Practitioner Review: Current best practice in the use of parent training and other behavioural interventions in the treatment of children and adolescents with attention deficit hyperactivity disorder

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of Well Parent Japan in routine care in Japan: The training and nurturing support for mothers (TRANSFORM) study

BACKGROUND

Well Parent Japan (WPJ) is a new hybrid group parent training programme combining sessions to improve mothers' psychological well-being with a culturally adapted version of the New Forest Parenting Programme (NFPP). This study investigates the effectiveness and cost-effectiveness of WPJ against treatment as usual (TAU) within Japanese child mental health services.

METHODS

TRANSFORM was a pragmatic multi-site randomised controlled trial (RCT) with two parallel arms. Altogether 124 mothers of 6-12-year-old children with DSM-5 ADHD were randomised to WPJ (n = 65) or TAU (n = 59). Participants were assessed at baseline, post-treatment and three-month follow-up. The primary outcome was parent-domain stress following intervention. Secondary outcomes included maternal reports of child-domain stress, parenting practices, parenting efficacy, mood, family strain, child behaviour and impairment. Objective measures of the parent-child relationship were collected at baseline and post-treatment. Data analysis was intention to treat (ITT) with treatment effects quantified through analysis of covariance (ANCOVA) via multilevel modelling. An incremental cost-effectiveness ratio (ICER) assessed WPJ's cost-effectiveness.

RESULTS

WPJ was superior to TAU in reducing parent-domain stress post-treatment (adjusted mean difference = 5.05, 95% CI 0.33 to 9.81, p = .036) and at follow-up (adjusted mean difference 4.82, 95% CI 0.09 to 9.55, p = .046). Significant WPJ intervention effects were also observed for parenting practices, parenting efficacy and family strain. WPJ and TAU were not significantly different post-intervention or at follow-up for the other secondary outcomes. The incremental cost of WPJ was 34,202 JPY (315.81 USD). The probability that WPJ is cost-effective is 74% at 10,000 JPY (USD 108.30) per one-point improvement in parenting stress, 92% at 20,000 JPY (216.60 USD). The programme was delivered with high fidelity and excellent retention.

CONCLUSIONS

WPJ can be delivered in routine clinical care at modest cost with positive effects on self-reported well-being of the mothers, parenting practices and family coping. WPJ is a promising addition to psychosocial interventions for ADHD in Japan.

Problems most concerning to parents of children with ADHD and emotional dysregulation in a randomized controlled trial of multinutrients: MADDY secondary analysis

OBJECTIVE

With dual focus on structured, objective quantification of parent observations of child's behavior and identifying behaviors most amenable to change, this report examines Parent Target Problems (PTP) as a secondary outcome in a randomized clinical trial (RCT) of children with attention-deficit/ hyperactivity disorder (ADHD) in which one primary outcome, Clinical Global Impression-Improvement, showed a significant advantage of multinutrients over placebo and the other, Likert-type parent ratings, showed significant improvement in both groups, without significant difference between them.

METHOD

In a multisite 8-week RCT of broad-spectrum micronutrients ("multinutrients"), parents of children ages 6-12 (N = 126, 73% male, 88% white) with ADHD and emotional dysregulation nominated their child's most concerning problem(s) at baseline and quantified them by frequency, duration, impairment, and consequences. At subsequent visits, parents re-quantified the problem(s). Blinded child psychiatrists independently reviewed the PTPs and rated change at two timepoints compared to baseline. PTPs were grouped into 9 categories. Mean ratings were compared between active and placebo groups and explored by category.

RESULTS

By week 8, a significant separation favored multinutrients: 38% of the multinutrient group were "definitely improved" or better, compared to 25% of the placebo group, and ratings of "no change" or "worse" occurred in 35% with placebo versus 23% with multinutrients (p = 0.04). Inattention (72.2%) and emotional dysregulation (69.1%) were the most frequently reported PTP categories. Inattention and internalizing symptoms improved more with multinutrients than placebo (p = 0.01, d = 0.55; p = 0.03, d = 0.80, respectively). The multinutrient advantage was not significant for 7 other symptoms, including hyperactivity/impulsivity, aggression, autistic symptoms, or emotional dysregulation/irritable oppositionality.

CONCLUSIONS

This secondary analysis found that the multinutrients, compared to placebo, were associated with improvements in parental concerns overall, and in two domains specifically: inattention and internalizing symptoms (anxiety/depression), but not in seven domains: hyperactivity/impulsivity, aggression, autistic symptoms or physiological symptoms, peer relationships or emotional dysregulation/irritable oppositionality.

Targeting Caregiver Psychopathology in Parent Management Training for Adolescents: A Scoping Review of Commercially Available Treatment Resources

Background

While parent management training (PMT) has been shown to be an effective treatment for adolescents with externalizing concerns, evidence suggests that effectiveness is not equitable across all types of families. Research suggests that caregiver psychopathology may adversely affect PMT success for adolescents. However, it remains unclear whether research on caregiver psychopathology is integrated within adolescent PMT resources (e.g., treatment manuals).

Objective

A scoping review of commercially available, clinician focused PMT resources was conducted to assess for information on caregiver psychopathology and clinical guidance for addressing caregiver psychopathology.

Methods

A search for commercially available resources was conducted among national treatment databases and book resource websites. Information on caregiver psychopathology was extracted from individual sessions of the PMT resources.

Results

Seven treatment resources met inclusion criteria. The majority of the treatment resources made at least one explicit comment that caregiver psychopathology may impact the course of treatment. There was very limited mention of caregiver psychopathology in skill building sections of the resources.

Conclusions

While most resources mentioned caregiver psychopathology, these comments lacked breadth and depth in providing clinicians with recommendations on how to tailor treatment to caregivers' needs. Recommendations are provided for how PMT programs might be improved in the future to support clinicians when faced with caregiver psychopathology by recognizing inequities and lack of diversity in resource development, using a transdiagnostic perspective (including a transdiagnostic approach to assessment of care-giver psychopathology), and integrating caregiver skill development.

Process Mechanisms in Behavioral Versus Nondirective Guided Self-help for Parents of Children with Externalizing Behavior

The study examined potential mediating effects of therapist behaviors in the per-protocol sample (n = 108) of a randomized controlled trial comparing a behavioral and a nondirective guided self-help intervention for parents of children with externalizing disorders (4-11 years). Additionally, from an exploratory perspective, we analyzed a sequential model with parental adherence as second mediator following therapist behavior. Outcomes were child symptom severity of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder rated by blinded clinicians, and parent-rated child functional impairment. We found a significant indirect effect on the reduction of ADHD and functional impairment through emotion- and relationship-focused therapist behavior in the nondirective intervention. Additionally, we found limited support for an extended sequential mediation effect through therapist behavior and parental adherence in the models for these outcomes. The study proposes potential mediating mechanisms unique to the nondirective intervention and complements previous findings on mediator processes in favor of the behavioral group. Trial registration ClinicalTrials.gov NCT01350986.

Treatments for ADHD in Children and Adolescents: A Systematic Review

CONTEXT

Effective treatment of attention-deficit/hyperactivity disorder (ADHD) is essential to improving youth outcomes.

OBJECTIVES

This systematic review provides an overview of the available treatment options.

DATA SOURCES

We identified controlled treatment evaluations in 12 databases published from 1980 to June 2023; treatments were not restricted by intervention content.

STUDY SELECTION

Studies in children and adolescents with clinically diagnosed ADHD, reporting patient health and psychosocial outcomes, were eligible. Publications were screened by trained reviewers, supported by machine learning.

DATA EXTRACTION

Data were abstracted and critically appraised by 1 reviewer and checked by a methodologist. Data were pooled using random-effects models. Strength of evidence and applicability assessments followed Evidence-based Practice Center standards.

RESULTS

In total, 312 studies reported in 540 publications were included. We grouped evidence for medication, psychosocial interventions, parent support, nutrition and supplements, neurofeedback, neurostimulation, physical exercise, complementary medicine, school interventions, and provider approaches. Several treatments improved ADHD symptoms. Medications had the strongest evidence base for improving outcomes, including disruptive behaviors and broadband measures, but were associated with adverse events.

LIMITATIONS

We found limited evidence of studies comparing alternative treatments directly and indirect analyses identified few systematic differences across stimulants and nonstimulants. Identified combination of medication with youth-directed psychosocial interventions did not systematically produce better results than monotherapy, though few combinations have been evaluated.

CONCLUSIONS

A growing number of treatments are available that improve ADHD symptoms and other outcomes, in particular for school-aged youth. Medication therapies remain important treatment options but are associated with adverse events.

Acceptance and utilization of web-based self-help for caregivers of children with externalizing disorders

BACKGROUND

Web-based self-help interventions for parents of children with ADHD and other externalizing disorders have been proven to be effective. In order to recommend individualized and optimized interventions, a better understanding of the acceptance and utilization of this innovative treatment approach is needed. Previous research has frequently employed subjective reports of utilization, but the validity of these studies may be limited.

