant improvement in ADHD symptoms with MPH (immediate release) versus placebo, two studies showed no difference between MPH and risperidone or MPH plus risperidone in relief of ADHD symptoms, and one study demonstrated the efficacy of atomoxetine versus placebo for ADHD symptoms in preschoolers. Conclusions: Further research is needed on pharmacotherapy for preschool children with ADHD.

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.

Pre-school attention deficit hyperactivity disorder: 12 weeks prospective study

INTRODUCTION

Extant literature lack studies on behavioural training or pharmacotherapy in Indian preschool children. With adverse long term outcomes, effective, safe and affordable early interventions for ADHD are a priority. Aim of this prospective study is to report on short term outcome of preschool ADHD with specific focus on safety and tolerability of medications.

METHODS

Children with ADHD aged 2.5-6 years were assessed for severity and adverse events at baseline and follow-up using Conner's abbreviated rating scale and Clinical Global Impression-Severity scale. Children with Autism spectrum disorder and those with social quotient less than 50 were excluded. Statistical Analysis included descriptive statistics and Repeated measures ANOVA.

RESULTS

Of 56 children recruited, 33.93 %(N = 19) were on behavioural interventions alone, 66.07 %(N = 37) were on a combination of medication and behavioural intervention. All children received treatment according to standard care. The most prescribed drug was clonidine (44.64%), then risperidone (28.7%), methylphenidate (10.7%) and atomoxetine (10.7%). Medication choice was determined by affordability, availability and comorbidity profile. Sedation occurred in 24 % of children on clonidine. Atomoxetine was not well tolerated in 2 children. Methylphenidate was well tolerated. Irrespective of medication choice, all children showed significant improvement at 12 weeks (p < 0.001).

CONCLUSIONS

Choice of interventions is largely determined by availability and affordability. There is a need for structured parent behavioural training program deliverable in low resource setting. Anti-ADHD medications should be made available under the NMHP, RBSK program and all government settings in India, to address over-prescription of antipsychotics in preschool ADHD.

Individualised stepwise adaptive treatment for 3-6-year-old preschool children impaired by attention-deficit/hyperactivity disorder (ESCApreschool): study protocol of an adaptive intervention study including two randomised controlled trials within the consortium ESCAlife

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a psychosocially impairing and cost-intensive mental disorder, with first symptoms occurring in early childhood. It can usually be diagnosed reliably at preschool age. Early detection of children with ADHD symptoms and an early, age-appropriate treatment are needed in order to reduce symptoms, prevent secondary problems and enable a better school start. Despite existing ADHD treatment research and guideline recommendations for the treatment of ADHD in preschool children, there is still a need to optimise individualised treatment strategies in order to improve outcomes. Therefore, the ESCApreschool study (Evidence-Based, Stepped Care of ADHD in Preschool Children aged 3 years and 0 months to 6 years and 11 months of age (3;0 to 6;11 years) addresses the treatment of 3-6-year-old preschool children with elevated ADHD symptoms within a large multicentre trial. The study aims to investigate the efficacy of an individualised stepwise-intensifying treatment programme.

METHODS

The target sample size of ESCApreschool is 200 children (boys and girls) aged 3;0 to 6;11 years with an ADHD diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or a diagnosis of oppositional defiant disorder (ODD) plus additional substantial ADHD symptoms. The first step of the adaptive, stepped care design used in ESCApreschool consists of a telephone-assisted self-help (TASH) intervention for parents. Participants are randomised to either the TASH group or a waiting control group. The treatment in step 2 depends on the outcome of step 1: TASH responders without significant residual ADHD/ODD symptoms receive booster sessions of TASH. Partial or non-responders of step 1 are randomised again to either parent management and preschool teacher training or treatment as usual.

DISCUSSION

The ESCApreschool trial aims to improve knowledge about individualised treatment strategies for preschool children with ADHD following an adaptive stepped care approach, and to provide a scientific basis for individualised medicine for preschool children with ADHD in routine clinical care.

TRIAL REGISTRATION

The trial was registered at the German Clinical Trials Register (DRKS) as a Current Controlled Trial under DRKS00008971 on 1 October 2015. This manuscript is based on protocol version 3 (14 October 2016).

