Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults

A Retrospective Chart Review Evaluating the Changes in Depressive Symptoms in Adult Patients With Attention-Deficit/Hyperactivity Disorder (ADHD) With the Treatment of the Underlying ADHD

INTRODUCTION

Adult attention-deficit/hyperactivity disorder (ADHD) represents a significant public health burden. ADHD is often comorbid with many other psychiatric disorders, with a high co-occurrence with depression. However, there is a paucity in our understanding of the potential impact of treating patients' ADHD on their depressive symptoms. The primary objective of this study was to assess the effect of treating adult ADHD on comorbid depressive symptoms without directly administering treatment for depression in an integrated behavioral health clinic in the primary care setting.

METHODS

We performed a retrospective chart review between April 2021 and May 2022 on adult patients treated in the Primary Care Adult Integrated Behavioral Health Clinic at an urban family medicine residency clinic. For patients with ADHD, we administered the Adult ADHD Self-Report Scale (ASRS-v1.1) to serve as a marker of ADHD symptom burden and the nine-item Patient Health Questionnaire (PHQ-9) to serve as a marker of depressive symptom burden. We administered the questionnaires prior to initiating ADHD treatment and again at the three-month follow-up visit. The ADHD treatment included pharmacotherapy and brief psychological interventions targeted at ADHD. We compared the ASRS scores and PHQ-9 scores at baseline and after three months to determine whether ADHD treatment had any impact on PHQ-9 scores.

RESULTS

At baseline, the average ASRS score was 11.3 and the average PHQ-9 score was 8.25. Comparing scores after three months of intervention to the initial scores, our preliminary results demonstrated a trend of improvement in both ASRS and PHQ-9 scores. A total of 75% (n=24/32) of the patients had an improvement in ASRS scores, and 56.7% (n=17/30) of the patients had an improvement in PHQ-9 scores at three months. At three months, there was a decline in PHQ-9 scores with a decrease in ASRS scores following treatment.

CONCLUSION

Our preliminary results suggest that integrated behavioral health treatment of ADHD using a combination of pharmacological and non-pharmacological interventions may play a role in improving comorbid depressive symptoms.

Long-term efficacy of a new 6-session cognitive behavioral therapy for adults with attention-deficit/hyperactivity disorder: A randomized, controlled clinical trial

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder that affects about 2.8 % of the adult population. Cognitive behavioral therapy (CBT) has been demonstrated to be the most effective psychological intervention for ADHD. The aim of this study was to explore the efficacy of a new 6-session CBT program in comparison with a 12-session CBT program for adults with ADHD at short- and long-term.

METHODS

81 adults with ADHD (58 % males; mean age = 41.27±9.26 years old) were randomly assigned to each treatment condition (6- or 12-session CBT). Validated instruments were used to assess ADHD symptoms, comorbidities (anxiety and depression), and functional impairments at post treatment, and at 3- and 6-month follow-up.

RESULTS

A significant improvement in ADHD severity, comorbidities (anxiety and depression) and functional impairments were found in both CBT programs after treatment. Furthermore, this improvement was also reported at 3- and 6-month follow-up.

CONCLUSION

The current study highlights that a 6-session CBT program is as effective as a 12-session CBT program for ADHD improvement at post treatment and follow-up. The newly developed 6-session CBT program can be used to treat a larger number of patients, reducing the financial cost.

Association and Interacting Factors between Bronchial Asthma and Attention-deficit Hyperactivity Disorder in Children: Meta-analysis and Systematic Review

BACKGROUND

This study aims to systematically assess the possible link between bronchial asthma usage and attention-deficit hyperactivity disorder (ADHD) in children.

METHODS

PubMed, Web of Science, ScienceDirect, CNKI, Wanfang, and the China Biological Medicine Database (CBM) were searched for relevant articles published from database inception until September 28, 2023. The statistical analyses were conducted using Stata 15.1 software, followed by a quantitative meta-analysis to synthesize the results of the odds ratios (ORs) and their corresponding 95% confidence intervals (CIs).

RESULTS

A total of 10 articles involving 729,375 participants were included in the meta-analysis. The overall analysis revealed a statistically significant association between ADHD and an increased likelihood of having bronchial asthma, as indicated by a pooled odds ratio (OR) of 1.46 and a 95% confidence interval (CI) ranging from 1.41 to 1.51, p < 0.001, I2 = 58%. Potential associated factors linking bronchial asthma and ADHD in children include demographic characteristics, healthcare access, socioeconomic factors, comorbidities, genetic susceptibility, immune dysregulation, chronic conditions, growth and development factors, and parental/environmental influences.

CONCLUSION

This systematic review and meta-analysis presents convincing evidence for a notable link between bronchial asthma and ADHD in children. The results indicate an increased likelihood of bronchial asthma among children with ADHD compared to those without the condition. Additionally, various potential factors can underlie the association between bronchial asthma and ADHD in children, necessitating further research to fully comprehend their complex relationship. These findings have implications for clinical practice, highlighting the need for an integrated approach in managing asthma and ADHD.

A Digital Mental Health Support Program for Depression and Anxiety in Populations With Attention-Deficit/Hyperactivity Disorder: Feasibility and Usability Study

BACKGROUND

A total of 1 in 2 adults with attention-deficit/hyperactivity disorder (ADHD) struggles with major depressive or anxiety disorders. The co-occurrence of these disorders adds to the complexity of finding utility in as well as adherence to a treatment option. Digital therapeutic solutions may present a promising alternative treatment option that could mitigate these challenges and alleviate symptoms.

OBJECTIVE

This study aims to investigate (1) the feasibility and acceptance of a digital mental health intervention, (2) participants' engagement and retention levels, and (3) the potential efficacy with respect to anxiety and depression symptoms in a population with ADHD. Our main hypothesis was that a digital, data-driven, and personalized intervention for adults with coexisting ADHD and depressive or anxiety symptoms would show high engagement and adherence, which would be accompanied by a decrease in depressive and anxiety symptoms along with an increase in quality of life and life satisfaction levels.

METHODS

This real-world data, single-arm study included 30 adult participants with ADHD symptomatology and coexisting depressive or anxiety symptoms who joined a 16-week digital, data-driven mental health support program. This intervention is based on a combination of evidence-based approaches such as cognitive behavioral therapy, mindfulness, and positive psychology techniques. The targeted symptomatology was evaluated using the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Barkley Adult ADHD Rating Scale-IV. Quality of life aspects were evaluated using the Satisfaction With Life Scale and the Life Satisfaction Questionnaire, and user feedback surveys were used to assess user experience and acceptability.

RESULTS

The study retention rate was 97% (29/30), and high engagement levels were observed, as depicted by the 69 minutes spent on the app per week, 5 emotion logs per week, and 11.5 mental health actions per week. An average decrease of 46.2% (P<.001; r=0.89) in depressive symptoms and 46.4% (P<.001; r=0.86) in anxiety symptoms was observed, with clinically significant improvement for more than half (17/30, 57% and 18/30, 60%, respectively) of the participants. This was followed by an average increase of 23% (P<.001; r=0.78) and 20% (P=.003; r=0.8) in Satisfaction With Life Scale and Life Satisfaction Questionnaire scores, respectively. The overall participant satisfaction level was 4.3 out of 5.