METHODS

Data from the German WASH study were used. Participants (n = 276) were randomly assigned to the intervention condition (a) web-based self-help or (b) web-based self-help with optional telephone-based support calls. Data collection took place at baseline (T1) and 12 weeks later (T2). Utilization data were tracked using a log file generated for each participant at T2. Prediction models were calculated using CART (Classification and Regression Trees), a method known mostly from the field of machine learning.

RESULTS

Acceptance, of the intervention as defined in this paper was very high on objective (89.4% have taken up the intervention) and subjective measures (91.4% reported having used the intervention and 95.3% reported they would recommend the intervention to a friend). The average number of logins corresponded to recommendations. Predictors of acceptance and predictors of utilization were similar and included, e.g., child's externalizing symptoms, parental psychopathology, and above all additional telephone-based support by counselors.

CONCLUSIONS

Through a detailed identification of acceptance and utilization, and the predictors thereof, we were able to gain a better understanding of the acceptance and utilization of web-assisted self-help for a parent management intervention in the treatment of children with ADHD and ODD. These findings can be used to recommend web-based interventions to particularly suitable families. It should be noted that some form of support is required for an intensive engagement with the content of the program.

TRIAL REGISTRATION

The protocol of the study (German Clinical Trials Register DRKS00013456 conducted on January 3rd, 2018) was approved by the Ethics Committee of the University Hospital, Cologne.

The detect consensus report on Attention Deficit/Hyperactivity Disorder and its management among Turkish children and adolescents (Detect: consensus report on ADHD among Turkish youth)

Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most common and heritable neurodevelopmental disorders which may last through the life-span. A consensus report on diagnosis and management of ADHD among Turkish youth was prepared previously. However, the participants as well as the management options were rather limited and developments in the past decade necessitated a revision and update of the consensus. Therefore, this review aims to summarize the consensus among Child and Adolescent Psychiatrists from Türkiye on the nature and management of pediatric ADHD. For those aims, the etiology of ADHD, diagnostic and evaluation process, epidemiology, developmental presentations, differential diagnoses and comorbidities, course/outcome and pharmacological as well as non-pharmacological management options were reviewed and suggestions for clinical practice are presented. Since ADHD is a chronic disorder with wide-ranging effects on functionality that is frequently accompanied by other mental disorders, a multidimensional therapeutic approach is recommended. However, since the disorder has neurobiological basis, pharmacotherapy represents the mainstay of treatment. Additional therapies may include psychosocial therapy, behavioral therapy, school-based therapeutic approaches, and family education. This review provides recommendations for ADHD at the national and global levels. It contains information about ADHD that will contribute to and facilitate clinicians' decision-making processes. It is advisable to consider this guideline in clinical practice.

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.

Parent training for disruptive behavior symptoms in attention deficit hyperactivity disorder: a randomized clinical trial

Background

Attention-Deficit/Hyperactivity Disorder (ADHD) affects 5% of children and 2.5% of adults worldwide. Comorbidities are frequent, and Oppositional Defiant Disorder (ODD) reaches 50%. Family environment is crucial for the severity of behaviors and for prognosis. In middle-income countries, access to treatment is challenging, with more untreated children than those under treatment. Face-to-face behavioral parent training (PT) is a well-established intervention to improve child behavior and parenting.

Method

A clinical trial was designed to compare PT-online and face-to-face effects to a waiting list group. Outcomes were the ADHD and ODD symptoms, parental stress and styles, and quality of life. Families were allocated into three groups: standard treatment (ST), ST + PT online, and ST + Face-to-Face PT. We used repeated measures ANOVA for pre × post treatment analysis corrected for multiple comparisons.

Results and discussion

Parent training was effective in reducing symptoms of ADHD (p = 0.030) and ODD (p = 0.026) irrespective of modality (p = 1.000). The combination of ST and PT was also associated with better quality of life in the physical domain for patients (p = 0.009) and their parents (p = 0.050). In addition to preliminary data, online intervention seems effective for parenting and improving social acceptance of children. The potential to reach many by an online strategy with a self-directed platform may imply effectiveness with a low cost for public health to support parents' symptoms management.

Behavioral Parent Training for School-Aged Children With ADHD: A Systematic Review of Randomized Control Trials

BACKGROUND

All guidelines for the treatment of ADHD in children include behavioral parent training in combination with other strategies. In the past, several systematic reviews have been carried out that were either outdated or not sufficiently specific to ADHD. We wanted to conduct a new review focusing on a specific ADHD population of school age (4-12 years) and on behavioral and cognitive programs. We aimed to test our hypothesis that behavioral parent training would improve parents' difficulties, children's symptomatology, and the quality of life of families with ADHD.

METHODS

PUBMED, PsychInfo, Web of Science, ERIC, and Cochrane databases were searched for original articles on randomized control trials on behavioral parent training group for children with ADHD aged from 4 to 12 years until July 2023.

RESULTS

A total of 20 studies were included in the systematic review. The results were divided into four categories: parent data, child data collected by parents, teachers, or researchers. A qualitative analysis revealed for parents, effects on parental stress, feelings of parental efficacy, and negative parental educational behavior. As regard children, only effects are noted for parental assessment, on ADHD symptomatology, externalized disorders, and social skills.

CONCLUSION

Despite the heterogeneity or small number of studies in some categories, BPTs have positive effects on both parents and children. There are no convincing results to support the generalization of progress. This would seem to indicate that it remains essential to consider actions specific to each problematic environment for the child.

Parent Training Tailored to Parents With ADHD: Development of the Improving Parenting Skills Adult ADHD (IPSA) Program

OBJECTIVE

To describe the development of the Improving Parenting Skills Adult ADHD (IPSA) parent training (PT) program, designed for parents with ADHD.

METHOD

IPSA was developed using an iterative co-creation approach, involving parents with ADHD from the initial knowledge mobilization phase onwards. The program prototype was evaluated by 16 parents with ADHD, in an open trial of program feasibility.

RESULTS

IPSA was deemed feasible in terms of acceptability and levels of active participation, with no evidence of unintended harm. All but one participant completed the program, attending on average 84% of sessions. Pre-to-post within-group comparisons of targeted skills and outcomes revealed changes in the expected direction regarding, for example, use of introduced parenting skills (Cohen's d = 1.3).

CONCLUSION

The program prototype was found acceptable, accessible, and safe. Findings support the potential value of adapting PT protocols for parents with ADHD and warrant further evaluation of IPSA in a randomized controlled trial.

Promoting Medication Adherence in Children with Attention Deficit Hyperactivity Disorder: A Mixed-Methods Systematic Review with Meta-analysis and Qualitative Comparative Analysis

OBJECTIVE

To evaluate the efficacy of ADHD medication adherence interventions and explore the pathways to effectiveness.

METHODS

A systematic review was conducted using multiple databases to identify relevant randomized controlled trials (RCTs). Pooled effect sizes were calculated for medication adherence and ADHD symptom outcomes. Qualitative Comparative Analysis (QCA) was used to identify pathways to effectiveness.

RESULTS

Six RCTs were included. The interventions significantly improved medication adherence (OR = 2.39, 95% CI [1.19, 4.79]) and ADHD symptoms (Hedges' g = -0.96, 95% CI [-1.38, -0.54]). Multi-regression analysis showed a positive relationship between medication adherence and ADHD symptom reduction. QCA revealed two paths for effectiveness: (1) Presence of ADHD drug education and absence of reminder and (2) Presence of tracking and absence of reminder.

CONCLUSION

ADHD medication adherence interventions have a positive impact on both medication adherence and ADHD symptoms. Interventions should consider including ADHD drug education or tracking to maximize effectiveness.

Hopelessness in caregivers of children with attention-deficit/hyperactivity disorder: Associations with depression and anxiety and multidimensionally related factors

BACKGROUND/PURPOSE

Hopelessness can compromise caregivers' mental health and impede their ability to take care of their child with attention-deficit/hyperactivity disorder (ADHD). The study aimed to explore the associations of hopelessness with caregiver depression and anxiety in caregivers of children with attention-deficit/hyperactivity disorder (ADHD). Additionally, the study examined the associations of child demographics, ADHD and oppositional defiance symptoms, and caregiver demographics, parenting stress, and affiliate stigma with hopelessness.

METHODS

The study included 213 caregivers of children with ADHD who completed various assessments. Caregiver hopelessness was assessed using the Beck Hopelessness Scale, while child ADHD and oppositional defiance symptoms were assessed using the Parent Form of the Swanson, Nolan, and Pelham Scale, Version IV. Parenting stress was measured using the Parenting Stress Index, Fourth Edition Short Form (PSI-4-SF), and affiliate stigma using the Affiliate Stigma Scale. Hierarchical regression analysis was used to investigate the multidimensional factors associated with caregiver hopelessness.

