Attention Deficit/Hyperactivity Disorder in Children with Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic neurological autoimmune disease; pediatric-onset multiple sclerosis (POMS) represents 5% to 10% of total MS population. Children with POMS may experience attention difficulties due to the disease's impact on the central nervous system. However, little is known regarding Attention Deficit Hyperactivity Disorder (ADHD) in POMS, and its relation to cognitive performance.

METHODS

A retrospective case review was conducted using medical records of 66 children and adolescent patients diagnosed with POMS between 2012 and 2021 in a MS center of a tertiary medical center. All patients had undergone routine clinical neurological examinations and had been assessed for a diagnosis of ADHD by a department pediatric neurologist. In addition, sociodemographic data, disease-related variables, and cognitive performance were collected.

RESULTS

Of the 66 patients, 31 (47%) had a diagnosis of ADHD; 29 (44%) had cognitive impairment. Moreover, we identified four different profiles of POMS: those with only ADHD (17, 26%); only cognitive impairment (15, 23%), ADHD and cognitive impairment (14, 21%), and only POMS (20, 30%). A significant difference in disease duration was found among the four profiles [F(3,65) = 8.17, p < .001, η² = 0.29], indicating that patients with ADHD and cognitive impairment were characterized by longer disease duration.

CONCLUSIONS

ADHD may be prominently involved in POMS, even during the early stages of the disease and early diagnosis is crucial in order to provide appropriate interventions and support.

Barriers and Enablers of Service Access and Utilization for Children and Adolescents With Attention Deficit Hyperactivity Disorder: A Systematic Review

OBJECTIVE

To update a systematic review of the literature on the barriers and enablers of service access and utilization for children and adolescents with a diagnosis, or symptoms of attention deficit/hyperactivity disorder (ADHD), from the perspective of caregivers, clinicians, and teachers.

METHODS

Five databases were searched for peer-reviewed literature published from May 2012 to March 2023. Two independent reviewers completed a two-stage screening process and quality assessment.

RESULTS

Of 4,523 search results, 30 studies were included. Five main themes were generated: 1) Awareness of ADHD, 2) Stigma, 3) Parental choice and partnerships, 4) Education services as an integral component, 5) Referrals, waiting times, and logistics. More than half of the studies reported poor acknowledgement, expertise of ADHD, and stigma.

CONCLUSION

Findings highlight the need for ongoing ADHD education for all involved and policy changes to service delivery systems to increase the availability of health providers with specialist ADHD expertise.

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.

Overcoming the Odds: Does Social Support Make a Difference for Young People With ADHD Symptoms?

OBJECTIVES

Young adults with ADHD symptoms have a risk of negative outcomes in cognitive development, emotional development, and social developmental problems. The research question is: Does social support make a difference for children with ADHD symptoms?

METHOD

Children born in 1984 were interviewed at age 25. The survey then obtained a 67% response rate which measures up to 2,980 interviewed persons. Validated constructs were used to measure outcomes, mediator, and ADHD symptoms.

RESULTS

Young people with ADHD symptoms have an increased rate of low educational achievement, low self-esteem, loneliness, suicide considerations, PTSD symptoms, behavioral problems, criminal behavior, peer problems, and substance abuse. Social support is a partial mediator for the negative outcomes except for criminal behavior and substance abuse problems.

CONCLUSIONS

Loss of social support partly explains the mentioned negative outcomes and we would suggest that future research also look for other mediators. These results indicate potential interventions.

Predictors of Engagement Barriers for Adolescent ADHD Treatment

OBJECTIVE

The purpose of this study was to understand patient characteristics that predict engagement barriers during behavior therapy for ADHD.

METHOD

Participants were 121 adolescents with ADHD and parents who received evidence-based behavior therapy for ADHD. Multiple regression examined relationships between six independent variables and frequency of barriers.

RESULTS

ODD comorbidity and parental ADHD predicted higher frequency of overall barriers. With respect to barriers subtypes, these variables also predicted higher frequencies of cognitive, teen, early-treatment and mid-treatment barriers. Late-treatment, ODD predicted higher frequency of barriers, while minority status predicted lower barriers.