CONCLUSIONS

The findings support the feasibility, acceptability, and value of the examined digital program for adults with ADHD symptomatology to address the coexisting depressive or anxiety symptoms. However, controlled trials with larger sample sizes and more diverse participant profiles are required to provide further evidence of clinical efficacy.

Effectiveness of cognitive behavioural-based interventions for adults with attention-deficit/hyperactivity disorder extends beyond core symptoms: A meta-analysis of randomized controlled trials

OBJECTIVES

To provide an updated systematic review of randomized controlled studies for the efficacy of cognitive behavioural therapy (CBT) in treating adults with attention-deficit/hyperactivity disorder (ADHD).

DESIGN

Meta-analysis.

METHODS

PROSPERO registration: CRD42021273633. The methods used aligned with the PRISMA guidelines. Database searches identified CBT treatment outcome studies eligible for conducted meta-analysis. Treatment response was summarized by calculating the standardized mean differences for changes in outcome measures for adults with ADHD. Measures included core and internalizing symptoms and were assessed on the basis of self-reporting and investigator evaluation.

RESULTS

Twenty-eight studies met the inclusion criteria. This meta-analysis indicates that CBT for adults with ADHD was effective in reducing both core and emotional symptoms. Decreases in depression and anxiety were predicted by the reduction of core ADHD symptoms. An increase in self-esteem and quality of life were also observed for adults with ADHD who were received CBT. Adults who received either individual or group therapy significantly exhibited a greater reduction of symptoms than those who received active control intervention, received treatment as usual, or were on the treatment waitlist. Traditional CBT was equally effective in reducing core ADHD symptoms but outperformed other CBT approaches in reducing emotional symptoms among adults with ADHD.

CONCLUSIONS

This meta-analysis offers cautiously optimistic support for the efficacy of CBT in treating adults with ADHD. The additional reduction of emotional symptoms demonstrates the potential of CBT in adults with ADHD who are at higher risk for depression and anxiety comorbidities.

Dismantling cognitive-behavioural therapy components for attention-deficit hyperactivity disorder in adolescents and adults: protocol for a network meta-analysis

INTRODUCTION

Cognitive-behavioural therapy (CBT) consists of multiple treatment techniques for each treatment model and is tailored to the patient's characteristics. Randomised controlled trials (RCTs) have reported that CBT is effective for attention-deficit/hyperactivity disorder (ADHD); however, which CBT components are effective is unknown. In order to provide the best treatment technique, it is important to know which therapeutic component or combination thereof is more effective and what the specific effect size is.

METHODS AND ANALYSIS

We will perform component network meta-analysis (cNMA). The search will include studies published from database inception up to 31 March 2022, in English. The electronic databases of MEDLINE (via PubMed), EMBASE, PsycINFO, ClinicalTrials.gov and Cochrane Library will be searched. We will systematically identify all RCTs in the treatment of ADHD between the ages of 10 and 60 years, comparing interventions composed of various CBT components with controlled interventions. We will perform pairwise and network meta-analysis with random effects to estimate summary ORs and standardised mean differences. We will assess the risk of bias in selected studies using the Cochrane risk of bias tool.

ETHICS AND DISSEMINATION

Since we will review published papers, ethical approval is not required. The results from this cNMA will provide a panorama of the CBT-based ADHD studies. The results of this study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022323898.

Current and Future Directions of Drug Delivery for the Treatment of Mental Illnesses

Mental illnesses including anxiety disorders, autism spectrum disorder, post-traumatic stress disorder, schizophrenia, depression, and others exact an immense toll on the healthcare system and society at large. Depression alone impacts 21 million adults and costs over $200 billion annually in the United States. However, pharmaceutical strategies to treat mental illnesses are lagging behind drug development in many other disease areas. Because many of the shortcomings of therapeutics for mental illness relate to delivery problems, drug delivery technologies have the potential to radically improve the effectiveness of therapeutics for these diseases. This review describes the current pharmacotherapeutic approaches to treating mental illnesses as well as drug delivery approaches that have improved existing therapies. Approaches to improve drug bioavailability, provide controlled release of therapeutics, and enable drug targeting to the central nervous system (CNS) will be highlighted. Moreover, next-generation delivery approaches such as environmentally-controlled release and interval/sequential drug release will be addressed. Based on the evolving landscape of the treatment of mental illnesses, the nascent field of drug delivery in mental health has tremendous potential for growth in terms of both economic and patient impact.

Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age-inappropriate levels of inattention, hyperactivity, and impulsivity, and is associated with long-term social, academic, and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Research has shown that children and adolescents with ADHD have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega-3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. This review is an update of a previously published Cochrane Review. Overall, there was little evidence that PUFA supplementation improved symptoms of ADHD in children and adolescents.

OBJECTIVES

To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents.

SEARCH METHODS

We searched 13 databases and two trials registers up to October 2021. We also checked the reference lists of relevant studies and reviews for additional references.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared PUFA with placebo or PUFA plus alternative therapy (medication, behavioural therapy, or psychotherapy) with the same alternative therapy alone in children and adolescents (aged 18 years and under) diagnosed with ADHD.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was severity or improvement of ADHD symptoms. Our secondary outcomes were severity or incidence of behavioural problems; quality of life; severity or incidence of depressive symptoms; severity or incidence of anxiety symptoms; side effects; loss to follow-up; and cost. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included 37 trials with more than 2374 participants, of which 24 trials were new to this update. Five trials (seven reports) used a cross-over design, while the remaining 32 trials (52 reports) used a parallel design. Seven trials were conducted in Iran, four each in the USA and Israel, and two each in Australia, Canada, New Zealand, Sweden, and the UK. Single studies were conducted in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Of the 36 trials that compared a PUFA to placebo, 19 used an omega-3 PUFA, six used a combined omega-3/omega-6 supplement, and two used an omega-6 PUFA. The nine remaining trials were included in the comparison of PUFA to placebo, but also had the same co-intervention in the PUFA and placebo groups. Of these, four trials compared a combination of omega-3 PUFA plus methylphenidate to methylphenidate. One trial each compared omega-3 PUFA plus atomoxetine to atomoxetine; omega-3 PUFA plus physical training to physical training; and an omega-3 or omega-6 supplement plus methylphenidate to methylphenidate; and two trials compared omega-3 PUFA plus dietary supplement to dietary supplement. Supplements were given for a period of between two weeks and six months. Although we found low-certainty evidence that PUFA compared to placebo may improve ADHD symptoms in the medium term (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.47 to 2.60; 3 studies, 191 participants), there was high-certainty evidence that PUFA had no effect on parent-rated total ADHD symptoms compared to placebo in the medium term (standardised mean difference (SMD) -0.08, 95% CI -0.24 to 0.07; 16 studies, 1166 participants). There was also high-certainty evidence that parent-rated inattention (medium-term: SMD -0.01, 95% CI -0.20 to 0.17; 12 studies, 960 participants) and hyperactivity/impulsivity (medium-term: SMD 0.09, 95% CI -0.04 to 0.23; 10 studies, 869 participants) scores were no different compared to placebo. There was moderate-certainty evidence that overall side effects likely did not differ between PUFA and placebo groups (RR 1.02, 95% CI 0.69 to 1.52; 8 studies, 591 participants). There was also moderate-certainty evidence that medium-term loss to follow-up was likely similar between groups (RR 1.03, 95% CI 0.77 to 1.37; 13 studies, 1121 participants).

