Psychosocial interventions in attention-deficit/hyperactivity disorder: update

The Multidimensional Dynamic Feedback Model: A Comprehensive Framework for Understanding and Managing Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by persistent inattention, hyperactivity, and impulsivity. These symptoms can significantly impact academic performance, social interactions, and daily activities, often creating cycles that worsen long-term challenges. This review introduces the Multidimensional Dynamic Feedback Model (MDFM), which aids in understanding ADHD's development and guiding intervention strategies. The model emphasizes the dynamic interactions among genetic, environmental, cognitive, and behavioral factors. The MDFM consists of three key aspects: (1) the interplay between genetic and environmental factors in shaping ADHD's biological basis, (2) the role of cognitive and neural processes in driving core symptoms, and (3) the influence of behavioral feedback loops that reinforce negative behaviors and hinder adaptation. The model highlights the importance of personalized interventions and effective feedback systems, including early prevention, supportive family and school environments, and the impact of social and cultural backgrounds on treatment outcomes. As a comprehensive framework, the MDFM offers a holistic perspective for clinicians, aiming to enhance long-term outcomes and promote the health and well-being of individuals with ADHD across the lifespan. By addressing implementation challenges, the model seeks to improve ADHD prevention and management, ultimately supporting individuals and their communities.

Research Review: Mechanisms of change and between-family differences in parenting interventions for children with ADHD - an individual participant data meta-analysis

BACKGROUND

Understanding the mechanisms of change and between-family differences in behavioural parenting interventions for children with attention-deficit/hyperactivity disorder (ADHD) may help personalise interventions. Therefore, we examined whether improvements in parenting are associated with changes in child behaviour and functional outcomes, and how these associations vary based on parents' baseline parenting levels.

METHODS

We collected individual participant data including 19 randomised controlled trials focusing on children with ADHD (n = 1,720). Immediate post-intervention measures of child ADHD and oppositional behaviour severity, reported by parents and functional impairment reported by either the parent or probably masked clinicians, were treated as outcomes. We estimated pathways from intervention (vs. control) to child outcomes, via immediate post-intervention parent reports of constructive parenting (e.g. praise), non-constructive parenting (e.g. physical punishment) and parent-child affection (e.g. warmth), while controlling for baseline values of both child outcomes and parenting levels. Baseline values of each parenting variable were used as moderators of the mediated pathways.

RESULTS

Improvements in parenting behaviours and parent-child affection immediately following the intervention jointly explained concurrent improvements in children's ADHD severity, oppositional behaviour and functional impairment. Furthermore, when reversing the direction of the pathways, improvements in all child outcomes jointly explained improvements in each aspect of parenting. Improvements in non-constructive parenting and parent-child affection uniquely accounted for intervention effects on functional impairment, especially for families with higher baseline levels of non-constructive parenting.

CONCLUSIONS

Our findings might indicate that improvements in both the behavioural and affective aspects of parenting are associated with concurrent reductions in child behaviour problems and functional impairment. However, more research is necessary to explore the potential causal directionality between parenting and child outcomes. Nonetheless, supporting families with poorer parenting skills may be especially important, as reductions in non-constructive parenting in these families are linked to stronger treatment effects on child functional impairment.

The short- and longer-term effects of brief behavioral parent training versus care as usual in children with behavioral difficulties: study protocol for a randomized controlled trial

BACKGROUND

The access to and uptake of evidence-based behavioral parent training for children with behavioral difficulties (i.e., oppositional, defiant, aggressive, hyperactive, impulsive, and inattentive behavior) are currently limited because of a scarcity of certified therapists and long waiting lists. These problems are in part due to the long and sometimes perceived as rigid nature of most evidence-based programs and result in few families starting behavioral parent training and high dropout rates. Brief and individually tailored parenting interventions may reduce these problems and make behavioral parent training more accessible. This protocol paper describes a two-arm, multi-center, randomized controlled trial on the short- and longer-term effectiveness and cost-effectiveness of a brief, individually tailored behavioral parent training program for children with behavioral difficulties.