CONCLUSIONS

Adolescents diagnosed with ADHD and comorbid ODD, or who have parents that are also diagnosed with ADHD, are at greatest risk for engagement barriers during behavior therapy. During all phases of treatment, this patient subgroup would benefit from enhancements to standard behavior therapy that focus on therapeutic engagement-particularly targeting teen beliefs about treatment.

Medication Use for ADHD and the Risk of Driving Citations and Crashes Among Teenage Drivers: A Population-Based Cohort Study

Objectives: To evaluate the real-world effectiveness of ADHD medications on adverse driving outcomes in teenage drivers with ADHD. Method: We retrospectively followed 15- to 20-year-old ADHD patients with valid driver's license to compare the risk for crashes and citations between periods with and without ADHD medication use, using Florida Medicaid records linked to Department of Motor Vehicles data from 1999 to 2004. Patient-level demographic, clinical, and driver licensing characteristics as well as county-level crash and traffic statistics were adjusted in Cox models. Results: A total of 2,049 patients had 67 crashes and 319 citations. Adjusted hazard ratios comparing ADHD medication use versus no use were 1.22 (95% confidence interval [CI] = [0.66, 1.90]) and 0.89 (95% CI = [0.69, 1.13]) for crashes and citations, respectively. Conclusion: Our study showed no evidence that ADHD medication use was associated with a reduced risk of adverse driving outcomes among teenage drivers enrolled in Medicaid programs. Limitations in interpreting this finding are presented.

Prevalence and Correlates of Self-Reported ADHD Symptoms in Children Attending School in India

Objective: To study the prevalence and correlates of self-reported ADHD symptoms among school-going adolescents from Kerala, India. Method: Seven thousand five hundred sixty students from Classes 8, 10, and 12, aged 12 to 19 years, across 73 schools selected by cluster random sampling, were invited to participate, but only 7,150 successfully completed the questionnaire incorporating standardized instruments. Results: Three hundred five (4.3%) self-reported symptoms for ADHD combined type, 131 (1.8%) for ADHD hyperactive-impulsive type, and 102 (1.4%) for ADHD inattentive type with a male predominance. Binary logistic regression analysis showed that those with symptoms of ADHD (combined type) compared with the non-ADHD group had poorer academic performance, significantly higher substance use, psychological distress, suicidality, and sexual abuse. Conclusion: The high prevalence of self-reported ADHD symptoms and its association with negative correlates previously reported in literature in those with a diagnosis of ADHD suggests that clinically significant self-reported ADHD symptoms could be as disabling as ADHD.

The Effects of Different Types of Environmental Noise on Academic Performance and Perceived Task Difficulty in Adolescents With ADHD

Objective: To examine the effects of environmental noises (speech and white noise) relative to a no noise control condition on the performance and difficulty ratings of youth with ADHD (N = 52) on academic tasks. Method: Reading performance was measured by an oral retell (reading accuracy) and the time spent reading. Writing performance was measured through the proportion of correct writing sequences (writing accuracy) and the total words written on an essay. Results: Participants in the white noise condition took less time to read the passage and wrote more words on the essay compared with participants in the other conditions, though white noise did not improve academic accuracy. The participants in the babble condition rated the tasks as most difficult. Conclusion: Although white noise appears to improve reading time and writing fluency, the findings suggest that white noise does not improve performance accuracy. Educational implications are discussed.

High School Athletes With ADHD and Learning Difficulties Have a Greater Lifetime Concussion History

Objective: Examine lifetime history of concussions in adolescents who have developmental problems in comparison with those with no developmental problems. Method: Thirty-two thousand four hundred eighty-seven adolescent athletes completed baseline/pre-season evaluations. Based on self-reported histories, athletes were divided into four groups: ADHD only, ADHD and learning difficulties (LD), LD only, and controls. Results: Athletes with ADHD, LD, or ADHD plus LD reported a greater prevalence of prior concussions than athletes without these developmental conditions (ps < .05). When adjusting for sex differences in concussion prevalence rates (boys are greater than girls), there was an increase in prevalence of prior injuries in those with ADHD, and ADHD plus learning difficulties compared with those with LD only. This pattern was found for both girls and boys. There was no additive effect of having both conditions. Conclusion: Developmental conditions in adolescent athletes, such as ADHD and learning difficulties, are associated with a greater prevalence rate of prior concussion.