RESULTS

Caregiver hopelessness was significantly linked to caregiver depression and anxiety. Child inattention, caregiver parenting stress, and affiliate stigma were significantly associated with caregiver hopelessness. A higher level of affiliate stigma increased the association between child inattention and caregiver hopelessness.

CONCLUSION

These findings suggest that it is necessary to develop intervention programs for alleviating the sense of hopelessness among caregivers of children with ADHD. Such programs should focus on addressing child inattention, caregiver parenting stress, and affiliate stigma.

Systematic Review and Meta-analysis: Reporting and Representation of Race/Ethnicity in 310 Randomized Controlled Trials of Attention-Deficit/Hyperactivity Disorder Medications

OBJECTIVE

To evaluate the reporting of race/ethnicity data in randomized controlled trials (RCTs) of attention-deficit/hyperactivity disorder (ADHD) medications. Secondary objectives were to estimate temporal trends in the reporting, and to compare the pooled prevalence of racial/ethnic groups in RCTs conducted in the US to national estimates.

METHOD

We drew on, adapted, and updated the search of a network meta-analysis by Cortese et al. (2018) up to March 2022. We calculated the percentage of RCTs reporting data on race/ethnicity of participants in the published article or in related unpublished material. Temporal trends were estimated with logistic regression. The pooled prevalence of each racial/ethnic group across US RCTs was calculated using random-effects model meta-analyses.

RESULTS

We retained 310 RCTs (including 44,447 participants), of which 231 were conducted in children/adolescents, 78 in adults, and 1 in both. Data on race/ethnicity were reported in 59.3% of the RCTs (75% of which were conducted in children/adolescents and 25% in adults) in the published article, and in unpublished material in an additional 8.7% of the RCTs. Reporting improved over time. In the US RCTs, Asian and White individuals were under- and overrepresented, respectively, compared to national estimates in the most recent time period considered.

CONCLUSION

More than 30% of the RCTs of ADHD medications retained in this review did not include data on race/ethnicity in their published or unpublished reports, and more than 40% in their published articles, even though reporting improved over time. Results should inform investigators, authors, editors, regulators, and study participants in relation to efforts to tackle inequalities in ADHD research.

DIVERSITY & INCLUSION STATEMENT

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote sex and gender balance in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Categorical and dimensional approaches to the developmental relationship between ADHD and irritability

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) and irritability commonly co-occur, and follow similar developmental trajectories from childhood to adolescence. Understanding of the developmental relationship between these co-occurrences is limited. This study provides a longitudinal assessment of how ADHD diagnostic status and symptom patterns predict change in irritability.

METHODS

A community sample of 337 participants (45.2% ADHD), recruited for the Childhood Attention Project, completed the Affective Reactivity Index (ARI) to measure irritability at baseline (mean age 10.5 years) and follow-up after 18-months. Latent change score models were used to assess how (a) baseline ADHD vs. control group status, (b) baseline symptom domain (inattention, hyperactivity-impulsivity) and (c) longitudinal change in ADHD symptom severity predicted change in irritability.

RESULTS

Irritability was significantly higher among the ADHD group than controls; however, change in irritability over time did not differ between groups. When assessed across the entire cohort, change in irritability was predicted by higher symptom count in the hyperactive-impulsive domain, but not the inattentive domain. Greater declines in ADHD symptoms over time significantly predicted greater declines in irritability. Baseline ADHD symptom severity was found to significantly predict change in irritability; however, baseline irritability did not significantly predict change in ADHD symptoms.

CONCLUSIONS

ADHD symptoms-particularly hyperactive-impulsive symptoms-predict the degree and trajectory of irritability during childhood and adolescence, even when symptoms are below diagnostic thresholds. The use of longitudinal, dimensional and symptom domain-specific measures provides additional insight into this relationship.

Healthcare pathways and practitioners' knowledge about ADHD in children

INTRODUCTION

Access to care for children and adolescents affected by ADHD in France remains below the levels attained in most industrialised countries. To contribute to improving ADHD care in France, we assessed existing ADHD knowledge among medical doctors (MDs) and described associated care pathways in two large French regions in 2021. We produced tools to evaluate the regional impact of implementing a stepped-care pathway for ADHD.

METHODS

A SurveyMonkey® study was sent to professionals from two regions in France accounting for 14 million inhabitants, allowing them to describe their role in child/adolescent ADHD, as well as their representations and knowledge about the disorder.

RESULTS

Around 9.4% of all MDs potentially involved with children took part in the study; 34.9% considered themselves untrained, 40.5% were involved in ADHD care at a first-tier level, and 19.6% at a second-tier level. Access to a second or third-tier service for ADHD was associated with mean waiting times of 5.7 and 8.5 months, respectively. Initiation of stimulant therapy remained mainly restricted to second or third-tier MDs, and adaptation of dosage or change in the galenic formulation was rarely performed by first-tier MDs (27.2% and 18%, respectively). Training in neurodevelopmental disorders and tier-level were the strongest determinants of knowledge, attitudes and self-assessed expertise about ADHD.

CONCLUSIONS

This study provides insight into training needs for MDs regarding healthcare pathways in ADHD and should support the implementation of health policies, such as a stepped healthcare access for ADHD. The study design and dissemination have been validated and will be available in France and other countries facing similar obstacles in care pathways for ADHD. Official recommendations on ADHD in children and adults are being updated in France, and our data and the survey design will be a starting point for their implementation.

Remote Recruitment Strategy and Structured E-Parenting Support (STEPS) App: Feasibility and Usability Study

BACKGROUND

The Structured E-Parenting Support (STEPS) app provides support for parents of children with elevated hyperactivity, impulsivity, inattention, and conduct problems who are awaiting clinical assessment. STEPS will be evaluated in a randomized controlled trial (RCT) within the Online Parent Training for the Initial Management of ADHD Referrals (OPTIMA) research program in the United Kingdom. Phase 1 of the OPTIMA tested the feasibility of participants' recruitment and the app's usability.

OBJECTIVE

This study aimed to adapt a digital routine clinical monitoring system, myHealthE, for research purposes to facilitate waitlist recruitment; test using remote methods to screen and identify participants quickly and systematically; pilot the acceptability of the recruitment and assessment protocol; and explore the usability of STEPS.

METHODS

myHealthE was adapted to screen patients' data. Parents' and clinicians' feedback on myHealthE was collected, and information governance reviews were conducted in clinical services planning to host the RCT. Potential participants for the observational feasibility study were identified from new referrals using myHealthE and non-myHealthE methods. Descriptive statistics were used to summarize the demographic and outcome variables. We estimated whether the recruitment rate would meet the planned RCT sample size requirement (n=352). In addition to the feasibility study participants, another group of parents was recruited to assess the STEPS usability. They completed the adapted System Usability Scale and responded to open-ended questions about the app, which were coded using the Enlight quality construct template.

RESULTS

Overall, 124 potential participants were identified as eligible: 121 (97.6%) via myHealthE and 3 (2.4%) via non-myHealthE methods. In total, 107 parents were contacted, and 48 (44.9%) consented and were asked if, hypothetically, they would be willing to participate in the OPTIMA RCT. Of the 28 feasibility study participants who provided demographic data, 21 (75%) identified as White. Their children had an average age of 8.4 (SD 1.7) years and 65% (31/48) were male. During the primary recruitment period (June to July 2021) when 45 participants had consented, 38 (84%) participants agreed hypothetically to take part in the RCT (rate of 19/mo, 95% CI 13.5-26.1), meeting the stop-go criterion of 18 participants per month to proceed with the RCT. All parents were satisfied or very satisfied with the study procedures. Parents (n=12) recruited to assess STEPS' usability described it as easy to navigate and use and as having an attractive combination of colors and visual design. They described the content as useful, pitched at the right level, and sensitively presented. Suggested improvements included adding captions to videos or making the recorded reflections editable.

CONCLUSIONS

Remote recruitment and study procedures for testing a parenting intervention app are feasible and acceptable for parents. The parents felt that STEPS was a useful and easy-to-use digital parenting support tool.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s40814-021-00959-0.

Factors Influencing Long-Term Behavioral Intervention Outcomes in Preschool Children with Attention-Deficit Hyperactivity Disorder in Southeast China

Introduction

Previous studies have demonstrated the long-term effectiveness of behavioral interventions for attention-deficit hyperactivity disorder (ADHD) in preschool children. We continue to design a case‒control study to further investigate the factors influencing the long-term effect of behavioral intervention.

Methods

From May 2020 to August 2021, children who were newly diagnosed with ADHD and not receiving any treatment received a one-year behavioral intervention. A total of 86 children completed the behavioral intervention and assessment.

