Cognitive-behavioral and pharmacologic interventions for hyperactive boys: comparative and combined effects

ADHD, Multimodal Treatment, and Longitudinal Outcome: Evidence, Paradox, and Challenge

Given major increases in the diagnosis of attention-deficit hyperactivity disorder (ADHD) and in rates of medication for this condition, we carefully examine evidence for effects of single versus multimodal (i.e., combined medication and psychosocial/behavioral) interventions for ADHD. Our primary data source is the Multimodal Treatment Study of Children with ADHD (MTA), a 14-month, randomized clinical trial in which intensive behavioral, medication, and multimodal treatment arms were contrasted with one another and with community intervention (treatment-as-usual), regarding outcome domains of ADHD symptoms, comorbidities, and core functional impairments. Although initial reports emphasized the superiority of well-monitored medication for symptomatic improvement, reanalyses and reappraisals have highlighted (a) the superiority of combination treatment for composite outcomes and for domains of functional impairment (e.g., academic achievement, social skills, parenting practices); (b) the importance of considering moderator and mediator processes underlying differential patterns of outcome, including comorbid subgroups and improvements in family discipline style during the intervention period; (c) the emergence of side effects (e.g., mild growth suppression) in youth treated with long-term medication; and (d) the diminution of medication's initial superiority once the randomly assigned treatment phase turned into naturalistic follow-up. The key paradox is that whereas ADHD clearly responds to medication and behavioral treatment in the short term, evidence for long-term effectiveness remains elusive. We close with discussion of future directions and a call for greater understanding of relevant developmental processes in the attempt to promote optimal, generalized, and lasting treatments for this important and impairing neurodevelopmental disorder.

Social cognition

Social cognition is a major problem underlying deficiencies in interpersonal relationships in several psychiatric populations. And yet there is currently no gold standard for pharmacological treatment of psychiatric illness that directly targets these social cognitive areas. This chapter serves to illustrate some of the most innovative attempts at pharmacological modulation of social cognition in psychiatric illnesses including schizophrenia, borderline personality disorder, autism spectrum disorders, antisocial personality disorder and psychopathy, social anxiety disorder, and posttraumatic stress disorder. Pharmacological modulation includes studies administering oxytocin, ecstasy (MDMA), modafinil, methylphenidate, and D-cycloserine. Furthermore, some background on social cognition research in healthy individuals, which could be helpful in developing future treatments, is provided as well as the potential for each drug as a long-term treatment option.

Behavioral interventions in attention-deficit/hyperactivity disorder: a meta-analysis of randomized controlled trials across multiple outcome domains

OBJECTIVE

Behavioral interventions are recommended as attention-deficit/hyperactivity disorder (ADHD) treatments. However, a recent meta-analysis found no effects on core ADHD symptoms when raters were probably blind to treatment allocation. The present analysis is extended to a broader range of child and parent outcomes.

METHOD

A systematic search in PubMed, Ovid, Web of Knowledge, ERIC, and CINAHAL databases (up to February 5, 2013) identified published randomized controlled trials measuring a range of patient and parent outcomes for children and adolescents diagnosed with ADHD (or who met validated cutoffs on rating scales).

RESULTS

Thirty-two of 2,057 nonduplicate screened records were analyzed. For assessments made by individuals closest to the treatment setting (usually unblinded), there were significant improvements in parenting quality (standardized mean difference [SMD] for positive parenting 0.68; SMD for negative parenting 0.57), parenting self-concept (SMD 0.37), and child ADHD (SMD 0.35), conduct problems (SMD 0.26), social skills (SMD 0.47), and academic performance (SMD 0.28). With probably blinded assessments, significant effects persisted for parenting (SMD for positive parenting 0.63; SMD for negative parenting 0.43) and conduct problems (SMD 0.31).

CONCLUSION

In contrast to the lack of blinded evidence of ADHD symptom decrease, behavioral interventions have positive effects on a range of other outcomes when used with patients with ADHD. There is blinded evidence that they improve parenting and decrease childhood conduct problems. These effects also may feed through into a more positive parenting self-concept but not improved parent mental well-being.

Do programs designed to train working memory, other executive functions, and attention benefit children with ADHD? A meta-analytic review of cognitive, academic, and behavioral outcomes

Children with ADHD are characterized frequently as possessing underdeveloped executive functions and sustained attentional abilities, and recent commercial claims suggest that computer-based cognitive training can remediate these impairments and provide significant and lasting improvement in their attention, impulse control, social functioning, academic performance, and complex reasoning skills. The present review critically evaluates these claims through meta-analysis of 25 studies of facilitative intervention training (i.e., cognitive training) for children with ADHD. Random effects models corrected for publication bias and sampling error revealed that studies training short-term memory alone resulted in moderate magnitude improvements in short-term memory (d=0.63), whereas training attention did not significantly improve attention and training mixed executive functions did not significantly improve the targeted executive functions (both nonsignificant: 95% confidence intervals include 0.0). Far transfer effects of cognitive training on academic functioning, blinded ratings of behavior (both nonsignificant), and cognitive tests (d=0.14) were nonsignificant or negligible. Unblinded raters (d=0.48) reported significantly larger benefits relative to blinded raters and objective tests (both p<.05), indicating the likelihood of Hawthorne effects. Critical examination of training targets revealed incongruence with empirical evidence regarding the specific executive functions that are (a) most impaired in ADHD, and (b) functionally related to the behavioral and academic outcomes these training programs are intended to ameliorate. Collectively, meta-analytic results indicate that claims regarding the academic, behavioral, and cognitive benefits associated with extant cognitive training programs are unsupported in ADHD. The methodological limitations of the current evidence base, however, leave open the possibility that cognitive training techniques designed to improve empirically documented executive function deficits may benefit children with ADHD.