METHODS

Parents of children aged 2-12 years referred to a child mental healthcare center are randomized to (i) three sessions of behavioral parent training with optional booster sessions or (ii) care as usual. To evaluate effectiveness, our primary outcome is the mean severity of five daily ratings by parents of four selected behavioral difficulties. Secondary outcomes include measures of parent and child behavior, well-being, and parent-child interaction. We explore whether child and parent characteristics moderate intervention effects. To evaluate cost-effectiveness, the use and costs of mental healthcare and utilities are measured. Finally, parents' and therapists' satisfaction with the brief program are explored. Measurements take place at baseline (T0), one week after the brief parent training, or eight weeks after baseline (in case of care as usual) (T1), and six months (T2) and twelve months (T3) after T1.

DISCUSSION

The results of this trial could have meaningful societal implications for children with behavioral difficulties and their parents. If we find the brief behavioral parent training to be more (cost-)effective than care as usual, it could be used in clinical practice to make parent training more accessible.

TRIAL REGISTRATION

The trial is prospectively registered at ClinicalTrials.gov (NCT05591820) on October 24th, 2022 and updated throughout the trial.

Propelling the Global Advancement of School Mental Health

Rates of mental health problems and disorders in children and youth have been increasing for at least three decades, and these have escalated due to the pandemic and multiple other societal stressors. It is increasingly recognized that students and families frequently struggle to receive needed care through traditional locations such as specialty mental health centers. Upstream mental health promotion and prevention strategies are gaining support as a public health approach to supporting overall population well-being, better utilizing a limited specialty workforce, and reducing illness. Based on these recognitions, there has been a progressive and escalating movement toward the delivery of mental health support to children and youth "where they are," with a prominent and more ecologically valid environment being schools. This paper will provide a brief review of the escalating mental health needs of children and youth, advantages of school mental health (SMH) programs in better meeting these needs, example model SMH programs from the United States and Canada, and national and international SMH centers/networks. We conclude with strategies for further propelling the global advancement of the SMH field through interconnected practice, policy, and research.

Efficacy of behavior modification training combined with electroencephalographic biofeedback therapy for attention deficit hyperactivity disorder in children: a randomized controlled trial

Background and aims

Attention deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in children. Multiple treatments are currently available with varying effectiveness, and our aim was to investigate the efficacy of behavior modification training combined with Electroencephalography (EEG) biofeedback treatment on ADHD in children.

Methods

Children with ADHD were randomly divided into a control group (n = 42), an EEG biofeedback group (n = 30) and a behavior modification training combined with EEG biofeedback group (i.e., a combined intervention group) (n = 30) according to the intervention. Swanson, Nolan, and Pelham, Version IV (SNAP-IV) and Conners Parent Symptom Questionnaire (PSQ) were assessed before and after three months of treatment.

Results

We found that in the EEG biofeedback group and the combined intervention group, the scores of all factors except "anxiety" and "psychosomatic disorder" were lower than before treatment, and the difference was statistically significant (P < 0.05). After treatment, the scores of the three groups were compared. The scores of "impulsivity-hyperactivity", "learning problems", "inattention factor" and "hyperactivity factor" were all lower than before, and the difference was statistically significant (P < 0.05). In the post-treatment comprehensive intervention group and the control group, the efficacy was apparent, and the differences in the scores of each factor were statistically significant (P < 0.05). In the comparison between the EEG biofeedback group and the control group, except for "anxiety", "psychosomatic disorder" and "conduct problem" the scores of each factor were statistically significant (P < 0.05). For the comparison between the integrated intervention group and the EEG biofeedback group, the scores of all factors before and after treatment were statistically significant (P < 0.05), except for "anxiety", "impulsivity-hyperactivity" and the scores of all the factors before and after treatment were statistically significant (P < 0.05), except for "anxiety", "impulsivity-hyperactivity" and "psychosomatic disorder".

Conclusions

The comprehensive efficacy of behavior modification training combined with EEG biofeedback therapy on the improvement of symptoms in children with ADHD is positive, and good compliance is worthy of clinical promotion.

Clinical Trial Registration

https://www.chictr.org.cn/indexEN.html, identifier (ChiCTR2300071511).

Involving Parents in Child Mental Health Treatments: Survey of Clinician Practices and Variables in Decision Making

OBJECTIVE

Child therapy outcomes research has indicated that involving parents in child mental health treatments is generally beneficial. This study aimed to explore clinicians' decisions to involve parents in treatment for childhood disorders and child-, parent-, and clinician-related variables influencing these decisions.