AUTHORS' CONCLUSIONS

Although we found low-certainty evidence that children and adolescents receiving PUFA may be more likely to improve compared to those receiving placebo, there was high-certainty evidence that PUFA had no effect on total parent-rated ADHD symptoms. There was also high-certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups. We found moderate-certainty evidence that overall side effects likely did not differ between PUFA and placebo groups. There was also moderate-certainty evidence that follow-up was similar between groups. It is important that future research addresses the current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow-up times.

Effects of music therapy as an alternative treatment on depression in children and adolescents with ADHD by activating serotonin and improving stress coping ability

OBJECTIVE

The objective of this study was to determine the effect of music therapy as an alternative treatment on depression in children and adolescents with attention-deficit hyperactivity disorder (ADHD) by activating serotonin (5-HT) and improving stress coping ability.

METHODS

This study is designed based on randomization method. A total of 36 subjects participated in the experiment, consisting of an ADHD control group (n = 18) and ADHD music therapy group (n = 18). The ADHD control group received standard care, while the ADHD music therapy group received music therapy and standard care. The ADHD music therapy group received both active music therapy (improvisation) and receptive music therapy (music listening) for 50 minutes, twice a week, for 3 months: a total of 24 times. From a neurophysiological perspective, changes in depression and stress were tracked by measuring 5-HT secretion, cortisol expression, blood pressure (BP), heart rate (HR), and CDI and DHQ psychological scales.

RESULTS

The ADHD music therapy group's 5-HT secretion increased (p < 0.001), whereas cortisol expression (p < 0.001), BP (p < 0.001) and HR (p < 0.001) decreased. The CDI and DHQ psychological scales also showed positive changes (p < 0.01 and p < 0.001, respectively). However, the ADHD Con G's (who did not receive music therapy) 5-HT secretion did not increase, whereas cortisol expression, BP, and HR did not decrease. In addition, the CDI and DHQ psychological scales did not display positive changes.

CONCLUSIONS

In conclusion, the application of music therapy as an alternative treatment for ADHD children and adolescents showed positive neurophysiological and psychological effects. Therefore, this study would like to propose a new alternative to medicine for preventing and treating depression through various uses of music therapy.

Pharmacological effects and therapeutic potential of natural compounds in neuropsychiatric disorders: An update

Neuropsychiatric diseases are a group of disorders that cause significant morbidity and disability. The symptoms of psychiatric disorders include anxiety, depression, eating disorders, autism spectrum disorders (ASD), attention-deficit/hyperactivity disorder, and conduct disorder. Various medicinal plants are frequently used as therapeutics in traditional medicine in different parts of the world. Nowadays, using medicinal plants as an alternative medication has been considered due to their biological safety. Despite the wide range of medications, many patients are unable to tolerate the side effects and eventually lose their response. By considering the therapeutic advantages of medicinal plants in the case of side effects, patients may prefer to use them instead of chemical drugs. Today, the use of medicinal plants in traditional medicine is diverse and increasing, and these plants are a precious heritage for humanity. Investigation about traditional medicine continues, and several studies have indicated the basic pharmacology and clinical efficacy of herbal medicine. In this article, we discuss five of the most important and common psychiatric illnesses investigated in various studies along with conventional therapies and their pharmacological therapies. For this comprehensive review, data were obtained from electronic databases such as MedLine/PubMed, Science Direct, Web of Science, EMBASE, DynaMed Plus, ScienceDirect, and TRIP database. Preclinical pharmacology studies have confirmed that some bioactive compounds may have beneficial therapeutic effects in some common psychiatric disorders. The mechanisms of action of the analyzed biocompounds are presented in detail. The bioactive compounds analyzed in this review are promising phytochemicals for adjuvant and complementary drug candidates in the pharmacotherapy of neuropsychiatric diseases. Although comparative studies have been carefully reviewed in the preclinical pharmacology field, no clinical studies have been found to confirm the efficacy of herbal medicines compared to FDA-approved medicines for the treatment of mental disorders. Therefore, future clinical studies are needed to accelerate the potential use of natural compounds in the management of these diseases.

A systematic review of interventions to support adults with ADHD at work—Implications from the paucity of context-specific research for theory and practice

Attention Deficit Hyperactivity Disorder (ADHD) is estimated to affect 3.5% of the global workforce. Despite the high prevalence rate, little is known about how best to support adults with ADHD (ADHDers) at work. Relevant research is dispersed across different disciplines such as medicine, health studies and psychology. Therefore, it is important to synthesize interventions aimed at ADHDers to examine what learning can be gleaned for effective workplace support. We conducted a systematic review of relevant interventions framed by realist evaluation and the Context-Intervention-Mechanism-Outcome classification to identify key mechanisms of effectiveness for workplace interventions. We searched 10 databases including a range of journals from medical science to business management applying predetermined inclusion criteria and quality appraisal through a risk of bias assessment for quantitative and qualitative methods. We synthesized 143 studies with realist evaluation. Most studies evaluated the effectiveness of pharmacological interventions highlighting the dominance of the medical approach to supporting ADHDers. Key mechanisms of effectiveness were identified from psychosocial interventions including group therapy, involvement of people in the ADHDers network, and the importance of the client-patient relationship. Overall, there is limited research that examines the effectiveness of workplace interventions for ADHDers. Furthermore, much of the existing research evaluates pharmacological interventions which is difficult to transfer to the workplace context. It is recommended that future research and practice consider the key mechanisms identified in this review when designing interventions as well as barriers to accessing support such as disclosure and self-awareness.

Sociodemographic and Clinical Factors Affecting Treatment Adherence in Adults with Attention Deficit and Hyperactivity Disorder

Background

This study aims to explore sociodemographic and clinical factors affecting medication adherence in adults with attention deficit and hyperactivity disorder and elicit dysfunctional domains and comorbidities with a focus on gender differences.

Methods

Patients were recruited from 2 specialty clinics using chart records in a natural treatment design. Adult attention deficit and hyperactivity disorder self-report scale, Diagnostic Interview for attention deficit and hyperactivity disorder in adults, was applied. Adherence is defined if the patient declared ≥80% adherence to medication throughout the last 8-12 weeks.

Results

From 205 attention deficit and hyperactivity disorder patients (male = 112 female = 93 (age (median) min-max = 29 (18-56)), 29% were non-adherent to attention deficit and hyperactivity disorder medication. In the multivariate analysis, having 2 or more comorbid disorders (P = .009), dysfunctions in academic/work (P = .049), and dysfunctions in family and other relationships (P = .047) increased the likelihood of adherence. Adherence rates did not significantly differ between methylphenidate and atomoxetine (P = .405). Women were more likely to have 2 or more comorbid psychiatric disorders (P = .004) and dysfunctions in social relationships (P = .001), free time activities, hobbies (P < .001), self-confidence, and self-image (P < .001).

Results

Nearly one-third of adult patients with attention deficit and hyperactivity disorder did not adhere to medication treatment. Comorbid psychiatric disorders and dysfunctions in life domains appear to increase the likelihood of adherence to attention deficit and hyperactivity disorder medications, possibly through increasing motivation for treatment. The effect of cognitive-behavioral therapy on compliance with attention deficit and hyperactivity disorder medication should further be explored with prospective controlled studies.