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

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) in children is associated with hyperactivity and impulsitivity, attention problems, and difficulties with social interactions. Pharmacological treatment may alleviate symptoms of ADHD but seldom solves difficulties with social interactions. Social skills training may benefit ADHD children in their social interactions. We examined the effects of social skills training on children's social competences, general behaviour, ADHD symptoms, and performance in school.

OBJECTIVES

To assess the effects of social skills training in children and adolescents with ADHD.

SEARCH METHODS

We searched the following electronic databases: CENTRAL (2011, Issue1), MEDLINE (1948 to March 2011), EMBASE (1980 to March 2011), ERIC (1966 to March 2011 ), AMED (1985 to June 2011), PsycINFO (1806 to March 2011), CINAHL (1980 to March 2011), and Sociological Abstracts (1952 to March 2011). We also searched the metaRegister of Controlled Trials on 15 October 2010. We did not apply any language or date restrictions to the searches. We searched online conference abstracts and contacted 176 experts in the field for possible information about unpublished or ongoing RCTs.

SELECTION CRITERIA

Randomised trials investigating social skills training for children with ADHD as a stand alone treatment or as an adjunct to pharmacological treatment.

DATA COLLECTION AND ANALYSIS

We conducted the review according to the Cochrane Handbook for Systematic Reviews of Intervention. Two authors (OJS, MS) extracted data independently using an appropriate data collection form. We performed the analyses using Review Manager 5 software.

MAIN RESULTS

We included 11 randomised trials described in 26 records (all full text articles) in the review. The trials included a total of 747 participants. All participants were between five and 12 years of age. No trials assessed adolescents. In 10 of the trials the participants suffered from different comorbidities.The duration of the interventions ranged from eight to 10 weeks (eight trials) up to two years. The types of social skills interventions were named social skills training, cognitive behavioural intervention, multimodal behavioural/psychosocial therapy, behavioural therapy/treatment, behavioural and social skills treatment, and psychosocial treatment. The content of the social skills interventions were comparable and based on a cognitive behavioural model. Most of the trials compared child social skills training and parent training plus medication versus medication alone. Some of the experimental interventions also included teacher consultations.More than half of the trials were at high risk of bias regarding generation of the allocation sequence and allocation concealment. No trial reported blinding of participants and personnel and most of the trials had no reports regarding differences between groups in collateral medication for comorbid disorders. Overall, the trials had high risk of bias due to systematic errors. Even so, as recommended by the Cochrane Handbook of Systematic Reviews of Interventions, we used all eligible trials in the meta-analysis, but the results are downgraded to low quality evidence.There were no statistically significant treatment effects either on social skills competences (positive value = better for the intervention group) (SMD 0.16; 95% CI -0.04 to 0.36; 5 trials, n = 392), on the teacher-rated general behaviour (negative value = better for the intervention group) (SMD 0.00; 95% CI -0.21 to 0.21; 3 trials, n = 358), or on the ADHD symptoms (negative value = better for the intervention group) (SMD -0.02; 95% CI -0.19 to 0.16; 6 trials, n = 515).No serious or non-serious adverse events were reported.

AUTHORS' CONCLUSIONS

The review suggests that there is little evidence to support or refute social skills training for adolescents with ADHD. There is need for more trials, with low risk of bias and with a sufficient number of participants, investigating the efficacy of social skills training versus no training for both children and adolescents.

Subtypes of aggression in children with attention deficit hyperactivity disorder: medication effects and comparison with typical children

We examined aggressive behavior in 6- to 12-year-old children, including 20 children with attention deficit hyperactivity disorder (ADHD) on stimulant medication, 19 children with ADHD on placebo (n = 19), and 32 controls. Children completed a laboratory provocation task designed to measure hostile, instrumental, reactive, and proactive aggression. Children in the ADHD-placebo group exhibited increased proactive and reactive aggression following high levels of provocation compared to controls. On the last trials, instrumental aggression dissipated for controls and hostile aggression dissipated for children in the ADHD-placebo group. Both instrumental and hostile aggression dissipated for children in the ADHD-medication group.

Cognitive Processes Underlying the Behavior Change in Cognitive Behavior Therapy with Childhood Disorders: A Review of Experimental Evidence

While Cognitive Behavior Therapy (CBT) has been widely used for treatment of childhood disorders, the process underlying the success of CBT in this area is still unclear. This paper attempts to examine empirically the above issue, using the literature from 1974 to 1989 to see whether there is support for the underlying changes in cognitive processes that are assumed to mediate the therapy. The results show that while CBT is relatively effective in treating some childhood disorders, there is little empirical evidence to support the underlying cognitive models of childhood disorders.