METHODS

Data on decision making and reported use of parent involvement by 40 therapists with patients ages 6-12 were obtained from a self-report survey. Most clinicians were psychologists, White, and female and worked in community-based clinics. They reported using cognitive-behavioral and family system interventions considerably more than psychodynamic therapy.

RESULTS

Clinician-reported use of parent involvement was significantly greater for children with oppositional defiant or conduct disorder than for those with attention-deficit hyperactivity disorder, depression, anxiety, or posttraumatic stress disorder or trauma. A child's age and diagnosis (100% of clinicians), parental level of stress (85%), and parent interest in working with the clinician (60%) were frequently reported as being important to clinicians' decisions. Ninety percent of clinicians reported that they believed working with parents was effective, whereas only 25% reported their own training to be influential in decision making.

CONCLUSIONS

Findings regarding use of parent involvement stratified by common childhood disorder were not surprising, given the behavioral and treatment complexities of oppositional defiant or conduct disorder. Clinicians often reported parents' stress level and interest in working with the clinician as influencing decision making, reflecting the importance of lesser researched decision variables. The relatively limited influence of training on decision making suggests the need for better parent involvement education for clinicians treating children.

Meta-analysis of the effects of physical activity on executive function in children and adolescents with attention deficit hyperactivity disorder

BACKGROUND

Executive function is a core deficit in children with attention deficit hyperactivity disorder (ADHD). This study systematically reviewed the evidence for the effects of physical activity (PA) interventions on executive function in children and adolescents with ADHD and explored the moderating effects of key variables of PA on executive function.

METHODS

Relevant literature in four electronic databases, Pubmed, Web of Science, Cochrane Library, and Embase, were systematically searched. Revman 5.4 was used for data analysis, and combined effect sizes, heterogeneity tests, subgroup analyses, and sensitivity analyses were calculated. Egger's test in Stata 15.0 was used for publication bias testing.

RESULTS

A total of 24 articles with 914 participants were included. Meta-analysis showed that PA interventions improved inhibitory control (SMD = -0.50, 95%CI [-0.71, -0.29], P < 0.00001), working memory (SMD = -0.50, 95%CI [-0.83, -0.16], P = 0.004) and cognitive flexibility in children and adolescents with ADHD (SMD = -0.45, 95%CI [-0.81, -0.09], P = 0.01). Subgroup analysis revealed a moderating effect of intervention intensity, motor skill type, sessions of PA, and weekly exercise volume on executive function.

CONCLUSION

PA interventions had positive effects on improvements in core executive functions in children and adolescents with ADHD and were influenced by intervention intensity, type of motor skill, sessions of PA, and amount of exercise. This has practical implications for the formulation of PA interventions programs.

Real-World Efficacy and Safety of Extended-Release Methylphenidate (PRC-063) in the Treatment of ADHD in Pediatric and Adult Subjects: Results of a Phase IV Multicenter Comparison With Lisdexamfetamine Dimesylate

OBJECTIVE

To evaluate the real-world efficacy, safety, and functional outcomes of PRC-063 (multilayer-release methylphenidate) versus lisdexamfetamine (LDX) in ADHD subjects in a phase IV, open-label study.

METHOD

The primary endpoint was the change in the ADHD-DSM-5 Rating Scale (ADHD-5-RS) total score from baseline to Month 4. Secondary endpoints included a non-inferiority comparison between PRC-063 and LDX and measures of functioning and evening behavior.

RESULTS

One hundred forty-three pediatric and 112 adult subjects were enrolled. Mean ADHD-5-RS scores (standard deviation) were reduced in pediatric (-16.6 [10.4]) and adult (-14.8 [10.6]) subjects treated with PRC-063 (p < .001). PRC-063 was non-inferior to LDX in the pediatric population but not in the adult population. Significant improvements were demonstrated in quality of life and functionality. Both medications were well-tolerated; more adverse events led to study discontinuation in pediatric subjects treated with LDX versus PRC-063.

CONCLUSION

PRC-063 and LDX significantly improved ADHD symptomatology and functioning and were well-tolerated.

A pairwise randomised controlled trial of a peer-mediated play-based intervention to improve the social play skills of children with ADHD: Outcomes of the typically-developing playmates

To examine the effectiveness of a play-based intervention for improving social play skills of typically-developing playmates of children with ADHD. Children (5-11 years) were randomised to an intervention (n = 15) or waitlisted control group (n = 14). The Test of Playfulness was scored by a blinded rater. Between-group statistics compared the change of the intervention (10-week intervention) and waitlisted control (10-week wait) groups. Change in the intervention group following intervention was significantly greater than the change in the waitlisted control group. When combining data from the groups, playmates' (n = 29) mean ToP scores improved significantly following intervention, with a large effect pre- to post-intervention and pre-intervention to follow-up. Typically-developing playmates of children with ADHD benefited from participation in a peer-mediated intervention.