Conclusion

We suggest that future longitudinal studies use objective measures of adherence and confirm the role of dysfunctional life domains and comorbid psychiatric disorders as correlates of medication adherence.

University students with attention deficit hyperactivity disorder (ADHD): a consensus statement from the UK Adult ADHD Network (UKAAN)

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is associated with poor educational outcomes that can have long-term negative effects on the mental health, wellbeing, and socio-economic outcomes of university students. Mental health provision for university students with ADHD is often inadequate due to long waiting times for access to diagnosis and treatment in specialist National Health Service (NHS) clinics. ADHD is a hidden and marginalised disability, and within higher education in the UK, the categorisation of ADHD as a specific learning difference (or difficulty) may be contributing to this.

AIMS

This consensus aims to provide an informed understanding of the impact of ADHD on the educational (or academic) outcomes of university students and highlight an urgent need for timely access to treatment and management.

METHODS

The UK Adult ADHD Network (UKAAN) convened a meeting of practitioners and experts from England, Wales, and Scotland, to discuss issues that university students with ADHD can experience or present with during their programme of studies and how best to address them. A report on the collective analysis, evaluation, and opinions of the expert panel and published literature about the impact of ADHD on the educational outcomes of university students is presented.

RESULTS

A consensus was reached that offers expert advice, practical guidance, and recommendations to support the medical, education, and disability practitioners working with university students with ADHD.

CONCLUSIONS

Practical advice, guidance, and recommendations based on expert consensus can inform the identification of ADHD in university students, personalised interventions, and educational support, as well as contribute to existing research in this topic area. There is a need to move away from prevailing notions within higher education about ADHD being a specific learning difference (or difficulty) and attend to the urgent need for university students with ADHD to have timely access to treatment and support. A multimodal approach can be adapted to support university students with ADHD. This approach would view timely access to treatment, including reasonable adjustments and educational support, as having a positive impact on the academic performance and achievement of university students with ADHD.

Impulsivity and Metacognition in a Psychiatric Population

OBJECTIVE

The main purpose of this study was to examine a possible relationship among the three constructs of impulsivity, according to Barratt's theory and metacognition subdimensions, as described in Wells and Cartwright-Hatton's theory, in various psychiatric disorders, in order to explore the potential predictive role of impulsivity on metacognition.

METHOD

The Barratt Impulsiveness Scale-11 (BIS-11) and the Metacognitions Questionnaire (MCQ-30) were administered to a sample of 100 patients affected by psychiatric disorders. Linear regression was used first to study the relationship between impulsivity as an independent variable and metacognition as a dependent variable and then to evaluate the relationship between the three construct of impulsivity and the five subdimensions of metacognition.

RESULTS

BIS-11 total score was a valid predictor of Total MCQ-30 (p <.0001), whereas Attentive Impulsiveness was a good predictor of the factors "Negative Beliefs" (p <.0001), "Cognitive Confidence" (p =.004) and "Need to control thoughts" (p =.002).

CONCLUSIONS

since "Attentive Impulsiveness", "Negative believes", "Cognitive Confidence" and "Need to Control Thought" are psychological constructs, psychotherapy is the more effective tool to intervene on their imbalance. In particular, literature demonstrates the effectiveness of Cognitive-Behavioural Therapy and Mindfulness therapies in rebalancing impulsivity and enhancing metacognitive skills.

Efficacy of Group Cognitive Behavior Therapy Targeting Time Management for Adults with Attention Deficit/Hyperactivity Disorder in Japan: A Randomized Control Pilot Trial

OBJECTIVE

Time-processing disorders in adults is a priority area for intervention. Time management program, which has been demonstrated to be effective in children with ADHD, has not been examined in adults. We anticipate the need for the development of specialized programs for adults. This is because it has been reported that time processing disorders have different patterns in childhood and adulthood. This study aimed to evaluate the therapeutic effect of a gCBT program focusing on time management for adults with ADHD.

METHOD

Adults with ADHD were randomly assigned to gCBT (n = 24) or a treatment as usual group (n = 24). Outcome measures were masked clinically rated, self-reported, and family-reported ADHD symptoms.

RESULTS

The gCBT group significantly reduced ADHD symptoms on all measures.

CONCLUSION

Interventions focused on time management have been shown to be effective not only in children with ADHD but also in adult patients.

Efficacy of Non-pharmacological Treatments on Emotional Symptoms of Children and Adults with Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis

BACKGROUND

The present meta-analysis aimed to evaluate the efficacy of various non-pharmacological interventions on comorbid emotional symptoms such as depression, anxiety, and emotional dysregulation (ED) in children and adults with ADHD.

METHOD

Forty-four randomized controlled trials (23 studies with ADHD children and 21 studies with ADHD adults) were included. Risk of bias, heterogeneity assessment, and subgroup analyses were conducted.

RESULTS

We found that therapies targeting the relationship between children and others (i.e., parent-training [on ED and depression] and social skills training [on ED]) were efficacious in the treatment of emotional symptoms in children with ADHD at post-intervention. As for adults with ADHD, cognitive behavioral therapy was found to be effective for the improvement of emotional symptoms at both post-intervention and follow-up.

CONCLUSION

Our findings demonstrate that the efficacy of non-pharmacological interventions varies substantially across children and adults with ADHD. These results provide important implications for the selection of non-pharmacological interventions for children with ADHD.

The impact of psychological theory on the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in adults: A scoping review

Psychological theory and interpretation of research are key elements influencing clinical treatment development and design in Attention Deficit Hyperactivity Disorder (ADHD). Research-based treatment recommendations primarily support Cognitive Behavioural Therapy (CBT), an extension of the cognitive behavioural theory, which promotes a deficit-focused characterisation of ADHD and prioritises symptom reduction and cognitive control of self-regulation as treatment outcomes. A wide variety of approaches have developed to improve ADHD outcomes in adults, and this review aimed to map the theoretical foundations of treatment design to understand their impact. A scoping review and analysis were performed on 221 documents to compare the theoretical influences in research, treatment approach, and theoretical citations. Results showed that despite variation in the application, current treatments characterise ADHD from a single paradigm of cognitive behavioural theory. A single theoretical perspective is limiting research for effective treatments for ADHD to address ongoing issues such as accommodating context variability and heterogeneity. Research into alternative theoretical characterisations of ADHD is recommended to provide treatment design opportunities to better understand and address symptoms.