ADHD and method variance: a latent variable approach applied to a nationally representative sample of college freshmen

This study employed a correlated trait-correlated method application of confirmatory factor analysis to disentangle trait and method variance from measures of attention-deficit/hyperactivity disorder obtained at the college level. The two trait factors were Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV ) Inattention and DSM-IV Hyperactivity-Impulsivity. The two source factors were self-reports and parent-reports. Data were collected for an epidemiological sample (N = 1,079) of college freshmen stratified for race/ethnicity, gender, and ability level according to national targets for the U.S. college population. Results revealed (a) parents' ratings were better measures of internalizing behavioral dimensions and that students' ratings were better measures of externalizing dimensions of behavior, (b) informants have a greater impact on behavior ratings than the behavioral construct that is presumed to be the primary cause of the behavior as measured by the CARE, (c) relationships among the method factors revealed a substantial amount of unique variance among informants, and (d) relationships among trait factors were largely within expectation.

Review of cognitive, cognitive-behavioral, and neural-based interventions for Attention-Deficit/Hyperactivity Disorder (ADHD)

Primary evidence-based treatment approaches for ADHD involve pharmacological and behavioral treatments. However, there continue to be investigations of cognitive-behavioral, cognitive, and neural-based intervention approaches that are not considered evidence-based practice. These particular treatments are summarized, as they all involve training in cognitive skills or cognitive strategies. We identified 26 studies (six cognitive-behavioral, six cognitive, and 14 neural-based), and calculated effect sizes where appropriate. Overall, our analysis suggests that further research is needed to determine the efficacy of these approaches on both cognitive and behavioral outcome measures, but that some of these methods show promise for treating ADHD. We discuss some important conceptual and methodological issues that need to be taken into account for future research in order to evaluate the clinical efficacy of these approaches.

Task demands interact with the single and combined effects of medication and contingencies on children with ADHD

OBJECTIVE

To investigate single and combined effects of stimulant medication and contingencies on the performance of ADHD children with tasks involving different cognitive demands.

METHOD

Children diagnosed with ADHD participated in a within-subjects design. At two separate sessions, children on either medication or placebo (administered in a double-blind fashion) completed two tasks, a match-to-sample task and a stop-signal task, under three conditions (reward, response cost, and no contingency) in a counterbalanced order.

RESULTS

Contingencies and medication administered singly improved performance on both tasks. For the match-to-sample task, the combination of medication and contingencies was more efficacious than either alone. For the stop-signal task, the combination of medication and reward was no more effective than either alone; however, medication and response cost combined was more effective than either treatment alone.

CONCLUSION

Results suggest that both medication and contingencies improve task performance. The findings suggest that task demands interact with single and combined treatment effects.

Risperidone augmentation for treatment-resistant aggression in attention-deficit/hyperactivity disorder: a placebo-controlled pilot study

OBJECTIVE

To evaluate the effects of risperidone augmentation for treatment-resistant aggression in children with attention-deficit/hyperactivity disorder (ADHD).

METHOD

Twenty-five children (ages 7-12 years) with attention-deficit/hyperactivity disorder (ADHD) and significant aggressive behaviors were randomized to risperidone or placebo for 4 weeks for this double-blind study. Subjects were already in treatment with a constant dose of psychostimulant medication. The primary efficacy measure was change from baseline in the Children's Aggression Scale-Parent (CAS-P) and -Teacher (CAS-T) total scores.

RESULTS

The mean risperidone dose at endpoint was 1.08 mg/day. For the CAS-P total score, a significant difference was found (chi(1)(2) = 4.30, p < .05) with 100% of risperidone subjects improving by more than 30% from baseline to endpoint, whereas only 77% of the placebo group reported a similar response. No differences were found on the CAS-T total score. For the CAS-P and CAS-T, no significant interaction was found between treatment group and time. Rates of adverse events did not differ significantly between groups.

CONCLUSIONS

Risperidone treatment appears to be well tolerated and modestly effective when used in combination with psychostimulants for treatment-resistant aggression in children with ADHD.

A meta-analysis of combined treatments for children diagnosed with ADHD

OBJECTIVE

Meta-analytic procedures are used to review the literature of combined treatments of psychosocial and pharmacological treatments for children diagnosed with ADHD.

METHOD

Eight combined treatment studies meet specific inclusion and exclusion criteria regarding the core and peripheral features of the disorder.

RESULTS

The results of this study highlight the individual and average effect sizes within the categories of inattention, hyperactivity, impulsivity, social skills, and academics. These findings are compared with the effect sizes of meta-analytic findings previously reported in the pharmacological literature.

CONCLUSION

The results reveal large effect sizes for the core features of the disorder and the peripheral feature of social skills. A small effect size is found for the peripheral feature of academics. Findings are discussed in light of the paucity of included studies focused on combined treatments for ADHD.