Attachment Representation Moderates the Effectiveness of Behavioral Parent Training Techniques for Children with ADHD: Evidence from a Randomized Controlled Microtrial

Behavioral parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but knowledge on the differential effects of behavioral techniques for specific subgroups of children is very limited. Attachment representations of children with ADHD may affect how receptive children are to changes in parenting. In this study, we investigated whether specific behavioral techniques were more or less effective for children with ADHD in relation to their attachment representations. We included parents of 74 children with ADHD (4-11 years, M = 8.15) who took part in a larger randomized controlled microtrial in which they were randomized to a two session training in antecedent-based techniques (i.e., stimulus control techniques: rules, instructions; n = 26), a two session training in consequent-based techniques (i.e., contingency management techniques: praise, rewards, ignoring; n = 25) or a waitlist control condition (n = 23). We examined whether attachment representation moderated the effectiveness of a) training versus waitlist, and b) antecedent- versus consequent-based techniques. Attachment representations were measured with a story stem task, the intervention outcome was daily parent-rated problem behaviors of the children. Attachment representation did not moderate the effects of the training compared to the waitlist. However, compared to antecedent-based techniques, consequent-based techniques were less effective for more securely and less disorganized attached children, and particularly effective for more disorganized attached children. This was the first study examining attachment as a moderator of behavioral techniques for ADHD. If replicated, the findings of this study can be used for treatment development and tailoring.

Academic, Interpersonal, Recreational, and Family Impairment in Children with Tourette Syndrome and Attention-Deficit/Hyperactivity Disorder

This study describes impairment in academic, interpersonal, recreational, and family financial or occupational domains across children in three mutually exclusive diagnostic groups: ever diagnosed with Tourette syndrome (TS), attention-deficit/hyperactivity disorder (ADHD), and both disorders. In 2014, parents reported on impairment and diagnostic status of children aged 4-17 years (n = 3014). Weighted analysis and pairwise t-tests showed more children with ADHD (with or without TS) experienced impairment in overall school performance, writing, and mathematics, relative to children with TS but not ADHD. More children with TS and ADHD had problematic handwriting relative to children with ADHD but not TS. More children with TS and ADHD had problematic interpersonal relationships relative to those with ADHD but not TS. Children with TS and ADHD had higher mean impairment across domains than children with either TS or ADHD. Findings suggest assessing disorder-specific contributions to impairment could inform targeted interventions for TS and ADHD.

The child behavior checklist can aid in characterizing suspected comorbid psychopathology in clinically referred youth with ADHD

OBJECTIVE

To examine the utility of the Child Behavior Checklist (CBCL) to aid in the identification of comorbid psychopathological conditions affecting referred youth with suspected ADHD prior to the evaluation. The CBCL is an easy-to-use assessment tool that may provide invaluable information regarding the severity and characteristics of the presenting complaints.

METHODS

The sample included 332 youths consecutively referred to an ADHD program for the assessment of suspected ADHD. Parents completed the CBCL, parent-rated ADHD Self-Report Scale (ASRS), Social Responsiveness Scale (SRS), and Behavior Rating Inventory of Executive Function (BRIEF). Because of the established association between the CBCL Attention Problems scale and a structured diagnostic interview of ADHD, all youths analyzed had abnormal Attention Problems T-scores (≥60).

RESULTS

Seventy-six percent of youths with elevated Attention Problems T-scores had ≥3 additional abnormal CBCL scales, suggesting they were likely affected with multiple comorbid psychopathological conditions. Moreover, 44% had ≥1 CBCL clinical scale with a T-score more severe than their Attention Problems T-score, suggesting the putative comorbid condition was more severe than the ADHD symptoms. Additional CBCL scale elevations were associated with more severe functional impairments as assessed by the ASRS, SRS, BRIEF, and CBCL competence scales.

CONCLUSION

The CBCL obtained before the clinical assessment identified high rates of comorbid psychopathology in youths referred for the assessment of ADHD. It provided detailed information about the types and severity of suspected psychopathological conditions impacting a particular youth, which is critical to guide the assessing clinician on likely differing needs of the affected child.