Research Brief: The Teen ADHD Workshop to Improve Adolescent ADHD Treatment Engagement

Objective: Adolescents with ADHD are at risk of functional problems that may be mitigated by consistent ADHD treatment. This study pilots a brief intervention for adolescents with ADHD and their parents to increase treatment knowledge and family motivation to seek treatment. Method: The 3-hr curriculum was developed by a multidisciplinary team and included psychoeducation, goal setting, and motivational interviewing. Fifteen adolescents and 20 caregivers participated in the workshop, completed pre- and post-test assessments, and reported on acceptability. Results: Acceptability and satisfaction with the intervention were high. Perceived knowledge of ADHD increased post intervention; stigma was unchanged. Parents reported more acceptability of stimulant medications and less willingness to use special diets or cognitive games. Family feedback informed modifications to the curriculum. Conclusion: The Teen ADHD Workshop is a feasible and acceptable intervention to increase knowledge of ADHD and evidence-based treatments. Further research will evaluate effects on treatment participation.

Testing the Similarity Fit/Misfit Hypothesis in Adolescents and Parents With ADHD

OBJECTIVE

Higher rates of conflict are observed between adolescents with ADHD and their parents due to cognitive, academic, social, and behavioral difficulties. Conflict should be even more pronounced when parents have ADHD themselves; however, some research suggests that parents with ADHD may have increased tolerance toward children who share similar challenges (i.e., similarity-fit hypothesis).

METHOD

We tested the similarity-fit model and its converse, the similarity-misfit model, in a sample of 93 ADHD adolescents, 63 comparison adolescents, and their parents with varying levels of ADHD. Quantity and intensity of conflict were examined in mothers and fathers separately.

RESULTS

We found evidence for the similarity-fit process in fathers, and similarity misfit in mothers, particularly regarding quantity of conflict between parent and adolescent.

CONCLUSION

Results indicate the importance of differential parental roles in mothers and fathers, and have implications for involving parents in treatment for ADHD in adolescents.

Internet Activities During Leisure: A Comparison Between Adolescents With ADHD and Adolescents From the General Population

OBJECTIVE

Adolescents' leisure activities are increasingly focusing on Internet activities, and today, these coexist with traditional leisure activities such as sport and meeting friends. The purpose of the present study was to investigate leisure activities, particularly Internet activities, among boys and girls with ADHD, and compare these with boys and girls from the general population. The objective was also to explore how traditional leisure activities and Internet activities interrelate among adolescents with ADHD.

METHOD

Adolescents with ADHD ( n = 102) were compared with adolescents from the general population on leisure activities and Internet use.

RESULTS

Leisure activities among adolescents with ADHD tended to focus on Internet activities, particularly online games. Internet activities were broadening leisure activities among adolescents with ADHD, rather than being a substitute for traditional leisure activities.

CONCLUSION

Internet activities may provide adolescents with ADHD accessible means of social interaction.

Regional Gray Matter Volume Differences Between Adolescents With ADHD and Typically Developing Controls: Further Evidence for Anterior Cingulate Involvement

OBJECTIVE

The present study investigated structural brain differences between adolescents with ADHD and matched control participants.

METHOD

Voxel-based morphometry (VBM) using the DARTEL approach was performed to assess regional gray matter (GM) volumes. Additionally, individual performance on tests of attention was recorded to correlate ADHD related cognitive impairments with regional gray matter abnormalities.

RESULTS

We found significantly smaller GM volume in subjects with ADHD compared to their matched controls within the anterior cingulate cortex (ACC), the occipital cortex, bilateral hippocampus/amygdala and in widespread cerebellar regions. Further, reductions of the ACC gray matter volume were found to correlate with scores of selective inattention.