ADHD and achievement: meta-analysis of the child, adolescent, and adult literatures and a concomitant study with college students

This article presents results from two interrelated studies. The first study conducted a meta-analysis of the published literature since 1990 to determine the magnitude of achievement problems associated with attention-deficit/hyperactivity disorder (ADHD). Effect sizes were significantly different between participants with and without ADHD (sample weighted r = .32, sample weighted d = . 71; p = .001). Effects were also examined according to the moderators of age, gender, achievement domain (reading, math, spelling), measurement method (standardized tests vs. grades, parent/teacher ratings, etc.), sample type (clinical vs. nonclinical), and system used to identify ADHD (DSM-III-R vs. DSM-IV). Significant differences emerged from the moderator comparisons. The second study, using averaged effect sizes from the first study as a baseline for comparison, investigated achievement levels for an understudied age group with ADHD, namely, college students. Unlike previous studies at the college level, the sample incorporated both student and parent ratings (N = 380 dyads). The results were comparable to outcomes from the meta-analysis for college students and adults. Analyses demonstrated modest (R = .21) but meaningful predictive validity across 1 year to end-of-first-year grades. However, unlike earlier studies with children and adolescents, student ratings were as predictive as parent ratings. Findings are discussed in terms of the impact of moderator variables on ADHD and achievement.

Treatment of attention-deficit/hyperactivity disorder: overview of the evidence

The American Academy of Pediatrics' Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, reviewed and analyzed the current literature for the purpose of developing an evidence-based clinical practice guideline for the treatment of the school-aged child with attention-deficit/hyperactivity disorder (ADHD). This review included several key reports, including an evidence review from the McMaster Evidence-Based Practice Center (supported by the Agency for Healthcare Research and Quality), a report from the Canadian Coordinating Office for Health Technology Assessment, the Multimodal Treatment for ADHD comparative clinical trial (supported by the National Institute of Mental Health), and supplemental reviews conducted by the subcommittee. These reviews provided substantial information about different treatments for ADHD and their efficacy in improving certain characteristics or outcomes for children with ADHD as well as adverse effects and benefits of multiple modes of treatment compared with single modes (eg, medication or behavior therapies alone). The reviews also compared the effects of different medications. Other evidence documents the long-term nature of ADHD in children and its classification as a chronic condition, meriting the application of general concepts of chronic-condition management, including an individual treatment plan with a focus on ongoing parent and child education, management, and monitoring. The evidence strongly supports the use of stimulant medications for treating the core symptoms of children with ADHD and, to a lesser degree, for improving functioning. Behavior therapy alone has only limited effect on symptoms or functioning of children with ADHD, although combining behavior therapy with medication seems to improve functioning and may decrease the amount of (stimulant) medication needed. Comparison among stimulants (mainly methylphenidate and amphetamines) did not indicate that 1 class outperformed the other.

ADHD and College Students: Exploratory and Confirmatory Factor Structures With Student and Parent Data

Exploratory factor analyses (EFAs) and confirmatory factor analyses (CFAs) were used to investigate the structure of the Student Report Inventory (SRI) and Parent Report Inventory (PRI) of the College Attention-Deficit/Hyperactivity Disorder (ADHD) Response Evaluation. The sample was composed of 1,080 college students and their parents and was stratified by ethnicity, gender, ability level, age, grade, region of residence, and psychoeducational classification status. Results varied according to the information source (self-report vs. parent). EFA uncovered and CFA confirmed 3 distinct and reliable dimensions for student reports: Inattention, Hyperactivity, and Impulsivity. By contrast, EFA and CFA uncovered a reliable 2-dimension structure for the parent-report data. Factor structures replicated across genders (3 factors for the SRI, and 2 factors for the PRI). Results are discussed in terms of the divergence of structures.

Attention deficit hyperactivity disorder in children: moving forward with divergent perspectives

Current controversy about diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) reflects the divergence between developmental and non-developmental approaches. While there is growing evidence for biological vulnerabilities associated with ADHD, we believe that environmental factors, including early problems in parental attachment, are also important in determining the type and timing of deficit that a child develops, the risk to academic and social performance and eventual outcome. We warn against labelling children with ADHD simply because they fulfil the cross-sectional diagnostic symptom criteria of the Diagnostic and statistical manual of mental disorders - 4th edition (DSM-IV). We advocate an integrated biopsychosocial approach to diagnosis and management with a thorough developmental assessment to identify developmental factors, such as deficits in early attachment, contributing to the presentation.

The effects of a stress-management program on self-concept, locus of control, and the acquisition of coping skills in school-age children diagnosed with attention deficit hyperactivity disorder

PROBLEM

What is the effectiveness of a stress-management program on self-concept, locus of control, and acquisition of appropriate coping strategies in children with attention deficit hyperactivity disorder (ADHD)?

METHODS

Forty-two children with ADHD (age range 9-12) were randomly assigned to a control group, a therapist-led group, or a group in which the stress-management techniques were taught by the parents. The subjects were pre- and posttested on self-concept, locus of control, and acquisition of coping skills.

FINDINGS

Although there were no significant changes in any of the three groups for acquisition of coping skills, the children in the therapist-led group reported more appropriate coping strategies.

CONCLUSIONS

Involving parents in a cognitive-behavioral approach could improve parent-child relationships and further increase the opportunities for successful academic and social functioning.

Once-a-day Concerta methylphenidate versus three-times-daily methylphenidate in laboratory and natural settings

OBJECTIVE

Methylphenidate (MPH), the most commonly prescribed drug for attention-deficit/hyperactivity disorder (ADHD), has a short half-life, which necessitates multiple daily doses. The need for multiple doses produces problems with medication administration during school and after-school hours, and therefore with compliance. Previous long-acting stimulants and preparations have shown effects equivalent to twice-daily dosing of MPH. This study tests the efficacy and duration of action, in natural and laboratory settings, of an extended-release MPH preparation designed to last 12 hours and therefore be equivalent to 3-times-daily dosing.