Schools As a Vital Component of the Child and Adolescent Mental Health System

This review examines the history and contemporary landscape of school mental health, describing evidence that schools are an essential component of the system of child and adolescent care and providing recommendations to advance this vital care delivery system. This literature review of scientific data and shifts to policy and practice in school mental health documents the evolution of collaboration between the education and mental health systems to support student mental health. This review describes best practices and provides examples for achieving the standards of the comprehensive school mental health systems model in states and local communities. Data demonstrate that multitiered systems of mental health support and services in schools, including mental health promotion, prevention, early intervention, and treatment, improve academic and psychosocial functioning and reduce risk of poor outcomes, including mental illness and school failure. Policy and practice shifts in the field reflect a movement toward integrating mental health systems into the education sector, including preparing the education workforce to promote mental health and to support early identification of and intervention to address mental illness. To create a full continuum of mental health supports for students, states and districts can draw on national best practices and state exemplars as they install multitiered systems of mental health supports in all schools, conduct universal student mental health monitoring, and coordinate school and community mental health systems.

Reviewing the role of emerging therapies in the ADHD armamentarium

Introduction: Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral disorder that can be treated with both pharmacologic and nonpharmacologic modalities. Effective drug treatments for ADHD have been available for more than six decades. However, initial treatments had limitations in duration of effect, need for multiple daily doses, requirement for patients to swallow intact tablets, adverse effects and risk for abuse and diversion. During the past 20 years, more than two dozen stimulant and nonstimulant drugs have been developed. Nonetheless, there remain unmet needs in the treatment of ADHD.Areas covered: New stimulant and nonstimulant formulations in development are reviewed with emphasis on drugs in phase II and III trials. Efficacy, mechanism of action and adverse effect data are described where available. Abuse liability studies are described for abuse-deterrent formulations in development.Expert opinion: The review found a robust pipeline of stimulants and nonstimulants. Medications in development are formulated to optimize onset and duration of effect, alter the time of administration, obviate the need to swallow whole capsules or tablets and to deter abuse. While each of these formulations may fill a unique niche, these incremental improvements based on new drug delivery technologies may lead to very significant clinical effects.

Effectiveness of Social Skills Interventions Incorporating Peer Interactions for Children With Attention Deficit Hyperactivity Disorder: A Systematic Review

IMPORTANCE

Few studies examining the use of peers during interventions have been published, and no systematic review has been conducted to evaluate the available literature.

OBJECTIVE

To examine the effectiveness of social skills interventions incorporating peers for children with attention deficit hyperactivity disorder (ADHD) to improve social interactions.

DATA SOURCES

A search of five databases (CINAHL, PubMed, Web of Science, Google Scholar, and PsycINFO) produced 697 articles. Sixty-one were retrieved for full-text review, and 15 articles met inclusion criteria.

STUDY SELECTION AND DATA COLLECTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to abstract data. Inclusion criteria: Participants younger than age 18 yr with any ADHD pattern, social skills interventions with peer involvement, outcome measures within the domain of occupational therapy, written in English, and involved a peer as the sole or primary component at some point in the social skills intervention. Exclusion criteria: Studies older than 20 yr or that used participants with comorbidities or multiple conditions.

FINDINGS

Interventions incorporating both peer categories were effective for increasing play skills, reducing undesirable social behaviors (e.g., inappropriate verbalizations, dominant behaviors, aggression), and improving communication (e.g., pragmatic language, collaboration, joint participation) and social participation. Improvements were maintained over time, as evidenced by follow-up studies.

CONCLUSIONS AND RELEVANCE

Outcomes of these studies demonstrate moderate evidence that supports the use of social skills interventions incorporating peers for children with ADHD to improve social interactions, supporting their use by occupational therapists and the need for more studies.

WHAT THIS ARTICLE ADDS

This article provides guidance to occupational therapy practitioners on social skills intervention options for children with ADHD.