Educational level, attention problems, and externalizing behaviour in adolescence and early adulthood: the role of social causation and health-related selection-the TRAILS study

Social causation and health-related selection may contribute to educational differences in adolescents' attention problems and externalizing behaviour. The social causation hypothesis posits that the social environment influences adolescents' mental health. Conversely, the health-related selection hypothesis proposes that poor mental health predicts lower educational attainment. From past studies it is unclear which of these mechanisms predominates, as attention problems and externalizing behaviour have the potential to interfere with educational attainment, but may also be affected by differences in the educational context. Furthermore, educational gradients in mental health may reflect the impact of 'third variables' already present in childhood, such as parental socioeconomic status (SES), and IQ. We investigated both hypotheses in relation to educational differences in externalizing behaviour and attention problems throughout adolescence and young adulthood. We used data from a Dutch cohort (TRAILS Study; n = 2229), including five measurements of educational level, externalizing behaviour, and attention problems from around age 14-26 years. First, we evaluated the directionality in longitudinal associations between education, externalizing behaviour, and attention problems with and without adjusting for individual differences using fixed effects. Second, we assessed the role of IQ and parental SES in relation to attention problems, externalizing behaviour, and educational level. Attention problems predicted decreases in education throughout all of adolescence and young adulthood. Differences in parental SES contributed to increases in externalizing behaviour amongst the lower educational tracks in mid-adolescence. Childhood IQ and parental SES strongly predicted education around age 14. Parental SES, but not IQ, also predicted early adolescent attention problems and externalizing behaviour. Our results provide support for the health-related selection hypothesis in relation to attention problems and educational attainment. Further, our results highlight the role of social causation from parental SES in determining adolescent educational level, attention problems, and externalizing behaviour.

An Exploratory Investigation of Goal Management Training in Adults With ADHD: Improvements in Inhibition and Everyday Functioning

Background: Adults with attention deficit/hyperactivity disorder (ADHD) are predominantly treated with medication. However, there is also a need for effective, psychologically based interventions. As ADHD is strongly associated with reduced inhibitory control, cognitive remediation approaches should be efficient. Goal management training (GMT) aims at enhancing inhibitory control and has shown positive effects on inhibitory control in non-ADHD patient groups. The aim of the current study was to explore whether GMT would specifically enhance inhibitory control in adults with ADHD, and if such an enhancement would lead to secondary improvements in self-reported everyday functioning. Methods: Twenty-one participants with ADHD (mean age: 39.05 years [SD 11.93]) completed the intervention and assessments pre-, post- and 6 months after the intervention. Measures included neuropsychological tests and self-report questionnaires pertaining to cognitive- and executive functioning, emotion regulation, quality of life, and ADHD symptoms. Results: Compared to baseline, the participants showed enhanced inhibitory control on performance-based measures at post-assessment and 6-month follow-up. The participants also reported increased productivity and reduced cognitive difficulties in everyday life at both assessments post-treatment, as well as improvements in aspects of emotion regulation and a reduction in the severity of core ADHD-symptoms at 6-month follow-up. Conclusion: Our exploratory study showed that GMT seems to specifically improve one of the core executive dysfunctions in ADHD, namely inhibitory control, with a positive effect lasting at least 6 months post-treatment. The adults with ADHD also reported improved self-regulation in their everyday life after completing GMT, providing strong arguments for further investigations of GMT as a treatment option for this group of adults. Clinical Trial Registration: The study is registered under ISRCTN.com (ISRCTN91988877; https://doi.org/10.1186/ISRCTN91988877).

A Review of Working Memory Training in the Management of Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Working memory deficits underlie many of the behavioural symptoms of ADHD. Alongside psychostimulant medications, strategies to improve working memory may play an important adjuvant role in the management of ADHD. In this study, we review the role of working memory deficits in ADHD, the evidence surrounding working memory training strategies in the management of the condition, and the factors affecting the success of these strategies in alleviating ADHD symptoms. More specifically, we review several non-pharmacological interventions that target working memory deficits in ADHD, with special emphasis on cognitive working memory training. We conclude that the development of evidence-based interventions such as computerised cognitive training (CCT) could provide an alternative or adjunct to the use of psychostimulants, especially in cases where side effects are a major issue.

The effects of sleep deprivation on the processing of emotional facial expressions in young adults with and without ADHD

The ability to recognize emotions from facial expressions is essential to the development of complex social cognition behaviors, and impairments in this ability are associated with poor social competence. This study aimed to examine the effects of sleep deprivation on the processing of emotional facial expressions and nonfacial stimuli in young adults with and without attention-deficit/hyperactivity disorder (ADHD). Thirty-five men (mean age 25.4) with (n = 19) and without (n = 16) ADHD participated in the study. During the five days preceding the experimental session, the participants were required to sleep at least seven hours per night (23:00/24:00–7:00/9:00) and their sleep was monitored via actigraphy. On the morning of the experimental session, the participants completed a 4-stimulus visual oddball task combining facial and nonfacial stimuli, and repeated it after 25 h of sustained wakefulness. At baseline, both study groups had poorer performance in response to facial rather than non-facial target stimuli on all indices of the oddball task, with no differences between the groups. Following sleep deprivation, rates of omission errors, commission errors and reaction time variability increased significantly in the ADHD group but not in the control group. Time and target type (face/non-face) did not have an interactive effect on any indices of the oddball task. Young adults with ADHD are more sensitive to the negative effects of sleep deprivation on attentional processes, including those related to the processing of emotional facial expressions. As poor sleep and excessive daytime sleepiness are common in individuals with ADHD, it is feasible that poor sleep quality and quantity play an important role in cognitive functioning deficits, including the processing of emotional facial expressions that are associated with ADHD.

ADHD: Reviewing the Causes and Evaluating Solutions

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder in which patients present inattention, hyperactivity, and impulsivity. The etiology of this condition is diverse, including environmental factors and the presence of variants of some genes. However, a great diversity exists among patients regarding the presence of these ADHD-associated factors. Moreover, there are variations in the reported neurophysiological correlates of ADHD. ADHD is often treated pharmacologically, producing an improvement in symptomatology, albeit there are patients who are refractory to the main pharmacological treatments or present side effects to these drugs, highlighting the importance of developing other therapeutic options. Different non-pharmacological treatments are in this review addressed, finding diverse results regarding efficacy. Altogether, ADHD is associated with different etiologies, all of them producing changes in brain development, leading to the characteristic symptomatology of this condition. Given the heterogeneous etiology of ADHD, discussion is presented about the convenience of personalizing ADHD treatment, whether pharmacological or non-pharmacological, to reach an optimum effect in the majority of patients. Approaches to personalizing both pharmacological therapy and neurofeedback are presented.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Prevalence and Risk Factors Associated With Attention-Deficit/Hyperactivity Disorder Among US Black Individuals: A Systematic Review and Meta-analysis

IMPORTANCE

As stated in the DSM-5, it is generally reported that the prevalence of attention-deficit/hyperactivity disorder (ADHD) is lower among Black individuals compared with the general population. However, Black individuals living in countries where they are considered a minority population group (eg, in Northern America and Europe) are underrepresented in studies evaluating ADHD.

OBJECTIVE

To estimate the pooled prevalence of ADHD and identify associated risk factors among US Black individuals.

DATA SOURCES

This systematic review and meta-analysis identified peer-reviewed studies published until October 18, 2019, using the APA PsycInfo, MEDLINE, Embase, Cochrane CENTRAL, CINAHL, ERIC, and Education Source databases.

STUDY SELECTION

Eligible trials were published in French or English, had empirical data on the prevalence of ADHD in samples or subsamples of Black people, and were conducted in countries with Black minority populations. All studies were assessed and passed quality evaluation.

DATA EXTRACTION AND SYNTHESIS

The PRISMA guideline was used for extracting and reporting data. Random-effects meta-analyses were generated to estimate the prevalence of ADHD among Black individuals using the metafor package in R.

MAIN OUTCOMES AND MEASURES

Prevalence and risk factors associated with ADHD among Black individuals were identified.