METHODS

Sixty-eight children with ADHD, 6 to 12 years old, participated in a within-subject, double-blind comparison of placebo, immediate-release (IR) MPH 3 times a day (tid), and Concerta, a once-daily MPH formulation. Three dosing levels of medication were used: 5 mg IR MPH tid/18 mg Concerta once a day (qd); 10 mg IR MPH tid/36 mg Concerta qd; and 15 mg IR MPH tid/54 mg Concerta qd. All children were currently medicated with MPH at enrollment, and each child's dose level was based on that child's MPH dosing before the study. The doses of Concerta were selected to be comparable to the daily doses of MPH that each child received. To achieve the ascending rate of MPH delivery determined by initial investigations to provide the necessary continuous coverage, Concerta doses were 20% higher on a daily basis than a comparable tid regimen of IR MPH. Children received each medication condition for 7 days. The investigation was conducted in the context of a background clinical behavioral intervention in both the natural environment and the laboratory setting. Parents received behavioral parent training and teachers were taught to establish a school-home daily report card (DRC). A DRC is a list of individual target behaviors that represent a child's most salient areas of impairment. Teachers set daily goals for each child's impairment targets, and parents provided rewards at home for goal attainment. Each weekday, teachers completed the DRC, and it was used as a dependent measure of individualized medication response. Teachers and parents also completed weekly standardized ratings of behavior and treatment effectiveness. To evaluate the time course of medication effects, children spent 12 hours in a laboratory setting on Saturdays and medication effects were measured using procedures and methods adapted from our summer treatment program. Measures of classroom behavior and academic productivity/accuracy were taken in a laboratory classroom setting during which children completed independent math and reading worksheets. Measures of social behavior were taken in structured, small-group board game settings and unstructured recess settings. Measures included behavior frequency counts, academic problems completed and accuracy, independent observations, teacher and counselor ratings, and individualized behavioral target goals. Reports of adverse events, sleep quality, and appetite were collected.

RESULTS

On virtually all measures in all settings, both drug conditions were significantly different from placebo, and the 2 drugs were not different from each other. In children's regular school settings, both medications improved behavior as measured by teacher ratings and individualized target behaviors (the DRC); these effects were seen into the evening as measured by parent ratings. In the laboratory setting, effects of Concerta were equivalent to tid MPH and lasted at least through 12 hours after dosing. Concerta was significantly superior to tid MPH on 2 parent rating scores, and when asked, more parents preferred Concerta than preferred tid IR MPH or placebo. Side effects on children's sleep and appetite were similar for the 2 preparations. In the lab setting, both medications improved productivity and accuracy on arithmetic seatwork assignments, disruptive and on-task behavior, and classroom rule following. Both medications improved children's rule following and negative behavior in small group board games, as well as in unstructured recess settings. Individual target behaviors also showed significant improvement with medication across domains in the laboratory setting. Children's behavior across settings deteriorated across the laboratory day, and the primary effect of medication was to prevent this deterioration as the day wore on. Results support the use of background behavioral treatment in clinical trials of stimulant medication, and illustrate the utility of a measure of individualized daily target goals (ie, the DRC) as an objective measure of medication response in both the laboratory and natural school settings.

CONCLUSION

This investigation clearly supports the efficacy of the Concerta long-acting formulation of MPH for parents who desire to have medication benefits for their child throughout the day and early evening. (ABSTRACT TRUNCATED)

Attention Deficit Hyperactivity Disorder

Management of attention deficit hyperactivity disorder (ADHD) encompasses two general domains: pharmacologic therapies and nonpharmacologic therapies, including educational, cognitive-behavioral, and other psychological and psychiatric approaches. Within the past year there have been two seminal developments in treatment. The first is that the Evidence-based Practice Center at McMaster University, under contract with the Agency for Health Care Policy and Research, produced an evidence based report on the treatment of ADHD. The topic was proposed to the AHCPR by the American Academy of Pediatrics and American Psychiatric Association, who served as partners to the center. The second is the completion of the Multisite Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA) study by the National Institutes of Mental Health, a 14-month double-blind placebo trial of medication and behavioral therapy in ADHD. In general, the result of the evidence-based review and the MTA study is that stimulants are the most effective agents for the treatment of ADHD. Results from the MTA study indicate that methylphenidate (MPH) and MPH combined with behavioral therapy are superior to behavioral therapy alone and that all three are superior to community therapy. The evidence-based review indicates that each of the stimulants is superior to placebo and the stimulants (regular and sustained-release MPH as well as d and l isomers of the stimulants) are comparable. As for other agents, tricyclic antidepressants, specifically desipramine, are superior to placebo. Only a few studies compared stimulants directly with tricyclic antidepressants, and these were technically inadequate, leading to the conclusion that more rigorous studies are required. Only five studies were found that examined nonpharmacologic treatment, and all contained major limitations in methodology. Despite the limitations, all showed that stimulants were more effective than the nonpharmacologic therapies, consonant with the results of the MTA study. There was lack of evidence to support the superiority of combination multimodal treatment over stimulant therapy alone, again consonant with the MTA study. Both the evidence-based review and the MTA study examined ADHD in middle childhood. Finally, most studies are relatively short-term, including the MTA study (at 14 months). Some evidence suggests that MPH reduces behavioral disturbance as long as it is taken.