Results

50 children (58.140%) were in the effective group, and 36 children (41.860%) were in the ineffective group. Attention retention time (OR=0.559, 0.322-0.969), Swanson, Nolan, and Pelham total score (OR=1.186, 1.024-1.374) at baseline, performance score for parents (OR=0.631, 0.463-0.859), and teacher coordination (OR=0.032, 0.002-0.413) were the influencing factors of behavioral intervention effects. The area under the receiver operating curve was 0.979 (p<0.001). The comprehensive nomogram model showed that the discrimination and mean absolute error were 0.979 and 0.023, respectively.

Discussion

During behavioral intervention, the implementation skills of parents should be evaluated in a timely manner. The behavioral intervention effect can be predicted based on a child's attention retention time at baseline, teacher involvement, behavioral scale score, and performance score for parents, which can guide clinicians in adjusting personalized treatment plans and provide a basis for clinical decision-making. The treatment of ADHD in preschool children requires a systematic framework that integrates family, school, and society.

Sustained improvements by behavioural parent training for children with attention-deficit/hyperactivity disorder: A meta-analytic review of longer-term child and parental outcomes

Background

Behavioural parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but little is known about the extent to which initial benefits are maintained.

Aims

This meta-analytic review investigated longer-term (i.e., more than 2 months post-intervention) child and parental outcomes of behavioural parent training for children with ADHD.

Materials & Methods

We searched for randomized controlled trials and examined ADHD symptoms, behavioural problems, positive parenting, negative parenting, parenting sense of competence, parent-child relationship quality, and parental mental health as outcomes. We included 27 studies (31 interventions; 217 effect sizes), used multilevel random-effects meta-analyses for between- and within-group comparisons (pre-intervention to follow-up and post-intervention to follow-up), and explored twelve predictors of change.

Results

Between pre-intervention and follow-up (M = 5.3 months), we found significant small-to-moderate between-group effects of the intervention on ADHD symptoms, behavioural problems, positive parenting, parenting sense of competence and parent-child relationship quality. Within-group findings show sustained improvements in the intervention conditions for all outcome domains. There were few significant changes from post-intervention to follow-up. Additionally, the large majority of the individual effect sizes indicated sustained outcomes from post-intervention to follow-up. There were seven significant predictors of change in child outcomes, including stronger reductions in ADHD symptoms of girls and behaviour problems of younger children. In contrast with some meta-analyses on short-term effects, we found no differences between masked and unmasked outcomes on ADHD symptoms at follow-up.

Discussion & Conclusion

We conclude that behavioural parent training has longer-term benefits for children's ADHD symptoms and behavioural problems, and for positive parenting behaviours, parenting sense of competence and quality of the parent-child relationship.

Parent-Child Inpatient Treatment in Child and Adolescent Mental Healthcare: Predictors of Child Outcomes

Family inpatient units in child and adolescent mental health (CAMH) services engage all admitted family members in the treatment of children's symptoms. Studies demonstrated improvements in child and family functioning following family inpatient treatment, but evidence regarding predictors of treatment outcome is lacking. We analyzed data of families (n = 66) who received a four-week inpatient treatment for families with severe parent-child interaction problems. Hierarchical linear regression analyses revealed that parents who recalled harsher parenting practices of their own fathers reported greater improvements in their children's externalizing and internalizing problems. Greater improvements in externalizing problems were further predicted by lower parental educational level, less adverse impacts of stressful life events, and less internalizing child problems prior to admission. We therefore conclude that family inpatient treatment was particularly effective for children in families with lower parental education and a history of harsh parenting.

The Effectiveness and Cost-Effectiveness of a Universal Digital Parenting Intervention Designed and Implemented During the COVID-19 Pandemic: Evidence From a Rapid-Implementation Randomized Controlled Trial Within a Cohort

BACKGROUND

Children's conduct and emotional problems increased during the COVID-19 pandemic.

OBJECTIVE

We tested whether a smartphone parenting support app, Parent Positive, developed specifically for this purpose, reversed these effects in a cost-effective way. Parent Positive includes 3 zones. Parenting Boosters (zone 1) provided content adapted from standard face-to-face parent training programs to tackle 8 specific challenges identified by parents and parenting experts as particularly relevant for parents during the pandemic. The Parenting Exchange (zone 2) was a parent-to-parent and parent-to-expert communication forum. Parenting Resources (zone 3) provided access to existing high-quality web-based resources on a range of additional topics of value to parents (eg, neurodevelopmental problems, diet, and sleep).

METHODS

Supporting Parents And Kids Through Lockdown Experiences (SPARKLE), a randomized controlled trial, was embedded in the UK-wide COVID-19: Supporting Parents, Adolescents and Children during Epidemics (Co-SPACE) longitudinal study on families' mental health during the pandemic. Parents of children aged 4 to 10 years were randomized 1:1 to Parent Positive or follow-up as usual (FAU) between May 19, 2021, and July 26, 2021. Parent Positive provided advice on common parenting challenges and evidence-based web-based resources and facilitated parent-to-parent and expert-to-parent support. Child conduct and emotional problems and family well-being were measured before randomization (T1) and at 1 (T2) and 2 (T3) months after randomization. Service use, costs, and adverse events were measured, along with app use and satisfaction. The primary outcome was T2 parent-reported child conduct problems, which were analyzed using linear mixed regression models.

RESULTS

A total of 320 participants were randomized to Parent Positive, and 326 were randomized to FAU. The primary outcome analysis included 79.3% (512/646) of the participants (dropout: 84/320, 26% on Parent Positive and 50/326, 15% on FAU). There were no statistically significant intervention effects on conduct problems at either T2 (standardized effect=-0.01) or T3 (secondary outcome; standardized effect=-0.09) and no moderation by baseline conduct problems. Significant intervention-related reductions in emotional problems were observed at T2 and T3 (secondary outcomes; standardized effect=-0.13 in both cases). Parent Positive, relative to FAU, was associated with more parental worries at T3 (standardized effect=0.14). Few intervention-attributable adverse events were reported. Parent Positive was cost-effective once 4 outliers with extremely high health care costs were excluded.

CONCLUSIONS

Parent Positive reduced child emotional problems and was cost-effective compared with FAU once outliers were removed. Although small when considered against targeted therapeutic interventions, the size of these effects was in line with trials of nontargeted universal mental health interventions. This highlights the public health potential of Parent Positive if implemented at the community level. Nevertheless, caution is required before making such an interpretation, and the findings need to be replicated in large-scale, whole-community studies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04786080; https://clinicaltrials.gov/ct2/show/NCT04786080.

Policies are Needed to Increase the Reach and Impact of Evidence-Based Parenting Supports: A Call for a Population-Based Approach to Supporting Parents, Children, and Families

Parents can be essential change-agents in their children's lives. To support parents in their parenting role, a range of programs have been developed and evaluated. In this paper, we provide an overview of the evidence for the effectiveness of parenting interventions for parents and children across a range of outcomes, including child and adolescent mental and physical health, child and adolescent competencies and academic outcomes, parental skills and competencies, parental wellbeing and mental health, and prevention of child maltreatment and family violence. Although there is extensive research showing the effectiveness of evidence-based parenting programs, these are not yet widely available at a population level and many parents are unable to access support. We outline how to achieve increased reach of evidence-based parenting supports, highlighting the policy imperative to adequately support the use of these supports as a way to address high priority mental health, physical health, and social problems.

Treatment of US Children With Attention-Deficit/Hyperactivity Disorder in the Adolescent Brain Cognitive Development Study

Importance

Characterizing the extent and pattern of unmet needs for treatment of children with attention-deficit/hyperactivity disorder (ADHD) could help target efforts to improve access to ADHD medications and outpatient mental health care.

Objective

To describe current ADHD medication use and lifetime outpatient mental health care among a large national sample of children with ADHD.

Design, Setting, and Participants

This study uses cross-sectional survey data from the first wave of the Adolescent Brain and Cognitive Development Study (n = 11 723), conducted from June 1, 2016, to October 15, 2018, among 1206 school children aged 9 and 10 years who met parent-reported Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for current ADHD. Statistical analysis was performed from March 23, 2022, to March 10, 2023.

Main Outcomes and Measures

Current ADHD medications including stimulants and nonstimulants, lifetime outpatient mental health care, or either treatment. Weighted results are reported.