RESULTS

A total of 24 independent samples and subsamples from 21 studies published between 1979 and 2020 (154 818 Black participants) were included in this systematic review and meta-analysis. All included studies were conducted in the US. Two studies were conducted assessing adults (aged 18 years or older), 8 assessing children (0-12 years), 1 assessing adolescents (aged 13-17 years), and 13 assessing both children and adolescents. The pooled prevalence of ADHD was 14.54% (95% CI, 10.64%-19.56%). In a narrative review of the studies in this analysis, some studies found risk factors associated with ADHD, such as sociodemographic characteristics (age, sex, race, and socioeconomic status), familial factors, environmental factors, and risk behaviors, but the data did not permit a moderation analysis to assess these findings in this study.

CONCLUSIONS AND RELEVANCE

Contrary to what is stated in the DSM-5, the results of this systematic review and meta-analysis suggest that Black individuals are at higher risk for ADHD diagnoses than the general US population. These results highlight a need to increase ADHD assessment and monitoring among Black individuals from different social backgrounds. They also higlight the importance of establishing accurate diagnoses and culturally appropriate care.

Psychological Effects of the COVID-19 Imposed Lockdown on Adults with Attention Deficit/Hyperactivity Disorder: Cross-Sectional Survey Study

BACKGROUND

The psychological effects of the COVID-19 government-imposed lockdown have been studied in several populations. These effects however have not been studied in adult populations with attention deficit/hyperactivity disorder (ADHD).

OBJECTIVE

We wanted to investigate the psychological effects of the COVID-19 imposed lockdown on an adult population with ADHD.

METHODS

We conducted a cross-sectional survey by administering the Patient Health Questionnaire-9, Generalized Anxiety Disorder Scale-7, Brief Adjustment Scale-6, Perceived Stress Scale, and Multidimensional Scale of Perceived Social Support to a pragmatic sample of adults with ADHD.

RESULTS

In total, 24 individuals (male: n=18, 75%; female: n=6, 25%; age: mean 21.75 years, SD 1.85 years) were included in this study. The adults with ADHD we surveyed had significant levels of emotional distress during the COVID-19 pandemic period. However, there was no evidence of significant deterioration to the mental health of our sample during the COVID-19 pandemic.

CONCLUSIONS

When treatment for ADHD is maintained, the effects of the COVID-19 pandemic on the mental health of adults with ADHD are mild. Targeted psychological interventions may be useful in such circumstances.

Trait impulsivity in Juvenile Myoclonic Epilepsy

Objective

Impulsivity is a multidimensional construct that can predispose to psychopathology. Meta‐analysis demonstrates an association between response impulsivity and Juvenile Myoclonic Epilepsy (JME), a common genetic generalized epilepsy. Here, we test the hypotheses that trait impulsivity is (i) elevated in JME compared to controls; (ii) moderated by specific seizure characteristics; and (iii) associated with psychiatric adverse effects of antiepileptic drugs (AEDs).

Methods

322 participants with JME and 126 age and gender‐matched controls completed the Barratt’s Impulsiveness Scale (BIS‐brief) alongside information on seizure history and AED use. We compared group BIS‐brief scores and assessed associations of JME BIS‐brief scores with seizure characteristics and AED adverse effects.

Results

The mean BIS‐brief score in JME was 18.1 ± 4.4 compared with 16.2 ± 4.1 in controls (P = 0.0007). Elevated impulsivity was associated with male gender (P = 0.027), frequent absence seizures (P = 0.0004) and lack of morning predominance of myoclonus (P = 0.008). High impulsivity significantly increased the odds of a psychiatric adverse event on levetiracetam (P = 0.036), but not any other psychiatric or somatic adverse effects.

Interpretation

Trait impulsivity is elevated in JME and comparable to scores in personality and neurotic disorders. Increased seizure frequency and absence of circadian seizure pattern moderate BIS score, suggesting disruption of both cortico‐striatal and thalamocortical networks as a shared mechanism between seizures and impulsivity in JME. These findings warrant consideration of impulsivity as a distinct target of intervention, and as a stratifying factor for AED treatment in JME, and perhaps other types of epilepsy. The role of impulsivity in treatment adherence and psychosocial outcome requires further investigation.

The transition from children’s services to adult services for young people with attention deficit hyperactivity disorder: the CATCh-uS mixed-methods study

Background

Attention deficit hyperactivity disorder was previously seen as a childhood developmental disorder, so adult mental health services were not set up to support attention deficit hyperactivity disorder patients who became too old for child services. To our knowledge, this is the first in-depth study of the transition of attention deficit hyperactivity disorder patients from child to adult health services in the UK.

Objectives

Our objectives were to explore how many young people with attention deficit hyperactivity disorder are in need of services as an adult, what adult attention deficit hyperactivity disorder services are available and how attention deficit hyperactivity disorder stakeholders experience transition from child to adult services.

Design

An interactive mixed-method design was adopted with three study streams: (1) a 12-month surveillance study with 9-month follow-up to find out how many young people required ongoing medication when they were too old for child services (929 surveys completed by children’s clinicians); (2) a mapping study to identify and describe services for young adults with attention deficit hyperactivity disorder (2686 respondents to online surveys for patients and health workers and freedom of information requests to service providers and commissioners); and (3) a qualitative study to explore key stakeholders’ experiences of transition from child to adult services (144 interviews with 64 attention deficit hyperactivity disorder patients, 28 parents and 52 health clinicians; 38 working in child or adult secondary health services and 14 general practitioners). Members of the public advised at each stage of the study.

Results

When corrected for non-response and case ascertainment, the annual number of young people with an ongoing need for medication for attention deficit hyperactivity disorder lies between 270 and 599 per 100,000 people aged 17–19 years. Among 315 individuals eligible for transition, 64% were accepted, but only 22% attended their first adult services appointment. Our interactive map describes 294 unique services for adults with attention deficit hyperactivity disorder across the UK, of which 44 are ‘dedicated’ attention deficit hyperactivity disorder services. Few services provide the full range of recommended provision; most focus on diagnosis and medication. Services are unevenly distributed across the UK, with nearly all ‘dedicated’ services being in England. Exploring stakeholders’ experiences revealed how invested the stakeholders are in continuing attention deficit hyperactivity disorder treatment and how the architecture of services affects transition. An association between attention deficit hyperactivity disorder, education and continuance of medication into young adulthood, plus parent involvement and feeling prepared for transition and adult life with attention deficit hyperactivity disorder, influenced investment. However, even with investment, how accessible adult services are, how patient needs fit with the remit of the adult service and the level of patient information available affect transition outcomes. The results also highlight how general practitioners can end up as care co-ordinators during transition by default.

Limitations

Transition estimates were based on those who want medication, so these indicate a minimum level of need.

Conclusions

Few of those who need ongoing support for attention deficit hyperactivity disorder successfully transfer to adult services, and a small proportion of those who transfer experience optimal transitional care. Adult attention deficit hyperactivity disorder service provision is patchy. Even among ‘dedicated’ services, few provide the whole range of National Institute for Health and Care Excellence-recommended treatments.

Future work

We need to evaluate various models of transitional care and adult attention deficit hyperactivity disorder provision, as well as develop and evaluate psychosocial interventions for young people and adults with attention deficit hyperactivity disorder.

Trial registration

Current Controlled Trials ISRCTN12492022.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 42. See the NIHR Journals Library website for further project information.