Attention deficit hyperactivity disorder: current progress and controversies

OBJECTIVE

Attention deficit hyperactivity disorder (ADHD) is a common chronic and disabling condition in children. This paper reviews the taxonomic issues and the major comorbid conditions, neurobiological correlates, treatment and public health issues associated with ADHD.

METHOD

Pertinent recent papers are reviewed from the psychological and psychiatric literature.

RESULTS

The two major taxonomies now define a similar group of children with ADHD of a combined type/hyperkinetic disorder. Advances in the understanding and treatment of ADHD demonstrate the complex multidimensional links between neurobiology, psychology and behaviour. Careful assessment of individual factors in treatment planning and ongoing monitoring of psychostimulant medication treatment in the longer term are recommended.

CONCLUSIONS

There is much still to learn about ADHD, and increased levels of clinical research and treatment resources are required.

Attention-deficit hyperactivity disorder in children and youth: a quantitative systematic review of the efficacy of different management strategies

OBJECTIVE

To obtain estimates of the relative efficacy of 3 main treatment strategies for attention-deficit hyperactivity disorder (ADHD) in children and youth (age < 18 years).

DESIGN

quantitative systematic review of randomized trials.

SUBJECTS

999 patients with ADHD from 26 randomized trials.

INTERVENTIONS

medications alone, behavioural interventions alone, and a combination of these 2 modalities.

MAIN OUTCOME MEASURE

differences in scores between treatment groups on commonly used teacher- and parent-completed behaviour rating scales.

RESULTS

Medication-only therapy was efficacious in ADHD. Behavioural therapies used alone appeared not to be efficacious in ADHD. Combination therapy was more efficacious than placebo or no treatment for parent but not teacher ratings, not more efficacious than drug therapy alone, and more efficacious than behavioural treatments alone based on parent but not teacher ratings.

CONCLUSION

Though stimulant medications were found to be an effective treatment strategy for ADHD in children and youth, it proved difficult to assess the relative benefits of behavioural interventions alone and combined medication and behavioural therapy because of the paucity of treatment studies other than medication-only treatment studies and heterogeneity of various kinds that exist in relation to ADHD studies and treatments.

Engagement in child and adolescent treatment: the role of parental cognitions and attributions

Parental engagement in the treatment process is influenced by parents' beliefs about the cause of their children's problems, perceptions about their ability to handle such problems, and expectations about the ability of therapy to help them. This paper examines the role of parental cognitions related to attributions and expectations in relation to engagement in child mental health treatment. Reviewed studies indicate that parental attributions and expectations influence three aspects of treatment: help seeking, engagement and retention, and outcome. This paper integrates findings from developmental and clinical research, highlights gaps in the literature, presents the beginnings of a model regarding the parental attributional process as it relates to engagement in treatment, recommends future research directions, and discusses clinical implications.

Methylphenidate and behavior modification in children with ADHD and comorbid ODD or CD: main and incremental effects across settings

OBJECTIVE

Although the combination of methylphenidate (MPH) and behavior modification (BMOD) has been advocated to enhance clinical outcome for children with attention-deficit hyperactivity disorder (ADHD) and comorbid disruptive disorders, few group studies have been conducted. This study evaluates the separate and incremental effects of these modalities on rating scale and observational measures in multiple settings.

METHOD

Sixteen of 22 children with ADHD and comorbid disruptive disorder completed a randomized, placebo-controlled study examining the separate and incremental effects of 2 doses of MPH and BMOD during a partial hospitalization program. Of the 6 who did not complete the study, 2 children developed significant side effects. For the 16 who did complete the study, effects were examined on measures of symptom ratings, behavioral frequencies, and stimulant side effects across program activities.

RESULTS

Based on alpha-adjusted analyses of variance, there were several main effects of MPH and BMOD on ADHD symptoms, oppositional behavior, and positive social behavior, with certain effects unique to each intervention and setting. One incremental effect each was found for MPH (positive mood/behavior) and BMOD (negative behavior). MPH and BMOD were associated with few side effects. Effect sizes for each intervention showed considerable variability in clinical response.

CONCLUSIONS

That MPH and BMOD had certain unique main and incremental effects extends findings supporting their combination and suggests that integrated studies evaluate multiple dimensions of functioning and in novel settings (e.g., home, school). The incorporation of other intervention components in combined treatments may be warranted to enhance clinical efficacy.

Criterion validity and the utility of reactive and proactive aggression: comparisons to attention deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, and other measures of functioning

Examined the criterion validity and the utility of Dodge and Coie's (1987) measure of reactive and proactive aggression. Participants were 405 children in kindergarten through 5th grade attending an urban elementary school. Examined criterion validity by testing whether reactive aggression or proactive aggression was significantly correlated with criterion measures of overall impairment as measured by the Impairment Rating Scale (Pelham, Gnagy, et al., 1996), classroom behavior as measured by a frequency count of classroom rule violations, and peer adjustment as measured by teacher ratings of peer behavior on the Pittsburgh Modified IOWA Conners (Pelham, Milich, Murphy, & Murphy, 1989). Examined utility by testing whether reactive aggression or proactive aggression was significantly correlated with criterion measures after controlling for each other and after controlling for attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder as measured by the Disruptive Behavior Disorder Rating Scales (Pelham, Gnagy, Greenslade, & Milich, 1992). Results showed good evidence of criterion validity for both reactive and proactive aggression, but mixed evidence for their utility.

