Multimodal treatments versus pharmacotherapy alone in children with psychiatric disorders: implications of access, effectiveness, and contextual treatment

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.

Coping With Information Style, Self-Concealment, Internalized Stigma, and Family Burden Among Parents of Children With Psychiatric Disorders

Parents of children with psychiatric disorders who are hospitalized in a psychiatric unit often experience family burden. Family burden has been found to be affected by many variables related to parents' personal traits and ways of reacting to the disorder. The current study examined the association between information coping styles (monitoring and blunting) and family burden, among parents of children who were hospitalized in a day care unit. The possible role of self-stigma as a mediator between coping style and family burden and the role of self-concealment as a moderator between coping style and self-stigma were examined. A total of 41 parents completed questionnaires assessing their levels of self-stigma, information coping style, self-concealment, and family burden. Self-stigma was found to mediate the positive association between the monitoring coping style and family burden. Moreover, a moderation effect of self-concealment was found, indicating that monitoring parents suffered from higher levels of self-stigma particularly if they had a high tendency toward self-concealment. Taking into account parents' information, coping style, self-stigma, and self-concealment can help professionals tailor family interventions according to parents' diverse needs. A monitoring coping style may not be beneficial especially when combined with concealment, suggesting the need to promote other coping styles.

An International Survey of Health Care Services Available to Patients With Tourette Syndrome

Objective: Tourette syndrome (TS) is a neuropsychiatric disorder that is highly associated with several comorbidities. Given the complex and multifaceted nature of TS, the condition is managed by a wide variety of practitioners in different disciplines. The goal of this study was to investigate health service delivery and care practices by clinicians who see TS patients across different geographic settings internationally. Methods: A comprehensive questionnaire was developed to assess clinical care resources for patients with TS and was sent to clinicians in Canada (CA), the United States (US), Europe (EU), and the United Kingdom (UK). Responses were compared quantitatively between geographic regions. Results: The majority of respondents, regardless of region, reported that fewer than 40% of their case-load are patients with tics. The accessibility of TS services varied among regions, as indicated by differences in wait times, telemedicine offerings, comorbidity management and the availability of behavioral therapies. First-line pharmacotherapy preferences varied among physicians in different geographical regions with CA respondents preferring alpha-2-adrenergic agonists and respondents from the UK and EU preferring dopamine receptor antagonists. Discussion: The results suggest that there is a scarcity of specialized TS clinics, potentially making access to services challenging, especially for patients newly diagnosed with TS. Differences in regional pharmacotherapeutic preferences are reflected in various published treatment guidelines in EU and North America. The lack of dedicated specialists and telemedicine availability, coupled with differences in comorbidity management, highlight the need for interprofessional care and holistic management to improve health care delivery to patients with TS.

Is psychoeducation for parents and teachers of children and adolescents with ADHD efficacious? A systematic literature review

Objective

To identify evidence from comparative studies on the effects of psychoeducation programs on clinical outcomes in children and adolescents with ADHD.

Method

Articles published between January 1980 and July 2010 were searched through electronic databases and hand search. A qualitative systematic review of comparative studies of psychoeducation in ADHD was performed. Psychoeducation was considered if studies use a specific therapeutic program focusing on the didactically communication of information and provide patients and families with coping skills.

Results

Seven studies were identified (four randomized-controlled trials, three uncontrolled pre-post treatment designs). Studies differed on whether psychoeducation approaches were applied to parents of ADHD children (three studies), to ADHD children/adolescents and their families (three studies) or to their teachers (one study). Positive outcomes measured as improvement on a number of different variables, including patient's behavior, parent and child satisfaction, child's knowledge of ADHD, children's opinion of the use of medication and adherence to medical recommendations were found.

Conclusions

Although available evidence is limited and some findings may be difficult to be interpreted, the positive role of psychoeducation and other educational interventions in children and adolescents with ADHD in regard to several outcome measures is supported by most of the literature referenced in this review.

The Care of Patients With Complex Mood Disorders

This article focuses on some common dilemmas facing clinicians, patients, and families in managing the treatment of complicated mood disorders. Specifically, this article reviews the interaction of depressive states, including unipolar, bipolar, and mixed, with other adversities, including comorbid physical and psychological disorders, personality vulnerabilities, misuse of drugs and alcohol, and social and family problems. These issues are not always clearly differentiated from the depressive illness. Each of these adversities can worsen an existing mood disorder and influence the patient's resolve to persist with a treatment plan. Although this article is not focused strictly on treatment-resistant depression, these coexisting issues make depressive states harder to manage therapeutically. For brevity, the aim of this article has been limited to discussion of some complex situations that psychiatrists in general practice may encounter.