Development of a Digital Content-Free Speech Analysis Tool for the Measurement of Mental Health and Follow-Up for Mental Disorders: Protocol for a Case-Control Study

BACKGROUND

The prevalence of mental disorders worldwide is very high. The guideline-oriented care of patients depends on early diagnosis and regular and valid evaluation of their treatment to be able to quickly intervene should the patient's mental health deteriorate. To ensure effective treatment, the level of experience of the physician or therapist is of importance, both in the initial diagnosis and in the treatment of mental illnesses. Nevertheless, experienced physicians and psychotherapists are not available in enough numbers everywhere, especially in rural areas or in less developed countries. Human speech can reveal a speaker's mental state by altering its noncontent aspects (speech melody, intonations, speech rate, etc). This is noticeable in both the clinic and everyday life by having prior knowledge of the normal speech patterns of the affected person, and with enough time spent listening to the patient. However, this time and experience are often unavailable, leaving unused opportunities to capture linguistic, noncontent information. To improve the care of patients with mental disorders, we have developed a concept for assessing their most important mental parameters through a noncontent analysis of their active speech. Using speech analysis for the assessment and tracking of mental health patients opens up the possibility of remote, automatic, and ongoing evaluation when used with patients' smartphones, as part of the current trends toward the increasing use of digital and mobile health tools.

OBJECTIVE

The primary objective of this study is to evaluate measurements of participants' mental state by comparing the analysis of noncontent speech parameters to the results of several psychological questionnaires (Symptom Checklist-90 [SCL-90], the Patient Health Questionnaire [PHQ], and the Big 5 Test).

METHODS

In this paper, we described a case-controlled study (with a case group and one control group). The participants will be recruited in an outpatient neuropsychiatric treatment center. Inclusion criteria are a neurological or psychiatric diagnosis made by a specialist, no terminal or life-threatening illnesses, and fluent use of the German language. Exclusion criteria include psychosis, dementia, speech or language disorders in neurological diseases, addiction history, a suicide attempt recently or in the last 12 months, or insufficient language skills. The measuring instrument will be the VoiceSense digital voice analysis tool, which enables the analysis of 200 specific speech parameters, and the assessment of findings using psychometric instruments and questionnaires (SCL-90, PHQ, Big 5 Test).

RESULTS

The study is ongoing as of September 2019, but we have enrolled 254 participants. There have been 161 measurements completed at timepoint 1, and a total of 62 participants have completed every psychological and speech analysis measurement.

CONCLUSIONS

It appears that the tone and modulation of speech are as important, if not more so, than the content, and should not be underestimated. This is particularly evident in the interpretation of the psychological findings thus far acquired. Therefore, the application of a software analysis tool could increase the accuracy of finding assessments and improve patient care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03700008; https://clinicaltrials.gov/ct2/show/NCT03700008.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/13852.

Efficacy of Nonpharmacological Treatments on Comorbid Internalizing Symptoms of Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review

Background: Attention-deficit/hyperactivity disorder (ADHD) is highly comorbid in adulthood. This meta-analysis was aimed at ascertaining the efficacy of different psychotherapies in improving comorbid internalizing symptoms in adults with ADHD. Method: Twenty randomized controlled trials and 12 uncontrolled pretest-posttest studies were included and combined using the inverse variance method. Risk of bias and heterogeneity assessment and moderator analyses were performed. Results: Cognitive-behavioral therapy (CBT) improved quality of life (QoL), emotional dysregulation (ED), depression, and anxiety symptoms, particularly at follow-up, which was predicted by core symptoms reduction. A significant between-group effect was obtained only on QoL, ED, and self-esteem for dialectical behavior therapy (DBT), mindfulness-based therapies (MBTs), and neurofeedback, respectively. Conclusion: Results support CBT efficacy for treating comorbid internalizing symptoms. More research is needed to determine the effectiveness of DBT, MBT, and neurofeedback. The small number of studies evaluating some therapies and the high risk of bias observed might limit these results.

Appraisal of clinical practice guidelines for the management of attention deficit hyperactivity disorder (ADHD) using the AGREE II Instrument: A systematic review

BACKGROUND AND OBJECTIVE

High quality evidence-based clinical practice guidelines (CPGs) have a major impact on the appropriate diagnosis and management and positive outcomes. The evidence-based healthcare for patients with attention deficit hyperactive disorder (ADHD) is challenging. The objective of this study was to appraise the quality of published CPGs for ADHD.

METHODS

A systematic review was conducted for ADHD CPGs using CPG databases, DynaMed, PubMed, and Google Scholar. The quality of each included CPG was appraised by three independent appraisers using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument.

RESULTS

Six CPGs were critically reviewed. The AGREE II standardized domain scores revealed variation between the quality of these CPGs with the National Institute of Health and Care Excellence (NICE), University of Michigan Health System, and American Academy of Pediatrics CPGs as the top three. Overall, the recommendations for management of ADHD were similar in these CPGs.

CONCLUSIONS

Reporting of CPG development is often poorly documented. Guideline development groups should aim to follow the AGREE II criteria to improve the standards and quality of CPGs. The NICE CPG showed the best quality. Embedding the AGREE II appraisal of CPGs in the training and education of healthcare providers is recommended. The protocol for this study was published in PROSPERO (International prospective register of systematic reviews). Link: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017078712 and is additionally available from protocols.io. Link: https://dx.doi.org/10.17504/protocols.io.q27dyhn.

Long-term Effects of Multimodal Treatment on Adult Attention-Deficit/Hyperactivity Disorder Symptoms: Follow-up Analysis of the COMPAS Trial

IMPORTANCE

Knowledge about the long-term effects of multimodal treatment in adult attention-deficit/hyperactivity disorder (ADHD) is much needed.

OBJECTIVE

To evaluate the long-term efficacy of multimodal treatment for adult ADHD.

DESIGN, SETTING, AND PARTICIPANTS

This observer-masked, 1.5-year follow-up of the Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS), a prospective, multicenter randomized clinical trial, compared cognitive behavioral group psychotherapy (GPT) with individual clinical management (CM) and methylphenidate (MPH) with placebo (2 × 2 factorial design). Recruitment started January 2007 and ended August 2010, and treatments were finalized in August 2011 with follow-up through March 2013. Overall, 433 adults with ADHD participated in the trial, and 256 (59.1%) participated in the follow-up assessment. Analysis began in November 2013 and was completed in February 2018.

INTERVENTIONS

After 1-year treatment with GPT or CM and MPH or placebo, no further treatment restrictions were imposed.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in the observer-masked ADHD Index of Conners Adult ADHD Rating Scale score from baseline to follow-up. Secondary outcomes included further ADHD rating scale scores, observer-masked ratings of the Clinical Global Impression scale, and self-ratings of depression on the Beck Depression Inventory.