Academic Outcomes Following a School-Based RCT for ADHD: 6-Year Follow-Up

Objective: For children with high levels of ADHD symptoms, to investigate the impact of early school-based interventions on academic outcomes in mid-childhood. Method: A 6-year follow-up of 4- to 5-year-olds (N = 52,075) whose schools participated in a cluster randomized controlled trial for children at risk of ADHD. School-level interventions involved the provision of a booklet with evidence-based information (book) and/or feedback of names (identification) of children with high levels of ADHD symptoms. At ages 10 to 11 years, outcome measures were scores in English and mathematics tests. Results: For children with high levels of ADHD symptoms, the interventions had no impact on academic outcomes. When all children were analyzed, the book intervention had a positive impact on mathematics. Baseline inattention was associated with poorer academic outcomes, whereas impulsiveness was associated with better academic outcomes. Conclusion: The provision of evidence-based information about helping children with ADHD at school may have wider academic benefits.

Are parental changes related to improvements in preschool children's disruptive behaviours?

OBJECTIVE

To investigate whether changes in parenting after behavioural parent training in routine clinical care are associated with improvements in preschool children's disruptive behaviours.

METHOD

We evaluated changes after parent training in maternal and paternal self-reports of parental discipline practices parenting sense of competence, and parents' ratings of child disruptive behaviours in parents of 63 children, with a one group pretest-posttest design. We also compared parenting parameters in this clinical sample with a nonclinical sample (n = 121).

RESULTS

Mothers' self-reports of parental discipline practices and parenting sense of competence significantly improved after behavioural parent training. Less over-reactivity in both mothers and fathers was associated with fewer disruptive behaviours in children. After parent training, mothers' ratings of their discipline techniques did not differ anymore from those in the nonclinical sample.

CONCLUSION

Positive changes in parental discipline practices, particularly less over-reactive parental behaviours, were related to a decrease of disruptive child behaviours.

Practitioner Review: Assessment and treatment of preschool children with attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) often emerges during the preschool years and remains impairing throughout the life span. Early identification and intervention may yield lasting benefits that alter the often-adverse trajectory of the disorder.

METHODS

This Practitioner Review provides up-to-date information regarding the evaluation and treatment of ADHD in preschool children. The clinical presentation of ADHD in preschool children, its persistence into later childhood, the applicability of DSM-5 criteria for preschoolers with ADHD, and early predictors of long-term trajectories are addressed, as well as current findings from randomized controlled trials of both nonpharmacological and pharmacological interventions.

RESULTS

Symptoms of hyperactivity/impulsivity extend down to age 3, but several inattention symptoms, as defined by DSM-V, less accurately differentiate preschoolers with and without ADHD. Most preschool youth with ADHD symptoms continue to manifest symptoms and impairment into school-age and adolescence. However, few predictors of persistence beyond early severity have been identified. Behavioral interventions constitute a first-line treatment for preschool ADHD symptoms, with telepsychiatry increasing in prominence to help to mitigate financial, geographic, and/or logistical barriers to care. Pharmacological interventions, particularly psychostimulants, also confer demonstrable benefits, yet efficacy and safety profiles are less desirable relative to findings in school-age youth.

CONCLUSIONS

Acute treatments have demonstrable efficacy, but do not appear to fundamentally alter underlying mechanisms or long-term trajectories.

Risks and Benefits of Attention-Deficit/Hyperactivity Disorder Medication on Behavioral and Neuropsychiatric Outcomes: A Qualitative Review of Pharmacoepidemiology Studies Using Linked Prescription Databases

Attention-deficit/hyperactivity disorder (ADHD) medication is one of the most commonly prescribed medication classes in child and adolescent psychiatry, and its use is increasing rapidly in adult psychiatry. However, major questions and concerns remain regarding the benefits and risks of ADHD medication, especially in real-world settings. We conducted a qualitative systematic review of studies that investigated the effects of ADHD medication on behavioral and neuropsychiatric outcomes using linked prescription databases from the last 10 years and identified 40 studies from Europe, North America, and Asia. Among them, 18 used within-individual designs to account for confounding by indication. These studies suggested short-term beneficial effects of ADHD medication on several behavioral or neuropsychiatric outcomes (i.e., injuries, motor vehicle accidents, education, substance use disorder), with estimates suggesting relative risk reduction of 9% to 58% for these outcomes. The within-individual studies found no evidence of increased risks for suicidality and seizures. Replication studies are needed for several other important outcomes (i.e., criminality, depression, mania, psychosis). The available evidence from pharmacoepidemiology studies on long-term effects of ADHD medication was less clear. We discuss time-varying confounding and other limitations that should be considered when interpreting results from pharmacoepidemiology studies. Furthermore, we highlight several knowledge gaps to be addressed in future research and implications for research on mechanisms of outcomes of ADHD medications.