Adaptive Interventions in Child and Adolescent Mental Health

The treatment or prevention of child and adolescent mental health (CAMH) disorders often requires an individualized, sequential approach to intervention, whereby treatments (or prevention efforts) are adapted over time based on the youth's evolving status (e.g., early response, adherence). Adaptive interventions are intended to provide a replicable guide for the provision of individualized sequences of interventions in actual clinical practice. Recently, there has been great interest in the development of adaptive intervenions by investigators working in CAMH. The development of such replicable, real-world, individualized sequences of decision rules to guide the treatment or prevention of CAMH disorders represents an important "next step" in interventions research. The primary purpose of this special issue is to showcase some recent work on the science of adaptive interventions in CAMH. In this overview article, we review why individualized sequences of interventions are needed in CAMH, provide an introduction to adaptive interventions, briefly describe each of the articles included in this special issue, and describe some exciting areas of ongoing and future research. A hopeful outcome of this special issue is that it encourages other researchers in CAMH to pursue creative and significant research on adaptive interventions.

Intervention for executive functions in attention deficit and hyperactivity disorder

This study aimed to investigate if an executive functions (EF) intervention could promote these skills in individuals with attention deficit and hyperactivity disorder (ADHD). Eighteen children and adolescents, 7-13 years old, divided into experimental (EG, N = 8) and control (CG, N = 10) groups, were assessed in the Block Design and Vocabulary subtests of the WISC III and seven tests of EF. Parents answered two scales, measuring EF and inattention and hyperactivity signs. EG children participated in a program to promote EF in twice-weekly group sessions of one hour each. After 8 months of intervention, groups were assessed again. ANCOVA, controlling for age, intelligence quotient and pretest performance, revealed gains in attention/inhibition and auditory working memory measures for the EG. No effect was found for scales or measures of more complex EF. Results are not conclusive, but they illustrate some promising data about EF interventions in children and adolescents with ADHD.

Psychosocial treatments for ADHD: a systematic appraisal of the evidence

OBJECTIVE

Children with learning disabilities often experience comorbid ADHD, impacting on the effectiveness of interventions for those children. In addition to pharmacologic intervention, clinicians and educators employ a variety of psychosocial methods to address the behavioral and social issues that arise in children with ADHD, including those with co-occurring learning disabilities. Numerous systematic reviews and meta-analyses have been conducted examining treatment studies using psychosocial interventions for children with ADHD. Because of the importance of such reviews to evidence based clinical and educational practice, it is essential that reviews be conducted with rigorous methodologies to avoid bias in conclusions (Schlosser, Wendt, & Sigafoos, 2007). The purpose of this study was to evaluate the quality of systematic reviews and meta-analyses conducted for psychosocial treatments of ADHD in children.

METHOD

Electronic databases were searched for peer-reviewed, English language studies of psychosocial treatments for ADHD in children up to 18-years-old from 1998 to 2010. Twenty-one studies were identified that met inclusion criteria (13 systematic reviews, 8 meta-analyses). Independent examiners used the quality rating scale proposed by Auperin, Pignon, and Pynard (1997) to rate the characteristics of good systematic reviews and meta-analyses.

RESULTS

Results indicated that certain methodological characteristics were common across trials reviewed, yet shortcomings were common among most reviews, including inadequate descriptions of data extraction methods and lack of quality ratings for trials included in the reviews.

CONCLUSION

Synthesis of findings from the five top-rated reviews and the literature on ADHD suggest that psychosocial treatments contribute to improvements on behavioral and social outcomes. How ADHD and LD interplay in treatment outcomes is largely unexplored.

Health care needs of children with Tourette syndrome

To document the impact of Tourette syndrome on the health care needs of children and access to health care among youth with Tourette syndrome, parent-reported data from the 2007-2008 National Survey of Children's Health were analyzed. Children with Tourette syndrome had more co-occurring mental disorders than children with asthma or children without Tourette syndrome or asthma and had health care needs that were equal to or greater than children with asthma (no Tourette syndrome) or children with neither asthma nor Tourette syndrome. Health care needs were greatest among children with Tourette syndrome and co-occurring mental disorders, and these children were least likely to receive effective care coordination. Addressing co-occurring conditions may improve the health and well-being of children with Tourette syndrome. Strategies such as integration of behavioral health and primary care may be needed to improve care coordination.