Results

Among a sample of 11 723 children, 1206 had parent-reported ADHD (aged 9-10 years; 826 boys [68.2%]; 759 White, non-Hispanic children [62.2%]), 149 (12.9%) were currently receiving ADHD medications. Children receiving ADHD medications included a significantly higher percentage of boys (15.7% [121 of 826]) than girls (7.0% [28 of 108]), White children (14.8% [104 of 759]) than Black children (9.4% [22 of 206]), children of parents without a high school education (32.2% [9 of 36]) than of parents with a bachelor's degree or higher (11.5% [84 of 715]), and children with the combined subtype of ADHD (17.0% [83 of 505]) than with the inattentive subtype (9.5% [49 of 523]). Approximately 26.2% of children (301 of 1206) with parent-reported ADHD had ever received outpatient mental health care. Children receiving outpatient mental health care included a significantly higher percentage of children whose parents had a high school education (36.2% [29 of 90]) or some college (31.0% [109 of 364]) than a bachelor's degree or higher (21.3% [153 of 715]), children with family incomes of less than $25 000 (36.5% [66 of 176]) or $25 000 to $49 999 (27.7% [47 of 174]) than $75 000 or more (20.1% [125 of 599]), and children with the combined subtype of ADHD (33.6% [166 of 505]) than with the predominantly inattentive subtype (20.0% [101 of 523]) or the hyperactive-impulsive subtype (22.4% [34 of 178]) of ADHD.

Conclusions and Relevance

This cross-sectional study of children with parent-reported ADHD suggests that most were not receiving ADHD medications and had never received outpatient mental health care. Gaps in treatment, which were not directly associated with socioeconomic disadvantage, underscore the challenges of improving communication and access to outpatient mental health care for children with ADHD.

Behavioural and nondirective parent training for children with externalising disorders: First steps towards personalised treatment recommendations

For children with externalising disorders, parent training programmes with different theoretical foundations are available. Currently, there is little knowledge concerning which programme should be recommended to a family based on their individual needs (e.g., single parenthood). The personalised advantage index (PAI) indicates the predicted treatment advantage of one treatment over another. The aim of the present study was to examine the usefulness of this score in providing individualised treatment recommendations. The analysis considered 110 parents (per-protocol sample) of children (4-11 years) with attention-deficit/hyperactivity (ADHD) or oppositional defiant disorder (ODD), randomised to either a behavioural or a nondirective telephone-assisted self-help parent training. In multiple moderator analyses with four different regression algorithms (linear, ridge, k-nearest neighbors, and tree), the linear model was preferred for computing the PAI. For ODD, families randomised to their PAI-predicted optimal intervention showed a treatment advantage of d = 0.54, 95% CI [0.17, 0.97]; for ADHD, the advantage was negligible at d = 0.35, 95% CI [-0.01, 0.78]. For children with conduct problems, it may be helpful if the PAI includes the treatment moderators single parent status and ODD baseline symptoms when providing personalised treatment recommendations for the selection of behavioural versus nondirective parent training. TRIAL REGISTRATION: The study was registered prospectively with ClinicalTrials.gov (Identifier NCT01350986).

Genetic nurture versus genetic transmission of risk for ADHD traits in the Norwegian Mother, Father and Child Cohort Study

Identifying mechanisms underlying the intergenerational transmission of risk for attention-deficit/hyperactivity disorder (ADHD) traits can inform interventions and provide insights into the role of parents in shaping their children's outcomes. We investigated whether genetic transmission and genetic nurture (environmentally mediated effects) underlie associations between polygenic scores indexing parental risk and protective factors and their offspring's ADHD traits. This birth cohort study included 19,506 genotyped mother-father-offspring trios from the Norwegian Mother, Father and Child Cohort Study. Polygenic scores were calculated for parental factors previously associated with ADHD, including psychopathology, substance use, neuroticism, educational attainment, and cognitive performance. Mothers reported on their 8-year-old children's ADHD traits (n = 9,454 children) using the Parent/Teacher Rating Scale for Disruptive Behaviour Disorders. We found that associations between ADHD maternal and paternal polygenic scores and child ADHD traits decreased significantly when adjusting for the child polygenic score (pΔβ = 9.95 × 10-17 for maternal and pΔβ = 1.48 × 10-14 for paternal estimates), suggesting genetic transmission of ADHD risk. Similar patterns suggesting genetic transmission of risk were observed for smoking, educational attainment, and cognition. The maternal polygenic score for neuroticism remained associated with children's ADHD ratings even after adjusting for the child polygenic score, indicating genetic nurture. There was no robust evidence of genetic nurture for other parental factors. Our findings indicate that the intergenerational transmission of risk for ADHD traits is largely explained by the transmission of genetic variants from parents to offspring rather than by genetic nurture. Observational associations between parental factors and childhood ADHD outcomes should not be interpreted as evidence for predominantly environmentally mediated effects.

Annual Research Review: Perspectives on progress in ADHD science - from characterization to cause

The science of attention-deficit/hyperactivity disorder (ADHD) is motivated by a translational goal - the discovery and exploitation of knowledge about the nature of ADHD to the benefit of those individuals whose lives it affects. Over the past fifty years, scientific research has made enormous strides in characterizing the ADHD condition and in understanding its correlates and causes. However, the translation of these scientific insights into clinical benefits has been limited. In this review, we provide a selective and focused survey of the scientific field of ADHD, providing our personal perspectives on what constitutes the scientific consensus, important new leads to be highlighted, and the key outstanding questions to be addressed going forward. We cover two broad domains - clinical characterization and, risk factors, causal processes and neuro-biological pathways. Part one focuses on the developmental course of ADHD, co-occurring characteristics and conditions, and the functional impact of living with ADHD - including impairment, quality of life, and stigma. In part two, we explore genetic and environmental influences and putative mediating brain processes. In the final section, we reflect on the future of the ADHD construct in the light of cross-cutting scientific themes and recent conceptual reformulations that cast ADHD traits as part of a broader spectrum of neurodivergence.

Association of Affiliate Stigma with Parenting Stress and Its Moderators among Caregivers of Children with Attention-Deficit/Hyperactivity Disorder

Caring for children with attention-deficit/hyperactivity disorder (CADHD) is stressful for caregivers. Identifying factors related to parenting stress in caregivers of CADHD can facilitate the development of intervention programs. This study aimed to examine the associations between affiliate stigma and various domains of parenting stress among caregivers of CADHD. This study also analyzed the moderating effects of demographic characteristics and the symptoms of childhood ADHD and oppositional defiant disorder (ODD) on the associations between affiliate stigma and parenting stress. In total, 213 caregivers of CADHD participated in this study. Parenting stress was assessed using the Parenting Stress Index, Fourth Edition Short Form (PSI-4-SF). Affiliate stigma was assessed using the Affiliate Stigma Scale. ADHD and ODD symptoms were assessed using the Parent Form of the Swanson, Nolan, and Pelham Scale, Version IV. The results indicated that higher affiliate stigma was significantly associated with greater parenting stress in all three domains of the PSI-4-SF. ODD symptoms increased the magnitude of parenting stress in two domains of parenting stress among caregivers with affiliate stigma. Intervention programs for relieving parenting stress among caregivers of CADHD should take affiliate stigma and child ODD symptoms into consideration.

Parent Training for ADHD: No Generalization of Effects From Clinical to Neuropsychological Outcomes in a Randomized Controlled Trial

OBJECTIVE

We examined whether neuropsychological function in ADHD can be improved by the New Forest Parenting Programme (NFPP), that combines standard parenting strategies with self-regulatory skills training, or predict ADHD and quality of life (QoL) treatment effects.

METHOD

Participants were 93 medication-naive preschool children with ADHD (3-7 years) randomized to either NFPP (n = 49) or treatment as usual (TAU; n = 44) in a recent randomized trial. Laboratory measures of executive function, reaction time variability, and delay of gratification were collected along with parent ratings of ADHD and QoL at baseline and post treatment. Ratings were collected again at 3-month follow-up.

RESULTS

NFPP did not improve neuropsychological function (compared to TAU), and baseline neuropsychological function did not predict treatment-related ADHD or QoL effects.

CONCLUSION

Although NFPP includes a neuropsychological training element and has been shown to improve several clinical outcomes, it did not improve the neuropsychological functions it targets.

Randomised controlled trial of the short-term effects of osmotic-release oral system methylphenidate on symptoms and behavioural outcomes in young male prisoners with attention deficit hyperactivity disorder: CIAO-II study

BACKGROUND

Research has shown that 20-30% of prisoners meet the diagnostic criteria for attention-deficit hyperactivity disorder (ADHD). Methylphenidate reduces ADHD symptoms, but effects in prisoners are uncertain because of comorbid mental health and substance use disorders.

AIMS

To estimate the efficacy of an osmotic-release oral system methylphenidate (OROS-methylphenidate) in reducing ADHD symptoms in young adult prisoners with ADHD.

METHOD

We conducted an 8-week parallel-arm, double-blind, randomised placebo-controlled trial of OROS-methylphenidate versus placebo in male prisoners (aged 16-25 years) meeting the DSM-5 criteria for ADHD. Primary outcome was ADHD symptoms at 8 weeks, using the investigator-rated Connors Adult ADHD Rating Scale (CAARS-O). Thirteen secondary outcomes were measured, including emotional dysregulation, mind wandering, violent attitudes, mental health symptoms, and prison officer and educational staff ratings of behaviour and aggression.