CONCLUSION

These findings underline that structural alterations in a widespread cortico-subcortical network seem to underlie the observable attention problems in patients with ADHD.

Prevalence and Correlates of ADHD Among Adolescent Students in Nigeria

OBJECTIVE

To determine the prevalence and psychosocial correlates of ADHD among adolescents in Jos, Nigeria.

METHOD

A cross-sectional descriptive two-stage study of 487 randomly selected participants using Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL), Raven's Standard Progressive Matrix (SPM) and the Children's Global Assessment Score (CGAS).

RESULTS

The prevalence of ADHD was 8.8%. The subtypes found were inattentive (3.08%), hyperactive-impulsive (2.05%), and combined (3.08%); male:female ratio of 1.4:1. ADHD was significantly associated with use of substance by father (odds ratio [OR] = 0.35; 95% confidence interval [CI] = [0.154, 0.781]), use of substance by mother (OR = 0.2; 95% CI = [0.055, 0.711]), and lower education of mother (OR = 0.3 95% CI = [0.116, 0.693]). Poor quality of handwriting (χ² = 8.120; p = .010) and impaired global functioning ( t test = 10.756; p < .001) were significantly associated with ADHD in the adolescents.

CONCLUSION

Given the burden of ADHD, efforts should be made to establish a system for the early identification and management.

The Romantic Relationships of Adolescents With ADHD

OBJECTIVE

This study compared the romantic relationships of adolescents with and without ADHD with regard to romantic involvement, relationship content, and relationship quality.

METHOD

A community sample of 58 participants (30 ADHD, 28 Comparison), ages 13 to 18, completed questionnaires assessing various features of romantic relationships.

RESULTS

Adolescents with ADHD reported having more romantic partners than their typically developing (TD) peers. Females with ADHD were found to have shorter romantic relationships than TD adolescents while males with ADHD reported their age of first intercourse to be nearly 2 years sooner than TD peers. Irrespective of gender, adolescents with ADHD had nearly double the number of lifetime sexual partners. However, the romantic relationships of adolescents with and without ADHD did not differ on levels of aggression or relationship quality.

CONCLUSION

Given the outcomes associated with poor-quality romantic relationships, comprehensive assessments of adolescents with ADHD should include queries into their romantic relationships.

Planning Skills of Adolescents With ADHD

OBJECTIVE

This study assesses planning skills of adolescents with ADHD using a multi-method assessment and explores subtype differences between inattentive and combined subtypes.

METHOD

One hundred fifteen adolescents with ADHD and 34 typically developing controls completed subtests of the Delis-Kaplan Executive Function System (D-KEFS), Behavioral Assessment of the Dysexecutive Syndrome (BADS), and Behavior Rating Inventory of Executive Function (BRIEF).

RESULTS

No group differences were found on the D-KEFS. The BADS Zoo Map test showed longer completion times in the inattentive than in the combined subtype and controls. The BRIEF showed more planning problems in adolescents with ADHD (both subtypes) than in controls, with the combined subtype showing most problems on overall executive functioning.

CONCLUSION

Only a proportion of adolescents with ADHD shows planning deficits. To capture these planning problems in adolescents with ADHD, it seems important to use multiple measures of planning, both ratings and "less structured" neurocognitive measures of planning.

Adolescents With ADHD: Experiences of Having an ADHD Diagnosis and Negotiations of Self-Image and Identity

OBJECTIVE

To develop an understanding of the meanings and consequences of a diagnosis of ADHD for young people during the transition from childhood to adolescence.

METHOD

Nine youth with an ADHD diagnosis were interviewed using a semi-structured interview guide on topics of management of identity and their own experiences of their difficulties relating to ADHD.

RESULTS

The meanings and consequences of the ADHD diagnosis is best understood in terms of overall identity development and social connectedness. In addition, cultural understandings of what ADHD is play a major role in negotiating the role of ADHD in identity.