RESULTS

At follow-up, 256 of 433 randomized patients (baseline measured in 419 individuals) participated. Of the 256 patients participating in follow-up, the observer-masked ADHD Index of Conners Adult ADHD Rating Scale score was assessed for 251; the mean (SD) baseline age was 36.3 (10.1) years; 125 patients (49.8%) were men; and the sample was well-balanced with respect to prior randomization (GPT and MPH: 64 of 107; GPT and placebo: 67 of 109; CM and MPH: 70 of 110; and CM and placebo: 55 of 107). At baseline, the all-group mean ADHD Index of Conners Adult ADHD Rating Scale score was 20.6, which improved to adjusted means of 14.2 for the GPT arm and 14.7 for the CM arm at follow-up with no significant difference between groups (difference, -0.5; 95% CI, -1.9 to 0.9; P = .48). The adjusted mean decreased to 13.8 for the MPH arm and 15.2 for the placebo arm (difference, -1.4; 95% CI, -2.8 to -0.1; P = .04). As in the core study, MPH was associated with a larger reduction in symptoms than placebo at follow-up. These results remained unchanged when accounting for MPH intake at follow-up. Compared with participants in the CM arm, patients who participated in group psychotherapy were associated with less severe symptoms as measured by the self-reported ADHD Symptoms Total Score according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) of Conners Adult ADHD Rating Scale (AMD, -2.1; 95% CI, -4.2 to -0.1; P = .04) and in the subscale of reducing pure hyperactive symptoms, measured via the Diagnostic Checklist for the diagnosis of ADHD in adults (AMD, -1.3; 95% CI, -2.8 to 0.1; P = .08). Regarding the Clinical Global Impression scale assessment of effectiveness, the difference between GPT and CM remained significant at follow-up (odds ratio, 1.63; 95% CI, 1.03-2.59; P = .04). No differences were found for any comparison concerning depression as measured with the Beck Depression Inventory.

CONCLUSIONS AND RELEVANCE

Results from COMPAS demonstrate a maintained improvement in ADHD symptoms for adults 1.5 years after the end of a 52-week controlled multimodal treatment period. The results indicate that MPH treatment combined with GPT or CM provides a benefit lasting 1.5 years. Confirming the results of the core study, GPT was not associated with better results regarding the primary outcome compared with CM.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN54096201.

Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a developmental condition characterised by symptoms of inattention, hyperactivity and impulsivity, along with deficits in executive function, emotional regulation and motivation. The persistence of ADHD in adulthood is a serious clinical problem.ADHD significantly affects social interactions, study and employment performance.Previous studies suggest that cognitive-behavioural therapy (CBT) could be effective in treating adults with ADHD, especially when combined with pharmacological treatment. CBT aims to change the thoughts and behaviours that reinforce harmful effects of the disorder by teaching people techniques to control the core symptoms. CBT also aims to help people cope with emotions, such as anxiety and depression, and to improve self-esteem.

OBJECTIVES

To assess the effects of cognitive-behavioural-based therapy for ADHD in adults.

SEARCH METHODS

In June 2017, we searched CENTRAL, MEDLINE, Embase, seven other databases and three trials registries. We also checked reference lists, handsearched congress abstracts, and contacted experts and researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating any form of CBT for adults with ADHD, either as a monotherapy or in conjunction with another treatment, versus one of the following: unspecific control conditions (comprising supportive psychotherapies, no treatment or waiting list) or other specific interventions.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures suggested by Cochrane.

MAIN RESULTS

We included 14 RCTs (700 participants), 13 of which were conducted in the northern hemisphere and 1 in Australia.Primary outcomes: ADHD symptomsCBT versus unspecific control conditions (supportive psychotherapies, waiting list or no treatment)- CBT versus supportive psychotherapies: CBT was more effective than supportive therapy for improving clinician-reported ADHD symptoms (1 study, 81 participants; low-quality evidence) but not for self-reported ADHD symptoms (SMD -0.16, 95% CI -0.52 to 0.19; 2 studies, 122 participants; low-quality evidence; small effect size).- CBT versus waiting list: CBT led to a larger benefit in clinician-reported ADHD symptoms (SMD -1.22, 95% CI -2.03 to -0.41; 2 studies, 126 participants; very low-quality evidence; large effect size). We also found significant differences in favour of CBT for self-reported ADHD symptoms (SMD -0.84, 95% CI -1.18 to -0.50; 5 studies, 251 participants; moderate-quality evidence; large effect size).CBT plus pharmacotherapy versus pharmacotherapy alone: CBT with pharmacotherapy was more effective than pharmacotherapy alone for clinician-reported core symptoms (SMD -0.80, 95% CI -1.31 to -0.30; 2 studies, 65 participants; very low-quality evidence; large effect size), self-reported core symptoms (MD -7.42 points, 95% CI -11.63 points to -3.22 points; 2 studies, 66 participants low-quality evidence) and self-reported inattention (1 study, 35 participants).CBT versus other interventions that included therapeutic ingredients specifically targeted to ADHD: we found a significant difference in favour of CBT for clinician-reported ADHD symptoms (SMD -0.58, 95% CI -0.98 to -0.17; 2 studies, 97 participants; low-quality evidence; moderate effect size) and for self-reported ADHD symptom severity (SMD -0.44, 95% CI -0.88 to -0.01; 4 studies, 156 participants; low-quality evidence; small effect size).Secondary outcomesCBT versus unspecific control conditions: we found differences in favour of CBT compared with waiting-list control for self-reported depression (SMD -0.36, 95% CI -0.60 to -0.11; 5 studies, 258 participants; small effect size) and for self-reported anxiety (SMD -0.45, 95% CI -0.71 to -0.19; 4 studies, 239 participants; small effect size). We also observed differences in favour of CBT for self-reported state anger (1 study, 43 participants) and self-reported self-esteem (1 study 43 participants) compared to waiting list. We found no differences between CBT and supportive therapy (1 study, 81 participants) for self-rated depression, clinician-rated anxiety or self-rated self-esteem. Additionally, there were no differences between CBT and the waiting list for self-reported trait anger (1 study, 43 participants) or self-reported quality of life (SMD 0.21, 95% CI -0.29 to 0.71; 2 studies, 64 participants; small effect size).CBT plus pharmacotherapy versus pharmacotherapy alone: we found differences in favour of CBT plus pharmacotherapy for the Clinical Global Impression score (MD -0.75 points, 95% CI -1.21 points to -0.30 points; 2 studies, 65 participants), self-reported depression (MD -6.09 points, 95% CI -9.55 points to -2.63 points; 2 studies, 66 participants) and self-reported anxiety (SMD -0.58, 95% CI -1.08 to -0.08; 2 studies, 66 participants; moderate effect size). We also observed differences favouring CBT plus pharmacotherapy (1 study, 31 participants) for clinician-reported depression and clinician-reported anxiety.CBT versus other specific interventions: we found no differences for any of the secondary outcomes, such as self-reported depression and anxiety, and findings on self-reported quality of life varied across different studies.

AUTHORS' CONCLUSIONS

There is low-quality evidence that cognitive-behavioural-based treatments may be beneficial for treating adults with ADHD in the short term. Reductions in core symptoms of ADHD were fairly consistent across the different comparisons: in CBT plus pharmacotherapy versus pharmacotherapy alone and in CBT versus waiting list. There is low-quality evidence that CBT may also improve common secondary disturbances in adults with ADHD, such as depression and anxiety. However, the paucity of long-term follow-up data, the heterogeneous nature of the measured outcomes, and the limited geographical location (northern hemisphere and Australia) limit the generalisability of the results. None of the included studies reported severe adverse events, but five participants receiving different modalities of CBT described some type of adverse event, such as distress and anxiety.