A Strength-Based Intervention to Increase Participation in Leisure Activities in Children with Neuropsychiatric Disabilities: A Pilot Study

The aim is to evaluate the feasibility of an intervention model with a client-centered goal-directed approach with the aim to enhance the child's participation in leisure activities, self-efficacy, and activity performance. A pilot intervention using a client-centered goal-directed approach and a single-subject design was performed. Two Swedish boys with neuropsychiatric diagnosis aged 12 and 14 years old were included, and 3 leisure activity goals were identified. The intervention was carried out over 8 weeks and took place in the adolescent's everyday environment and at the pediatric rehabilitation center. The goal attainment of participation goals (GAS), the perceived performance ability according to the Canadian Occupational Performance Measure (COPM), the self-efficacy, and the participants' satisfaction were used to study the effect. The participants succeeded in attaining their leisure goals as specified by the GAS by achieving +2 on one goal and +1 on the other two goals. They estimated higher performance ability and self-efficacy in their goal performance. Participants, parents, and therapists were overall satisfied and found the intervention to be applicable and helpful in optimizing leisure participation. The intervention model with a client-centered goal-directed approach in which participants define their own leisure activity goals appears to be effective in increasing participation in leisure activities.

Parents' perceptions of the long-term appropriateness of a psychosocial intervention for children with attention deficit hyperactivity disorder

BACKGROUND/AIM

Designing psychosocial interventions that parents perceive as appropriate is essential to enhancing their engagement with the intervention and their long-term use of the intervention strategies. The aim of this study was to explore the long-term appropriateness of a play-based psychosocial intervention for children with Attention Deficit Hyperactivity Disorder (ADHD) from the perspectives of parents.

METHODS

Semi-structured phone interviews were conducted with 14 parents of children with ADHD who participated in a randomised controlled trial of the play-based intervention 1 year earlier.

RESULTS

Thematic analysis led to the development of three core-themes: (i) Everybody needs a parenting handbook, (ii) No one thing you are dealing with, and (iii) A different approach: Reframing.

DISCUSSION

The core-themes related back to a definition of intervention appropriateness that acknowledges the intervention as important/relevant, beneficial, socially and ecologically valid and promotes sustainable change, indicating parents perceived the intervention as appropriate. The core-themes also resembled aspects of the process of family adaptation. Findings highlight the importance of designing interventions that are appropriate from parents' perspectives to enhance their long-term engagement and use of the intervention strategies as well as outcomes for their child in the long term.

A Randomized Controlled Trial of Mindfulness-Based Cognitive Therapy for College Students With ADHD

OBJECTIVE

Between 2% and 8% of college students meet criteria for ADHD, with increased incidence in recent decades. There are very few clinical trials conducted on the meaningful intervention of ADHD in college. Mindfulness-based cognitive therapy (MBCT) effectively treats college students with ADHD and could be more feasibly applied in college mental health clinics.

METHOD

Fifty-four undergraduates with ADHD between ages 19 and 24 were randomized to receive either MBCT or wait-list (WL) during a 6-week intervention phase. ADHD symptoms, neuropsychological performance, and related outcomes were assessed at pre-treatment, post-treatment, and 3-month follow-up.

RESULTS

Participants receiving MBCT group showed greater treatment response rates (57%-71% vs. 23%-31%) and experience less anxiety and depression, and greater levels of mindfulness; MBCT participants show greater improvement on neuropsychological performance.

CONCLUSION

MBCT may be a useful intervention for college students with ADHD, improving participants' ADHD symptoms, mindfulness, and sustained attention.

Educational Outcomes Associated With School Behavioral Health Interventions: A Review of the Literature

BACKGROUND

There is an unmet need for behavioral health support and services among children and adolescents, which school behavioral health has the potential to address. Existing reviews and meta-analyses document the behavioral health benefits of school behavioral health programs and frameworks, but few summaries of the academic benefits of such programs exist. We provide exemplars of the academic benefits of school behavioral health programs and frameworks.

METHODS

A literature review identified school behavioral health-related articles and reports. Articles for inclusion were restricted to those that were school-based programs and frameworks in the United States that included an empirical evaluation of intervention academic-related outcomes.

RESULTS

Findings from 36 primary research, review, and meta-analysis articles from the past 17 years show the benefits of school behavioral health clinical interventions and targeted interventions on a range of academic outcomes for adolescents.

CONCLUSION

Our findings are consistent with reports documenting health benefits of school behavioral health frameworks and programs and can facilitate further efforts to support school behavioral health for a range of stakeholders interested in the benefits of school behavioral health programs and frameworks on academic outcomes.

Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder During Adolescence in the Primary Care Setting: A Concise Review

Attention deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder with a worldwide prevalence of about 5% in school-age children. This review is intended to assist primary care providers (PCPs) in diagnosing and treating ADHD in adolescents. PubMed, PsychInfo, and Science Citation Index databases were searched from March 1990 to 2015 with the keywords: ADHD, primary care/pediatrics, and children/adolescents. Abstracts addressing diagnosis and/or treatment with 105 citations were identified including supplementary treatment guidelines/books. Adolescent ADHD presents with significant disturbances in attention, academic performance, and family relationships with unique issues associated with this developmental period. Diagnostic challenges include the variable symptom presentation during adolescence, complex differential diagnosis, and limited training and time for PCPs to conduct thorough evaluations. The evidence base for treatments in adolescence in comparison to those in children or adults with ADHD is relatively weak. Providers should be cognizant of prevention, early identification, and treatment of conditions associated with ADHD that emerge during adolescence such as substance use disorders. Adolescent ADHD management for the PCP is complex, requires further research, and perhaps new primary care psychiatric models, to assist in determining the optimal care for patients at this critical period.

Clinical Reasoning in the Assessment and Intervention Planning for Attention-Deficit/Hyperactivity Disorder

The purpose of this article is to provide the reader with insight into the clinical reasoning involved in the assessment and intervention planning for a child with Attention-Deficit/Hyperactivity Disorder. The reader will be guided through the authors’ conceptualization of this case, and suggestions for intervention in the classroom will be discussed.

Pharmacological Management of Pediatric Patients with Comorbid Attention-Deficit Hyperactivity Disorder Oppositional Defiant Disorder

Attention-deficit hyperactivity disorder (ADHD) is a common developmental neurobiological condition of childhood characterized by age-inappropriate degrees of hyperactivity/impulsivity and inattention to tasks requiring sustained vigilance. Oppositional defiant disorder (ODD) is an externalizing behavior disorder characterized by difficulties with emotional and behavioral regulation that frequently brings the child into conflict with authority figures. In the clinical setting, ODD is the most common ADHD comorbidity. The combination portends more severe symptom severity, daily impairment, and a more at-risk prognosis than either disorder alone. We briefly review the literature on the characteristics and treatment of the ADHD and ODD child. A clinical approach to evaluation and treatment of ADHD and ODD is then presented. This approach emphasizes the importance of child and parent psychoeducation about the two disorders alone and in combination, the importance of behavioral management therapy approaches, the possible need for school and academic supports, and the decision to use evidence-based stimulant or non-stimulant ADHD medications depending on symptom severity combined with child and parental wishes and choice.

Use of Cognitive Behavioral Therapy and Token Economy to Alleviate Dysfunctional Behavior in Children with Attention-Deficit Hyperactivity Disorder

Medication has proved highly efficacious as a means of alleviating general symptoms of attention-deficit hyperactivity disorder (ADHD). However, many patients remain functionally impaired by inappropriate behavior. The present study analyzed the use of cognitive behavioral therapy (CBT) with the Token-Economy (TE) technique to alleviate problem behavior for 25 participants with ADHD, all children (19 boys, mean age 10.11) on long-term methylphenidate medication, who were given 20 CBT sessions with 10 weeks of TE introduced as of session 5. Their ten most acute problem behaviors were selected and written records kept. On weekdays, parents recorded each inappropriate behavior and provided a suitable model for their actions. At weekly sessions, problem behaviors were counted and incident-free participants rewarded with a token. To analyze improvement (less frequent problem behavior), a list of 11 behavioral categories was rated: inattention, impulsivity, hyperactivity, disorganization, disobeying rules and routines, poor self-care, verbal/physical aggression, low frustration tolerance, compulsive behavior, antisocial behavior, lacking in initiative and distraction. Two CBT specialists categorized behaviors and an ADHD specialist ruled on discrepancies. Statistical analyses used were Generalized Estimating Equations with Poisson distribution and autoregressive order correlation structure. In the course of the sessions, problematic behaviors decreased significantly in seven categories: impulsiveness, hyperactivity, disorganization, disobeying rules and routine, poor self-care, low frustration tolerance, compulsive behaviors, and antisocial behaviors. Caregiver attitudes to children's inappropriate behavior were discussed and reshaped. As functional improvement was observed on applying TE for 10 weeks, this type of intervention may be useful as an auxiliary strategy combined with medication.