Self-management as a strategy to improve the classroom behavior of adolescents with ADHD

This article reports on the application of a self-management strategy for improving the classroom behavior of students with attention-deficit/hyperactivity disorder (ADHD). Based on the work of Rhode, Morgan, and Young (1983), the intervention focuses on teaching students to systematically rate their own behavior according to the rating of their teacher. Although, historically, self-management strategies based on cognitive control have not been found to be effective for students with ADHD, strategies based on contingency management have not been widely reported in the literature. A description of the intervention and two case study illustrations are provided. Potential limitations and implications for research in using this strategy are discussed.

Empirically supported psychosocial treatments for attention deficit hyperactivity disorder

Reviews and evaluates psychosocial treatments for attention deficit hyperactivity disorder (ADHD) in children and adolescents according to Task Force Criteria (Lonigan, Elbert, & Johnson, this issue). It is concluded that behavioral parent training and behavioral interventions in the classroom meet criteria for well-established treatments. Cognitive interventions do not meet criteria for well-established or probably efficacious treatments. Issues regarding the evaluative process are discussed and future directions for psychosocial treatment for ADHD are outlined.

Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children, adolescents, and adults with attention-deficit/hyperactivity disorder (ADHD). There are three types of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and combined. Together, they occur in as many as 10% of boys and 5% of girls of elementary school age. Prevalence declines with age, although up to 65% of hyperactive children are still symptomatic as adults. Frequency in adults is estimated to be 2% to 7%. Assessment includes clinical interviews and standardized rating scales from parents and teachers. Testing of intelligence and academic achievement usually are required. Comorbidity is common. The cornerstones of treatment are support and education of parents, appropriate school placement, and pharmacology. The primary medications are psychostimulants, but antidepressants and alpha-adrenergic agonists are used in special circumstances. Other treatments such as behavior modification, school consultation, family therapy, and group therapy address remaining symptoms.

NIMH collaborative multisite multimodal treatment study of children with ADHD: I. Background and rationale

OBJECTIVE

The National Institute of Mental Health's recently initiated 5-year, multisite, multimodal treatment study of children with attention-deficit hyperactivity disorder (MTA) is the first major clinical trial in its history focused on a childhood mental disorder. This article reviews the major scientific and clinical bases for initiating the MTA.

METHOD

A selective review of the literature is presented in the service of describing the estimated prevalence of ADHD among children and adolescents, its core clinical features, evidence concerning psychopharmacological and psychosocial treatment effects, and related research issues and trends leading to the development of the MTA.

RESULTS

Despite decades of treatment research and clinical practice, there is an insufficient basis for answering the following manifold question: under what circumstances and with what child characteristics (comorbid conditions, gender, family history, home environment, age, nutritional/metabolic status, etc.) do which treatments or combinations of treatment (stimulants, behavior therapy, parent training, school-based intervention) have what impacts (improvement, stasis, deterioration) on what domains of child functioning (cognitive, academic, behavioral, neurophysiological, neuropsychological, peer relations, family relations), for how long (short versus long term), to what extent (effect sizes, normal versus pathological range), and why (processes underlying change)?

CONCLUSIONS

The important scientific, clinical, and public health issues nested within this manifold question provide both the impetus and scaffolding for the MTA.

Differential effects of methylphenidate and self-reinforcement on attention-deficit hyperactivity disorder

Six boys aged 9 to 12 years attended a tutoring class focusing on reading for 30 minutes each morning. The investigators employed a modified Latin-square design in which each child began with a 5-day baseline phase followed by six 10-day treatment phases that used drug placebo, noncontingent reinforcers, 0.3 mg/kg methylphenidate, 0.7 mg/kg methylphenidate, and self-reinforcement in various combinations. Amount of academic performance was the major measure of outcome and the target behavior of self-reinforcement. Drug placebo and noncontingent reinforcers had no systematic impact. Methylphenidate had differential effects across the recorded behaviors. Self-reinforcement improved the target behavior; the mean effect size for self-reinforcement was 2.66. The combined effects of methylphenidate and self-reinforcement on academic performance were greater than either of the treatments given alone (mean effect size = 2.89).

Parent training and social skills training for children with attention-deficit hyperactivity disorder: how can they be combined for greater effectiveness?

Attention-deficit hyperactive disorder (ADHD) is a chronic and treatment-refractory syndrome affecting academic, social and emotional adjustment in children. Stimulant medication is the treatment of choice and is often paired with psychosocial treatment. However, no single treatment modality alleviates the symptoms or improves the negative peer status of these children in their social ecology over the long term. This article reviews two psychosocial treatments used for ADHD, parent training and social skills training and suggests ways that these two components may be combined for greater effectiveness by encouraging the parent to: 1. learn more about the importance of developing social competence and positive peer status; 2. use incidental teaching and self-evaluation strategies; 3. become strategic organizers of the child's social life; and 4. become case managers to facilitate more consistency between the significant adults in the child's social environment.