RESULTS

In the OROS-methylphenidate arm, mean CAARS-O score at 8 weeks was estimated to be reduced by 0.57 points relative to the placebo arm (95% CI -2.41 to 3.56), and non-significant. The responder rate, defined as a 20% reduction in CAARS-O score, was 48.3% for the OROS-methylphenidate arm and 47.9% for the placebo arm. No statistically significant trial arm differences were detected for any of the secondary outcomes. Mean final titrated dose was 53.8 mg in the OROS-methylphenidate arm.

CONCLUSIONS

ADHD symptoms did not respond to OROS-methylphenidate in young adult prisoners. The findings do not support routine treatment with OROS-methylphenidate in this population. Further research is needed to evaluate effects of higher average dosing and adherence to treatment, multi-modal treatments and preventative interventions in the community.

Child attachment and ADHD: a systematic review

Attention Deficit/Hyperactivity Disorder (ADHD) is a frequent neurodevelopmental disorder in children. ADHD has a multifactorial origin, combining genetic and environmental factors. Several studies suggested an influence of early parent-child relationships on the symptomatic expression of ADHD. In this review, we examine the studies that have investigated the links between attachment and ADHD in children. We searched for studies published between January 2000 and November 2019 on PsychInfo, PubMed, and Scopus. Selected studies included a theoretically based measure of attachment and an explicit measure of ADHD symptoms or an ADHD diagnosis. Studies that included children from adoption, institutionalization, or mistreatment were not included. We found only 26 studies meeting the inclusion criteria. Almost all these studies indicated a link between the attachment type and the presence of attentional difficulties and hyperactivity. However, associations were better explained, in several studies, by confounding factors such as comorbidities, cognitive difficulties, or contextual factors. The method used to assess attachment and parental mental health also had an impact. An increasing number of studies show a link between the type of attachment and the presence of attentional difficulties and hyperactivity in children. However, the nature of this link remains unclear. Implications for future research are discussed.

Mainstreaming adult ADHD into primary care in the UK: guidance, practice, and best practice recommendations

BACKGROUND

ADHD in adults is a common and debilitating neurodevelopmental mental health condition. Yet, diagnosis, clinical management and monitoring are frequently constrained by scarce resources, low capacity in specialist services and limited awareness or training in both primary and secondary care. As a result, many people with ADHD experience serious barriers in accessing the care they need.

METHODS

Professionals across primary, secondary, and tertiary care met to discuss adult ADHD clinical care in the United Kingdom. Discussions identified constraints in service provision, and service delivery models with potential to improve healthcare access and delivery. The group aimed to provide a roadmap for improving access to ADHD treatment, identifying avenues for improving provision under current constraints, and innovating provision in the longer-term. National Institute for Health and Care Excellence (NICE) guidelines were used as a benchmark in discussions.

RESULTS

The group identified three interrelated constraints. First, inconsistent interpretation of what constitutes a 'specialist' in the context of delivering ADHD care. Second, restriction of service delivery to limited capacity secondary or tertiary care services. Third, financial limitations or conflicts which reduce capacity and render transfer of care between healthcare sectors difficult. The group recommended the development of ADHD specialism within primary care, along with the transfer of routine and straightforward treatment monitoring to primary care services. Longer term, ADHD care pathways should be brought into line with those for other common mental health disorders, including treatment initiation by appropriately qualified clinicians in primary care, and referral to secondary mental health or tertiary services for more complex cases. Long-term plans in the NHS for more joined up and flexible provision, using a primary care network approach, could invest in developing shared ADHD specialist resources.

CONCLUSIONS

The relegation of adult ADHD diagnosis, treatment and monitoring to specialist tertiary and secondary services is at odds with its high prevalence and chronic course. To enable the cost-effective and at-scale access to ADHD treatment that is needed, general adult mental health and primary care must be empowered to play a key role in the delivery of quality services for adults with ADHD.

Diagnosis and treatment children and adolescents with autism and ADHD

Attention-deficit/hyperactivity disorder (ADHD) and autism are neurodevelopmental disorders that emerge in childhood. There is increasing recognition that ADHD and autism frequently co-occur. Yet, questions remain among clinicians regarding the best ways to evaluate and treat co-occurring autism and ADHD. This review outlines issues relevant to providing evidence-based practice to individuals and families who may be experiencing difficulties associated with co-occurring autism and ADHD. After describing the complexities of the co-occurrence of autism and ADHD, we present practical considerations for best practice assessment and treatment of co-occurring autism and ADHD. Regarding assessment, this includes considerations for interviewing parents/caregivers and youth, using validated parent and teacher rating scales, conducting cognitive assessments, and conducting behavior observations. Regarding treatment, consideration is given to behavioral management, school-based interventions, social skills development, and the use of medications. Throughout, we note the quality of evidence that supports a particular component of assessment or treatment, highlighting when evidence is most relevant to those with co-occurring autism and ADHD across stages of development. In light of the current evidence for assessment and treatment of co-occurring autism and ADHD, we conclude by outlining practical implications for clinical and educational practice.

Pediatric Psychotropic Polypharmacy: An Evaluation of the Correlates and Prevalence Across Assessment Cycles in the National Health and Nutrition Examination Survey

Background: Pediatric psychotropic polypharmacy (PPP) is the prescription of more than one medication targeting psychiatric disorders among people younger than 18 years. Recent data suggested that PPP rates may be plateauing. Few studies have evaluated this question in large, nationally recruited samples. Objective: The National Health and Nutrition Examination Survey was used to examine the correlates and prevalence of PPP across assessment cycles. Independent assessments were obtained biannually between 2013 and 2018. Methods: Eleven thousand four hundred thirty-nine participants (4-17 years; Mage = 8.69 years; standard deviation = 5.16) were included in analyses. The Anatomic Therapeutic Chemical coding scheme was employed to classify medications, and participants were characterized as taking psychotropic medication if the medication was associated with a psychiatric diagnosis code. Participants self-reported past month medication use. Logistic regressions were used to examine correlates of pediatric psychotropic monotherapy compared with psychotropic polypharmacy. Results: Across assessments, 1.2% of respondents reported using two or more psychotropic medications. This estimate is lower than has been observed in specialized samples, but higher than other work using national samples. There was a small, significant difference in PPP across assessment cycles, such that rates of PPP were higher at the latter assessments. Correlates of PPP accorded with prior work, including male gender, increasing age, and markers of low socioeconomic status. The most robust predictor was having seen a mental health professional in the past year. Conclusions: This study documents that ∼1% of U.S. participants from a nationally recruited sample endorsed PPP. Findings are situated in the broader literature and the need for additional, prospective data to better characterize those trends in the United States and around the world. Key Takeaway Points It is known that many children and adolescents in the United States take more than one psychotropic medication, although few studies have examined trends in large, nationally recruited datasets. This study adds to this literature by documenting the prevalence of pediatric psychotropic polypharmacy in a large, unselected sample (i.e., 1.2%) and shows that rates were slightly higher at subsequent assessment intervals. Plain Language Summary Many kids take more than one medication for psychological problems. We analyzed data from ∼11,000 children and adolescents from across the United States, evaluated between 2013 and 2018. The number of kids taking multiple medications for psychological problems was different (higher) when measured later in time. Being a boy, being older, living in poverty, and having seen a mental health professional in the past year were associated with taking multiple medications for psychological problems. Implications for Managed Care Pharmacy These findings suggest rates of pediatric psychotropic polypharmacy (PPP) remain high in the United States, and correlate with male gender, poverty, and having recently seen a mental health professional. Relative to White children and adolescents, Black participants were less likely and Hispanic participants more likely to endorse PPP. Policy considerations include fully educating families and practitioners about the benefits as well as potential downsides of PPP and additional intervention options for mental health problems.

Changes in Eating Behaviors Following Taste Education Intervention: Focusing on Children with and without Neurodevelopmental Disorders and Their Families: A Randomized Controlled Trial

Fussy-eating children often display problematic behaviors around mealtimes, such as irritation, opposition, or may even throw tantrums. This may lead to reduced food variety and poor nutritional profiles, which may increase parents' worries about their children's diet, particularly when the children also have neurodevelopmental disorders (ND) such as Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactive Disorder (ADHD). To investigate the effect of Taste Education on problematic mealtime behaviors, 81 children aged 8-12 years, with ND (n = 33) and without (n = 48), and their parents, participated in a 7-week Taste Education intervention. Children were matched on age, sex, and ND, and allocated at random into Immediate-intervention and Delayed-intervention groups. Parents completed the Meals in Our Household Questionnaire (MiOH). To examine changes in MiOH-scores, repeated-measures analysis-of-variance with time-points were used, with condition as factors (Immediate intervention and Delayed intervention). Baseline measures were adjusted for, and a robust linear mixed-model was fitted. Results showed superior outcomes for Intervention compared to waiting on all measures of MiOH, with stable effects through six-month follow-up. Differences were non-significant between children with and without ND. The Taste Education program suggests a promising, simple, and non-intrusive way to reduce children's problematic mealtime behaviors in the long term.