Neurofeedback for the treatment of children and adolescents with ADHD: a randomized and controlled clinical trial using parental reports

BACKGROUND

A randomized and controlled clinical study was performed to evaluate the use of neurofeedback (NF) to treat attention-deficit/hyperactivity disorder (ADHD) in children and adolescents.

METHODS

The ADHD population was selected from an outpatient clinic for Child and Adolescent Mental Health in Norway. Ninety-one of the 275 children and adolescents ranging in age from 6 to 18 years (10.5 years) participated in 30 sessions of an intensive NF program. The reinforcement contingency was based on the subjects' production of cortical beta1 activity (15-18 Hz). The ADHD participants were randomized into three groups, with 30 in the NF group, 31 controls in a group that was given methylphenidate, and 30 in a group that received NF and methylphenidate. ADHD core symptoms were reported by parents using the parent form of the Clinician's Manual for Assessment by Russell A. Barkley.

RESULTS

Ninety-one children and adolescents were effectively randomized by age, sex, intelligence and distribution of ADHD core symptoms. The parents reported significant effects of the treatments, but no significant differences between the treatment groups were observed.

CONCLUSIONS

NF was as effective as methylphenidate at treating the attentional and hyperactivity symptoms of ADHD, based on parental reports.

TRIAL REGISTRATION

Current Controlled Trials NCT01252446.

Amfetamine and methylphenidate medications for attention-deficit/hyperactivity disorder: complementary treatment options

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among school-aged children. It is highly symptomatic and associated with significant impairment. This review examines the role of stimulant medications in the treatment of children and adolescents with ADHD. Published clinical studies that compared methylphenidate- and amfetamine-based stimulants in children and adolescents with ADHD support the therapeutic utility of stimulant treatments, and suggest robust efficacy and acceptable safety outcomes in groups treated with either stimulant. Evidence-based guidelines agree that each patient with ADHD is unique and individual treatment strategies that incorporate both drug and non-drug treatment options should be sought. In seeking to optimize individual response and outcomes to stimulant therapy, important considerations include the selection of stimulant class, the choice of long- or short-acting stimulant formulations, addressing effectively any emergent adverse effects and strategies aimed at enhancing adherence to dosing regimen and persistence on therapy.

Parent training interventions for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 5 to 18 years

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterised by high levels of inattention, hyperactivity and impulsivity that are present before the age of seven years, seen in a range of situations, inconsistent with the child's developmental level and causing social or academic impairment. Parent training programmes are psychosocial interventions aimed at training parents in techniques to enable them to manage their children's challenging behaviour.

OBJECTIVES

To determine whether parent training interventions are effective in reducing ADHD symptoms and associated problems in children aged between five and eigtheen years with a diagnosis of ADHD, compared to controls with no parent training intervention.

SEARCH METHODS

We searched the following electronic databases (for all available years until September 2010): CENTRAL (2010, Issue 3), MEDLINE (1950 to 10 September 2010), EMBASE (1980 to 2010 Week 36), CINAHL (1937 to 13 September 2010), PsycINFO (1806 to September Week 1 2010), Dissertation Abstracts International (14 September 2010) and the metaRegister of Controlled Trials (14 September 2010). We contacted experts in the field to ask for details of unpublished or ongoing research.

SELECTION CRITERIA

Randomised (including quasi-randomised) studies comparing parent training with no treatment, a waiting list or treatment as usual (adjunctive or otherwise). We included studies if ADHD was the main focus of the trial and participants were over five years old and had a clinical diagnosis of ADHD or hyperkinetic disorder that was made by a specialist using the operationalised diagnostic criteria of the DSM-III/DSM-IV or ICD-10. We only included trials that reported at least one child outcome.

DATA COLLECTION AND ANALYSIS

Four authors were involved in screening abstracts and at least 2 authors looked independently at each one. We reviewed a total of 12,691 studies and assessed five as eligible for inclusion. We extracted data and assessed the risk of bias in the five included trials. Opportunities for meta-analysis were limited and most data that we have reported are based on single studies.