The effects of a multimodal intervention with attention-deficit hyperactivity disorder children: a 9-month follow-up

Using a double-blind, placebo design, we evaluated 96 attention-deficit hyperactivity disordered children for the effects of methylphenidate alone and in combination with behavioral parent training plus child self-control instruction. Seventy one of the children completed the treatment protocol. As reported previously, main effects were found for medication at posttest; however, there was no evidence of additive effects. Nine months after the termination of the behavioral interventions and the withdrawal of the stimulant medication, we found limited support for the hypothesis that the combined conditions would produce greater maintenance of treatment gains than would medication alone.

Self-management therapies and attention-deficit hyperactivity disorder. Reinforced self-evaluation and anger control interventions

The lack of sufficiency of the primary treatment modalities for children with Attention-Deficit Hyperactivity Disorder (ADHD)-operant behaviormodification procedures and psychostimulant medications-have prompted exploration of cognitive-behavioral self-management treatments as altematives or adjuncts. Although self-instructional treatments are not adequate interventions for such children, reinforcement-and rehearsal-based behavioral interventions can be combined with self-management approaches to supplement and extend the gains induced by behavioral procedures. After presenting background material regarding cognitive-behavioral treatments for ADHD, we present case material related to multimodality treatment, with focus on training in anger management and self-evaluation skills. We argue against unsubstantiated claims for the efficacy of cognitive-behavioral interventions but contend that, when combined with pharnacologic and behavioral approaches, self-management procedures deserve consideration for the difficult social and behavioral problems of ADHD children.

Effects of two treatment techniques on delay and vigilance tasks with attention deficit hyperactive disorder (ADHD) children

In this study, we examined the effects of two treatment techniques under on-medication and off-medication conditions on the hyperactive behavior patterns of children. Three groups of subjects were compared: a control group, a behavior modification group, and a cognitive training group. The Gordon Diagnostic System (Gordon, McClure, & Post, 1986) was used to assess the subjects at the initial screening, during treatment without medication, and during treatment with medication. The two medication conditions were counterbalanced during the second and third testing sessions. Results showed that when the cognitive intervention was combined with medication, there was a significant improvement in the subjects' ability to delay impulsive responding. However, no significant effects were seen for sustained vigilance for either the behavioral or cognitive groups. Parents rated children in the cognitive group significantly higher than those in the control group.

Additive effects of psychostimulants, parent training, and self-control therapy with ADHD children

Utilizing a double-blind, placebo design, the effects of a high (0.8 mg/kg) and a low (0.4 mg/kg) dose of methylphenidate alone and in combination with behavioral parent training plus child self-control instruction were evaluated with 96 attention deficit hyperactivity disorder children. No evidence of the superiority of the combined conditions relative to medication alone was found. Some limited support was found for the hypothesis that the effects of a high dose of psychostimulant medication could be achieved by combining the low dose with a behavioral intervention. The importance of the latter finding is highlighted by the fact that both the benefits and untoward effects of the psychostimulants appear to increase with the dose.

Treatment of attentional and hyperactivity problems in children with sympathomimetic drugs: a comprehensive review

Issues concerning sympathomimetic drug treatment of children with attentional problems and hyperactivity are considered in light of cumulative and current research. These issues concern the atypical or "paradoxical" drug response of such children, predictability of drug response from neurological or biochemical assessments, and, especially, long-term outcome or effectiveness of sympathomimetic medication. Short-term drug effects on behavior and performance are well documented. However, follow-up studies that exist presently suggest little long-term impact of sympathomimetic drugs on school achievement, peer relationships, or behavior problems in adolescence. Questions remain concerning development of tolerance in children, ways to define subgroups of disordered children who may respond uniquely to stimulants, the efficacy of medication in combination with other treatments, and possible long-term negative consequences of medication.

The effects of behavioral parent training on families with young hyperactive children

We sought to assess, through two case-studies, the strengths and limitations of a time-limited, family-based behavioral intervention for preschool-aged children with attention-deficit-hyperactivity disorder (ADHD). The families completed a ten week child management training program and attended a number of follow-up sessions. Changes in parent and child functioning were assessed with a variety of rating scales, interviews, and data collected by parents at home on targeted behavior problems. Improvements were found in parents' confidence in their child management ability and knowledge of behavioral principles, in certain child behavior problems, in parental ratings of hyperactivity, and in the parent-child relationship. Implications of the findings for the treatment of young children with hyperactivity are discussed.

Piagetian conservation and response to cognitive therapy in attention deficit disordered children

Cognitive therapy is often used in treating attention-deficit-disordered (ADD) children because of its purported ability to address this population's attentional deficits and behavioral difficulties and to create durable therapeutic effects. Nonetheless, research findings on these treatments have been inconsistent. This study sought to explain these inconsistencies by examining the influence of cognitive development on children's ability to benefit from such treatment. The ability to conserve number and substance was shown to influence treatment outcome, as measured by laboratory tasks of cognitive style and impulsivity. No effects were found on standardized academic achievement measures or on behavioral ratings by teachers or parents. Further study of individual development will be important in understanding the outcomes of cognitive therapy.

Psychophysiological effects of methylphenidate (Ritalin)

The nature and psychophysiological effects of methylphenidate whose metabolism, pharmacokinetics, and effects on human behavior are not well known are the focus of this review. Methylphenidate treatment of attention deficit disorder with hyperactivity is presented summarily.