Treatment of child externalizing behavior problems: a comprehensive review and meta-meta-analysis on effects of parent-based interventions on parental characteristics

This is the first meta-meta-analysis examining the effects of parent-based interventions for children with externalizing behavior problems on parental characteristics (parenting, parental perceptions, parental mental health, parental relationship quality). Parent training interventions are recognized as evidence-based interventions for the treatment of externalizing behavior problems, although meta-analytic effects are heterogeneous. The objective of the present study was to comprehensively combine meta-analytic results on parent training interventions to arrive at valid effect predictions. Electronic databases were searched (PsycINFO, Medline, PubMed). In total, 11 meta-analyses were included that mainly comprised parents of children under the age of 13 years. Analyses were based on random effects models. Effect estimates were transformed to standardized mean differences (SMD) and corrected for primary study overlap. Results revealed a significant moderate overall effect for parenting (SMD 0.53) as well as for parents' report of parenting (SMD 0.60) and parental perceptions (SMD 0.52). Effects remained stable to follow-up. Results for observational data, parental mental health and parental relationship quality were small and only partially significant. Considerable heterogeneity within results was revealed. Overall, parent training interventions proved to be effective in improving parental characteristics for parents of children with externalizing behavior problems. Effectiveness was stronger regarding characteristics explicitly targeted by interventions. The findings should encourage health-care providers to apply evidence-based parent training interventions.

Longitudinal Trends in the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Stimulant Use in Preschool Children on Medicaid

OBJECTIVES

To describe trends in the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and prescribing of stimulants in preschool-age children receiving Medicaid and to identify factors associated with the receipt of psychosocial care.

STUDY DESIGN

Data were extracted from 2012-2016 Kentucky Medicaid claims for children aged <6 years. ADHD was identified using International Classification of Diseases, Tenth Revision codes F90.0, F90.1, F90.2, F90.8, and F90.9. Psychosocial therapy was defined as having at least 1 relevant Current Procedural Terminology code in a claim within the year. A generalized linear model with a logit link and binomial distribution was used to assess factors associated with receipt of psychosocial treatment in 2016.

RESULTS

More than 2500 (1.24%) preschool-aged children receiving Medicaid had a diagnosis of ADHD in 2016, with 988 (38.2%) of those receiving a stimulant medication. Children in foster care were diagnosed with and/or treated for ADHD 4 times more often than other Medicaid recipients. Of the 1091 preschoolers receiving stimulants, 99 (9%) did not have a diagnosis of ADHD. There were no significant differences in diagnoses by race/ethnicity, but children reported to be black, Hispanic, or other race/ethnicity received stimulants at a lower rate than white children. Positive predictors for receiving psychosocial therapy in 2016 included having the diagnosis but not receiving a stimulant, having at least 1 prescription written by a psychiatrist, having comorbidities, and age. The use of stimulants in children aged <6 years declined from 0.9% in 2012 to 0.5% in 2016.

CONCLUSIONS

Promising trends demonstrate a decreasing use of stimulants in preschoolers; however, continued vigilance is needed to promote the optimal use of psychosocial interventions.

[The prevention of externalizing disturbances]

The prevention of externalizing disturbances Abstract. Objectives: Externalizing disturbances (attention deficit-hyperactivity disorders, oppositional defiant disorders, conduct disorders) in children and adolescents have a high prevalence, are stable over time, and precipitate a high individual and economic burden. Method: This review article presents the state of research based on selected current meta-analyzes and systematic reviews. Additionally, evidenced-based German-language prevention programs are discussed. Results: As in treatment, a multimodal approach to prevention is recommended which aims at reducing externalizing symptoms in specific settings. Interventions that focus on the specific environment in the family and the (pre-)school are preferable. Child-focused interventions are especially important in the context of peer-related problematic behavior because parent-based or teacher-based interventions may be less able to affect peer interactions. Conclusions: Comprehensive parent-based and (pre-)school-based preventive interventions of externalizing disturbances should be implemented. These should also include child-based approaches and additional parent-based group interventions. The effects of these interventions should be tested in large-scale studies.

Treatment strategies for ADHD: an evidence-based guide to select optimal treatment

Attention-deficit/hyperactivity disorder (ADHD) is a common and impairing disorder affecting children, adolescents, and adults. Several treatment strategies are available that can successfully ameliorate symptoms, ranging from pharmacological to dietary interventions. Due to the increasing range of available options, an informed selection or prioritization of treatments is becoming harder for clinicians. This review aims to provide an evidence-based appraisal of the literature on ADHD treatment, supplemented by expert opinion on plausibility. We outline proposed mechanisms of action of established pharmacologic and non-pharmacologic treatments, and we review targets of novel treatments. The most relevant evidence supporting efficacy and safety of each treatment strategy is discussed. We review the individualized features of the patient that should guide the selection of treatments in a shared decision-making continuum. We provide guidance for optimizing initiation of treatment and follow-up of patients in clinical settings.