CONCLUSION

Youth with ADHD moving from childhood to adulthood need support for identity development. Health care professionals should be aware of young people's experiences of ADHD symptoms in the context of their life situations and the cultural understanding of ADHD during treatment and psychoeducation.

Diagnostic and Demographic Differences Between Incarcerated and Nonincarcerated Youth (Ages 6-15) With ADHD in South Carolina

OBJECTIVE

Analyze diagnostic and demographic factors to identify predictors of delinquency resulting in incarceration within a group of children/adolescents diagnosed with ADHD.

METHOD

The study followed a cohort of 15,472 Medicaid covered children/adolescents with ADHD, ages 6 to 15 inclusive, between January 1, 2003, and December 31, 2006. The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [ DSM-IV-TR]), 2000 Codes were used for qualifying diagnosis codes. Available demographic characteristics included race, sex, and residence. The outcome was incarceration at the South Carolina Department of Juvenile Justice during 2005-2006.

RESULTS

Among youth with ADHD, incarceration was more likely among black, male, and urban youth. Children/adolescents with comorbid ODD and/or CD were at greater risk compared with those with ADHD alone.

CONCLUSION

Within ADHD-diagnosed youth, comorbid conditions and demographic characteristics increase the risk of incarceration. Intervention and treatment strategies that address behavior among youth with these characteristics are needed to reduce incarceration.

Self-Awareness of Executive Functioning Deficits in Adolescents With ADHD

OBJECTIVE

Children with ADHD lack self-awareness of their social and academic deficits, frequently rating themselves more favorably than external sources. The purpose of the current study was to assess whether adolescents with ADHD also hold a positive bias toward their executive functioning (EF).

METHOD

Participants include 22 control and 35 ADHD subjects, aged 11 to 16. Participants and their parents completed the Behavior Rating Inventory of Executive Functioning (BRIEF) Self and Parent forms, respectively. Discrepancy scores were calculated for each domain by subtracting the adolescents' T-score from the parents' T-score.

RESULTS

Discrepancy scores were significantly higher in the ADHD group than controls within the Inhibit, Shift, Monitor, Emotional Control, Working Memory, and Plan/Organization domains (all p < .05).

CONCLUSION

As compared with controls, adolescents with ADHD tend to endorse fewer EF difficulties than what parents report. This is the first study to demonstrate that those with ADHD may overestimate their EF ability.

Feasibility of School-Based ADHD Interventions: A Mixed-Methods Study of Perceptions of Adolescents and Adults

OBJECTIVE

Little is known about perceptions surrounding academic interventions for ADHD that determine intervention feasibility.

METHOD

As part of a longitudinal mixed-methods research project, representative school district samples of 148 adolescents (54.8%), 161 parents (59.4%), 122 teachers (50.0%), 46 health care providers (53.5%), and 92 school health professionals (65.7%) completed a cross-sectional survey. They also answered open-ended questions addressing undesirable intervention effects, which were analyzed using grounded theory methods.

RESULTS

Adolescents expressed significantly lower receptivity toward academic interventions than adult respondents. Stigma emerged as a significant threat to ADHD intervention feasibility, as did perceptions that individualized interventions foster inequality.

CONCLUSION

Findings suggest that adolescents' viewpoints must be included in intervention development to enhance feasibility and avoid interventions acceptable to adults, but resisted by adolescents.

Changing Academic Support in the Home for Adolescents with Attention-Deficit/Hyperactivity Disorder: A Family-Based Clinical Protocol for Improving School Performance

Attention-Deficit/Hyperactivity Disorder (ADHD) is highly prevalent among adolescent clinical populations and associated with myriad deficits in school functioning. Yet, behavior therapists have few developmentally appropriate tools for addressing school problems in this group. This article introduces a behavioral protocol designed to fill the gap: Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA). CASH-AA is a family-based intervention that targets home environment, adolescent skills, and family-school partnership characteristics in order to improve school performance. Protocol components are derived from three evidence-based approaches for adolescent behavior problems: family psychoeducation, clinical family interventions to heighten adolescent and caregiver motivation to change, and training interventions for homework planning and organization skills. CASH-AA contains four treatment modules: (1) Psychoeducation: ADHD and Academic Functioning; (2) Motivation & Preparation: Home Academic Environment; (3) Behavior Change: School Attendance and Homework Plan; (4) Collaboration: Therapist-Family-School Partnership. The protocol can be implemented as a stand-alone intervention for ADHD or an adjunct to other behavioral interventions for co-occurring disorders. Two case examples with markedly different treatment profiles are presented to illustrate the utility and flexibility of the protocol.