MAIN RESULTS

We found five studies including 284 participants that met the inclusion criteria, all of which compared parent training with de facto treatment as usual (TAU). One study included a nondirective parent support group as a second control arm.  Four studies targeted children's behaviour problems and one assessed changes in parenting skills. Of the four studies targeting children's behaviour, two focused on behaviour at home and two focused on behaviour at school. The two studies focusing on behaviour at home had different findings: one found no difference between parent training and treatment as usual, whilst the other reported statistically significant results for parent training versus control. The two studies of behaviour at school also had different findings: one study found no difference between groups, whilst the other reported positive results for parent training when ADHD was not comorbid with oppositional defiant disorder. In this latter study, outcomes were better for girls and for children on medication.We assessed the risk of bias in most of the studies as unclear at best and often as high. Information on randomisation and allocation concealment did not appear in any study report. Inevitably, blinding of participants or personnel was impossible for this intervention; likewise, blinding of outcome assessors (who were most often the parents who had delivered the intervention) was impossible.We were only able to conduct meta-analysis for two outcomes: child 'externalising' behaviour (a measure of rulebreaking, oppositional behaviour or aggression) and child 'internalising' behaviour (for example, withdrawal and anxiety). Meta-analysis of three studies (n = 190) providing data on externalising behaviour produced results that fell short of statistical significance (SMD -0.32; 95% CI -0.83 to 0.18, I(2) = 60%). A meta-analysis of two studies (n = 142) for internalising behaviour gave significant results in the parent training groups (SMD -0.48; 95% CI -0.84 to -0.13, I(2) = 9%). Data from a third study likely to have contributed to this outcome were missing, and we have some concerns about selective outcome reporting bias.Individual study results for child behaviour outcomes were mixed. Positive results on an inventory of child behaviour problems were reported for one small study (n = 24) with the caveat that results were only positive when parent training was delivered to individuals and not groups. In another study (n = 62), positive effects (once results were adjusted for demographic and baseline data) were reported for the intervention group on a social skills measure.The study (n = 48) that assessed parenting skill changes compared parent training with a nondirective parent support group. Statistically significant improvements were reported for the parent training group. Two studies (n = 142) provided data on parent stress indices that were suitable for combining in a meta-analysis. The results were significant for the 'child' domain (MD -10.52; 95% CI -20.55 to -0.48) but not the 'parent' domain (MD -7.54; 95% CI -24.38 to 9.30). Results for this outcome from a small study (n = 24) suggested a long-term benefit for mothers who received the intervention at an individual level; in contrast, fathers benefited from short-term group treatment. A fourth study reported change data for within group measures of parental stress and found significant benefits in only one of the two active parent training group arms (P ≤ 0.01).No study reported data for academic achievement, adverse events or parental understanding of ADHD.

AUTHORS' CONCLUSIONS

Parent training may have a positive effect on the behaviour of children with ADHD. It may also reduce parental stress and enhance parental confidence. However, the poor methodological quality of the included studies increases the risk of bias in the results. Data concerning ADHD-specific behaviour are ambiguous. For many important outcomes, including school achievement and adverse effects, data are lacking.Evidence from this review is not strong enough to form a basis for clinical practice guidelines. Future research should ensure better reporting of the study procedures and results.

Psychoeducational groups for youth attention-deficit hyperactivity disorder: a family medicine pilot project

Attention-deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioural disorder of youth and is estimated to affect ∼4% of school-age children. Although medication is the most common and efficacious treatment for ADHD, some experts believe that multimodal treatment strategies help children improve symptoms more than medicine alone. Psychoeducational strategies focus on educating youth and families about a given disorder. This study compared youth who participated with their parents in a five-session, one-hour psychoeducational group at a family medicine clinic and those who received customary treatment and were on a waiting list for the intervention. Findings of youth behaviour from parent and teacher perspectives were compared at the outset of the group and one month after group completion using the Vanderbilt scales. Results revealed that youth in both conditions improved over the two months of the study from the parent perspective in terms of all ADHD symptoms (e.g. inattention, hyperactivity/impulsivity) and in terms of school functioning. However, no gains were made in youth functioning or ADHD behaviour from the teacher perspective. Youth in the treatment group made modest gains in school performance from the parent perspective when compared with youth in the control condition. The results suggest that parents of ADHD youth should be involved in the treatment process to maximise the likelihood of improvement. Psychoeducational groups can be of modest benefit to help educate parents and youth regarding the challenges of ADHD management.

Point-counter-point: psychotherapy in the age of pharmacology

The long-held view that medicine or therapy is an "art" is quickly becoming obsolete. To procure referrals and reimbursement, clinicians are being forced to be accountable (ie, use empirically supported, effective, reproducible, and efficient treatment interventions) by insurance companies, professional credentialing bodies, and their consumers. This article focuses on reviews of treatment interventions by scholars, researchers, clinicians, and study groups who have examined multiple databases of published studies and ongoing treatment protocols. Behavioral and cognitive-behavioral therapies were most often identified as well-established treatments for specific mental and behavioral health disorders in children and adolescents. Psychotherapy alone or in conjunction with pharmacotherapy can be powerful tools in helping youth manage or eliminate negative outcomes of mental and behavioral disorders.