Functional outcomes of extended-release methylphenidate and atomoxetine in children: retrospective chart analysis

Background

Recent guidelines emphasize the importance of functional outcomes in children with attention-deficit/hyperactivity disorder (ADHD). Here, we assess the functional outcomes of the oral delivery system of osmotic-release methylphenidate (OROS-MPH) and atomoxetine (ATX) from the retrospective review of the chart for the last 2 years in the clinic.

Results

Linear mixed-effects models were performed with outcome measures of difference in ADHD symptoms and functional impairment. After 9–12 weeks, OROS-MPH and ATX were statistically equivalent for total Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) scores (difference in slope is β = 0.004, p = 1.000). However, OROS-MPH was superior to ATX in terms of school domain (difference in slope is β = 0.139, p < 0.001); ATX was superior in the family domain (slope difference in slope is β = 0.103, p < 0.001). The other domains of functioning both were not responsive to pharmacotherapy and were similar between the two medications.

Conclusions

Optimal management should monitor functional progress in ADHD beyond the core symptoms. As expected, ADHD medications provide a distinct pattern of functional improvement. Pharmacotherapy alone offers promising and reliable outcomes to improve school and family functions in ADHD. Some functional improvements did not respond to the medication; therefore, many of the techniques derived from behavioral interventions should be considered.

Children's behavioral problems, screen time, and sleep problems' association with negative and positive parenting strategies during the COVID-19 outbreak in Brazil

Families' health, safety, and economic stability were jeopardized during the pandemic. Parental stress is a risk factor for hostile and less supportive parenting. Parenting styles are a set of attitudes, feelings and behaviors related to parenting that modulate the child's psychosocial functioning and might impact on the adaptability to a stressful time.

OBJECTIVE

To investigate the group differences among children raised by negative and positive parenting families during COVID-19 pandemic.

METHODS

We have done an online survey with 329 parents. Parents answer about parenting strategies and styles, children's behavior, Covid related questions, socio-economic information, sleep and gaming disorders.

RESULTS

Parents' frequent use of negative strategies were a risk factor to have a negative outcome related to mental health, games, sleep, and children behavior.

DISCUSSION

Parenting strategies are some targets pointed in this study for intervention. Parents' styles and strategies training to better manage children might be even more important to avoid negative consequences for children in stressful times.

Meta-analysis: Altered Perceptual Timing Abilities in Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

We meta-analyzed studies comparing perceptual timing abilities in the range of milliseconds to several seconds in persons with attention-deficit/hyperactivity disorder (ADHD) and neurotypical participants, using the well-established time discrimination, time estimation, time production, and time reproduction paradigms.

METHOD

We searched PubMed, OVID databases, and Web of Knowledge through September 17, 2020. From 2,266 records, 55 studies were retained and meta-analyzed with random effects models. We conducted meta-regression analyses to explore moderating effects of task parameters and neuropsychological measures of working memory, attention, and inhibition on timing performance.

RESULTS

Compared with persons without ADHD, those with ADHD had significantly more severe difficulties in discriminating stimuli of very brief durations, especially in the sub-second range. They also had more variability in estimating the duration of stimuli lasting several seconds. Moreover, they showed deficits in time estimation and time production accuracy, indicative of an accelerated internal clock. Additional deficits in persons with ADHD were also found in the time reproduction paradigm, involving attentional (slower counting at short time intervals due to distraction) and motivational (faster counting at long time intervals due to increased delay aversion) functions.

CONCLUSION

There is meta-analytic evidence of a broad range of timing deficits in persons with ADHD. Results have implications for advancing our knowledge in the field (eg, for refinement of recent timing models in ADHD) and clinical practice (eg, testing timing functions to characterize the clinical phenotype of the patient and implementation of interventions to improve timing abilities).

Prediction of Educational Attainment and Occupational Functioning in Young Adults With a Childhood Diagnosis of ADHD: Results from the Cologne Adaptive Multimodal Treatment (CAMT) Study

OBJECTIVE

This longitudinal study examined early predictors of educational attainment and occupational functioning in adults with a childhood diagnosis of attention-deficit/hyperactivity disorder (ADHD).

METHOD

Participants (n = 70) of the Cologne Adaptive Multimodal Treatment (CAMT) Study were diagnosed with ADHD and received adaptive multimodal ADHD treatment during childhood. They were then followed through adolescence into adulthood.

RESULTS

Hierarchical regression analysis revealed that poor reading skill and externalizing behaviors in childhood were early predictors of educational and occupational difficulties in adulthood. The use of stimulant medication in childhood predicted lower high school achievement, probably because medication use was confounded by indication. The regression models improved when intelligence scores and/or externalizing behaviors, especially delinquency, assessed in adolescence were considered as additional predictors.

CONCLUSION

Children with ADHD, who continue to show reading difficulties and externalizing behavior problems after initial treatment, are at risk for educational and occupational difficulties and may need additional support.

Beneficial Effects of Behavioral Parent Training on Inhibitory Control in Children With Attention-Deficit/Hyperactivity Disorder: A Small-Scale Randomized Controlled Trial

The purpose of this study was to examine whether the beneficial effects of behavioral parent training (BPT), as an indirect type of psychosocial treatment, are extended to cognitive manifestations beyond behavioral symptoms of attention-deficit/hyperactivity disorder (ADHD). Although previous studies of community families have shown an association between parenting quality and a child's cognitive functions, little is known about the effects of BPT on cognitive manifestations in children with ADHD. In this study, we focused on inhibitory control among cognitive domains, which is considered to be the most malleable to direct types of psychosocial treatment for ADHD. We hypothesized that inhibitory control is affected by BPT, which uses parents as the primary agents of change to help their children. Thirty school-age children (6-12 years old) with ADHD and their parents (mothers) participated and were randomly assigned to either the standard BPT or waitlist control group. Using two objective laboratory-based tasks of inhibitory control (i.e., go/no-go and single response selection tasks), we assessed baseline and post-treatment response inhibition to suppress task-irrelevant responses and response selection to select task-relevant responses. In addition to decreased ADHD symptoms and negative parenting, the BPT group exhibited significantly improved performance in the single response selection task, but not in the go/no-go task, compared with the waitlist control group. Although tentative, these findings partially support our hypothesis that BPT has beneficial effects on the cognitive inhibitory control of ADHD, highlighting the potential for supportive environmental modifications to advance cognitive development in children with ADHD.

Review: Which components of behavioral parent and teacher training work for children with ADHD? - a metaregression analysis on child behavioral outcomes

BACKGROUND

This metaregression analysis examined which behavioral techniques that are commonly used in behavioral parent and teacher training programs for children with attention-deficit/hyperactivity disorder (ADHD) were related to program effectiveness on children's behavioral outcomes.

METHODS

We included 32 randomized controlled trials (N = 2594 children) investigating behavioral parent training, teacher training, or a combination, in children with ADHD under 18 years. Outcomes were symptom counts of total ADHD, inattention, and hyperactivity-impulsivity and behavioral problems. The dosage of techniques was extracted from the intervention manuals. Metaregression was used to assess which techniques and intervention characteristics (setting, delivery method, duration, and home-school collaboration) were associated with intervention effectiveness.

RESULTS

Higher dosage of psycho-education for parents was associated with smaller effects on behavioral problems and, only in case of parent training, also with smaller effects on ADHD symptoms. Higher dosage of teaching parents/teachers to use negative consequences was associated with larger effects on behavioral problems. Individual training compared with group training was associated with larger effects on ADHD and hyperactivity-impulsivity symptoms.

CONCLUSIONS

This study provides first insights into the specific techniques that are essential in behavioral parent and teacher training programs for children with ADHD. This knowledge can eventually be used to improve and tailor interventions.

Meta-analysis: Which Components of Parent Training Work for Children With Attention-Deficit/Hyperactivity Disorder?

OBJECTIVE

Behavioral parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but it is unknown which of its components are most effective. This meta-regression analysis investigated which specific behavioral techniques that parents learn in parent training are associated with effects on parental outcomes.

METHOD

A search was performed for randomized controlled trials on parent training for children with ADHD, with positive parenting, negative parenting, parenting sense of competence, parent-child relationship quality, and parental mental health as outcome measures. After screening 23,026 publications, 29 studies contributing 138 effect sizes were included (N = 2,345). For each study, the dosage of 39 behavioral techniques was derived from intervention manuals, and meta-regression determined which techniques were related to outcomes.

RESULTS

Parent training had robust small- to medium-sized positive effects on all parental outcomes relative to control conditions, both for unblinded and probably blinded measures. A higher dosage of techniques focusing on the manipulation of antecedents of behavior was associated with better outcomes on parenting sense of competence and parental mental health, and a higher dosage of techniques focusing on reinforcement of desired behaviors was related to larger decreases in negative parenting. Higher dosages of psychoeducation were negatively related to parental outcomes.