Clinical Strategies for Integrating Medication Interventions Into Behavioral Treatment for Adolescent ADHD: The Medication Integration Protocol

Attention-Deficit/Hyperactivity Disorder (ADHD) is highly prevalent among adolescents enrolled in behavioral health services but remains undertreated in this age group. Also the first-line treatment for adolescent ADHD, stimulant medication, is underutilized in routine practice. This article briefly describes three behavioral interventions designed to promote stronger integration of medication interventions into treatment planning for adolescent ADHD: family ADHD psychoeducation, family-based medication decision-making, and behavior therapist leadership in coordinating medication integration. It then introduces the Medication Integration Protocol (MIP), which incorporates all three interventions into a five-task protocol: ADHD Assessment and Medication Consult; ADHD Psychoeducation and Client Acceptance; ADHD Symptoms and Family Relations; ADHD Medication and Family Decision-Making; and Medication Management and Integration Planning. The article concludes by highlighting what behavior therapists should know about best practices for medication integration across diverse settings and populations: integrating medication interventions into primary care, managing medication priorities and polypharmacy issues for adolescents with multiple diagnoses, providing ADHD medications to adolescent substance users, and the compatibility of MIP intervention strategies with everyday practice conditions.

Adolescent and caregiver reports of ADHD symptoms among inner-city youth: agreement, perceived need for treatment, and behavioral correlates

OBJECTIVE

This study investigated adolescent and caregiver reports of ADHD symptoms in a sample of clinically referred inner-city adolescents.

METHOD

Participants (N = 168) included youth ages 12-18 (54% male, 98% ethnic minority) and their caregivers who each completed diagnostic interviews of ADHD symptoms and assessments of perceived need for ADHD treatment and correlated behavior problems.

RESULTS

Informants showed poor agreement on DSM-IV diagnostic categories and also dimensional scales, Inattention/Disorganization (I/D) and Hyperactivity/Impulsivity (H/I). Both caregiver and adolescent reports of I/D symptoms, but not H/I symptoms, were related to perceived need for ADHD treatment. Caregiver reports were linked to behavioral correlates typically associated with ADHD: I/D symptoms correlated with planning/organization and socioemotional deficits, and H/I symptoms correlated with externalizing and behavior regulation deficits. In contrast, adolescent reports of I/D were related to internalizing and externalizing problems, and their reports of H/I correlated with externalizing only. Few gender effects were found.

CONCLUSION

Study results underscore the developmental salience of I/D symptoms and have implications for ADHD diagnosis and treatment planning for adolescents.

Neural correlates of forethought in ADHD

OBJECTIVE

The purpose of the present investigation was to delineate the neural correlates of forethought in the ADHD children relative to typically developing (TD) children.

METHOD

In all, 21 TD and 23 ADHD adolescents underwent functional magnetic resonance imaging (fMRI) while performing a forethought task. The participants had to identify congruent and incongruent stimuli from cartoon stories representing sequences of action.

RESULTS

The findings revealed significantly greater activation in the bilateral prefrontal cortex (PFC) in TD versus ADHD children, and more activation in the cerebellar vermis in the adolescents with ADHD versus TD, during performance of the incongruent relative to congruent condition.

CONCLUSION

The inverse pattern of activation of the PFC and the cerebellar vermis in both groups could reflect a compensatory role played by the cerebellum or suggest the malfunction of the neural network between those regions in ADHD. Further research of the neural correlates of forethought in ADHD is warranted.