CONCLUSION

Although techniques were not investigated in isolation, the results suggested that manipulation of antecedents of behavior and reinforcement techniques are key components of parent training for children with ADHD in relation to parental outcomes. These exploratory findings may help to strengthen and tailor parent training interventions for children with ADHD.

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.

Restoring Connectedness in and to Nature: Three Nordic Examples of Recontextualizing Family Therapy to the Outdoors

Mentalization-based family therapy and family rehabilitation represent a rich variety of approaches for assisting families with difficult interaction patterns. On the other hand, adventure therapy methods have been successfully used with families to offer them empowering experiences of succeeding together against difficult odds and to improve communication between family members. Further, the health promoting qualities of spending time outdoors are now well established and recognized. The Nordic approach to mentalization-based family rehabilitation combines adventure, outdoor, and systemic therapy. We provide three examples of nature-based family rehabilitation practices that are delivered as brief, multi-family psychological interventions taking place in nearby nature and aiming to support sustainable, systemic change. The current contribution is a description of clinical practice, not a systematic review or a formal evaluation. We propose that recontextualizing mentalization-based family rehabilitation to the outdoors can not only provide added health benefits, but also strengthen intra-familial attuned interaction and emotional connectedness. The outdoor adventure provides the families with embodied, multisensory experiences of verbal and, especially, non-verbal interaction that can be usefully examined through the lens of theory of mentalization. The concreteness of adventure experiences is particularly beneficial for families that have difficulties in verbal communication and/or utilizing executive functions, perhaps due to neuropsychiatric traits, intellectual disabilities, or learning difficulties. Furthermore, outdoor adventure can support the participants’ connectedness to nature.

Clinically Meaningful Improvements in Early Morning and Late Afternoon/Evening Functional Impairment in Children with ADHD Treated with Delayed-Release and Extended-Release Methylphenidate

OBJECTIVE

The Before School Functioning Questionnaire and Parent Rating of Evening and Morning Behavior-Revised assess early morning (BSFQ, PREMB-R AM subscale) and late afternoon/evening (PREMB-R PM subscale) functional impairment in children with ADHD. Clinically meaningful improvements were identified and applied to a trial of delayed-release and extended-release methylphenidate (DR/ER-MPH) in children with ADHD (NCT02520388) to determine if the statistically-determined improvements in functional impairment were also clinically meaningful.

METHOD

Clinically meaningful improvements in BSFQ/PREMB-R were established post hoc by receiver operating characteristics curves, using anchors of Clinical Global Impression-Improvement (CGI-I) = 1 and CGI-I ≤ 2. Percentages of participants achieving these thresholds were calculated.

RESULTS

Thresholds for CGI-I = 1/CGI-I ≤ 2, respectively, were 27/20 (BSFQ), 5/3 (PREMB-R AM), and 9/5 (PREMB-R PM)-point decreases. More children achieved clinically meaningful improvements with DR/ER-MPH versus placebo (all p < .05).

CONCLUSION

DR/ER-MPH increased proportions of children achieving clinically meaningful improvements in BSFQ and PREMB-R.

An Individual Participant Data Meta-analysis: Behavioral Treatments for Children and Adolescents With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Behavioral interventions are well established treatments for children with attention-deficit/hyperactivity disorder (ADHD). However, insight into moderators of treatment outcome is limited.

METHOD

We conducted an individual participant data meta-analysis (IPDMA), including data of randomized controlled behavioral intervention trials for individuals with ADHD <18 years of age. Outcomes were symptoms of ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) and impairment. Moderators investigated were symptoms and impairment severity, medication use, age, IQ, sex, socioeconomic status, and single parenthood.

RESULTS

For raters most proximal to treatment, small- to medium-sized effects of behavioral interventions were found for symptoms of ADHD, inattention, hyperactivity/impulsivity (HI), ODD and CD, and impairment. Blinded outcomes were available only for small preschool subsamples and limited measures. CD symptoms and/or diagnosis moderated outcome on ADHD, HI, ODD, and CD symptoms. Single parenthood moderated ODD outcome, and ADHD severity moderated impairment outcome. Higher baseline CD or ADHD symptoms, a CD diagnosis, and single parenthood were related to worsening of symptoms in the untreated but not in the treated group, indicating a protective rather than an ameliorative effect of behavioral interventions for these children.

CONCLUSION

Behavioral treatments are effective for reducing ADHD symptoms, behavioral problems, and impairment as reported by raters most proximal to treatment. Those who have severe CD or ADHD symptoms, a CD diagnosis, or are single parents should be prioritized for treatment, as they may evidence worsening of symptoms in the absence of intervention.

Personalized at-home neurofeedback compared to long-acting methylphenidate in children with ADHD: NEWROFEED, a European randomized noninferiority trial

BACKGROUND

Neurofeedback is considered a promising intervention for the treatment of attention-deficit hyperactivity disorder (ADHD). NEWROFEED is a prospective, multicentre, randomized (3:2), reference drug-controlled trial in children with ADHD aged between 7 and 13 years. The main objective of NEWROFEED was to demonstrate the noninferiority of personalized at-home neurofeedback (NF) training versus methylphenidate in the treatment of children with ADHD.

METHODS

The NF group (n = 111) underwent eight visits and two treatment phases of 16 to 20 at-home sessions with down-training of the theta/beta ratio (TBR) for children with high TBR and enhancing the sensorimotor rhythm (SMR) for the others. The control group (n = 67) received optimally titrated long-acting methylphenidate. The primary endpoint was the change between baseline and endpoint in the Clinician ADHD-RS-IV total score in the per-protocol population (90 NF/59 controls).

TRIAL REGISTRATION

US National Institute of Health, ClinicalTrials.gov #NCT02778360.

RESULTS

Our study failed to demonstrate noninferiority of NF versus methylphenidate (mean between-group difference 8.09 90% CI [8.09; 10.56]). However, both treatment groups showed significant pre-post improvements in core ADHD symptoms and in a broader range of problems. Reduction in the Clinician ADHD-RS-IV total score between baseline and final visit (D90) was 26.7% (SMD = 0.89) in the NF and 46.9% (SMD = 2.03) in the control group. NF effects increased whereas those of methylphenidate were stable between intermediate and final visit.

CONCLUSIONS

Based on clinicians' reports, the effects of at-home NF were inferior to those of methylphenidate as a stand-alone treatment.

Parent Management Training Combined with Group-CBT Compared to Parent Management Training Only for Oppositional Defiant Disorder Symptoms: 2-Year Follow-Up of a Randomized Controlled Trial

Parent management training (PMT) is recommended treatment for children with oppositional defiant disorder (ODD) and child-directed cognitive behavior therapy (CBT) is also recommended for school-aged children. The current study examined 2-year follow-up effects of parent management training (PMT) combined with the CBT based group intervention Coping Power Program (CPP) compared to PMT only. Results showed long-term effectiveness of both PMT and PMT combined with CPP in reduced disruptive behavior problems and harsh parenting strategies, and increased emotion regulation- and social communication skills. The earlier reported increase in emotion regulation- and social communication skills in the PMT with CPP condition during treatment remained stable while the PMT condition showed continued improvement during the follow-up period. To conclude, PMT with CPP did generally not provide significant benefits at the 2-year follow-up compared to PMT, apart from an improvement earlier in time regarding emotion regulation- and social communication skills.Trial registration number ISRCTN10834473, date of registration: 23/12/2015.

Symptomatology of attention deficit, hyperactivity and defiant behavior as predictors of academic achievement

BACKGROUND

It is essential to understand the factors that affect the academic achievement of schoolchildren, both in general and in terms of the major subsectors of each grade. Although symptoms of Attention Deficit Hyperactivity Disorder (ADHD) and Negative Defiant Disorder (NDD-which are commonly recognized as externalizing problems in childhood and adolescence-have been associated with lower academic achievement in the international literature, few studies have addressed this problem in Latin America. This study aimed to analyze the possible predictive relationship of attention problems, hyperactivity, and defiant behavior on academic achievement.

METHODS

We recruited a sample of 4580 schoolchildren (50.9% female, 1754 belonging to primary school, and 2826 to secondary school, ranging from 9 to 18 years old). This cross-sectional study used the scales pertaining to attention problems, hyperactivity, and challenging behavior from the Child and Adolescent Evaluation System.

RESULTS

The analysis showed that attention problems significantly affected all academic achievement areas, while hyperactivity and challenging behavior affected only some of them. The regression models explained 24% of the variability in overall academic achievement in primary school and 17% in secondary school. Other predictors included sex, age, socioeconomic level, and school attendance.

CONCLUSIONS

It is important to consider this symptomatology in the design of educational interventions.