From Consensus Statement to Pills to Pixels: New Innovations in Attention-Deficit/Hyperactivity Disorder Care

Objectives: This review aims to present recent innovations and advancements in attention-deficit/hyperactivity disorder (ADHD) care, encompassing international consensus statement, new medication formulations, digital therapeutics, and neurostimulation devices. Methods: A comprehensive literature search of relevant articles published in the past five years was conducted, emphasizing the evidence base, efficacy, safety, and practical implications of these advancements. Results: The World Federation of ADHD Consensus Statement offers an updated diagnostic and treatment framework rooted in global scientific evidence. There are several newer ADHD medication formulations, including a nonstimulant (Viloxazine extended release) and the first transdermal amphetamine patch approved to treat ADHD. These options offer some unique benefits to personalize treatment based on symptom profile, lifestyle, preferences, and response. Digital tools offer additional means to restructure environments for individuals with ADHD, reducing impairment and reliance on others. In addition, digital therapeutics enhance access, affordability, personalization, and feasibility of ADHD care, complementing or augmenting existing interventions. Trigeminal nerve stimulation emerges as a well-tolerated nonpharmacological, device-based treatment for pediatric ADHD, with initial trials indicating effect sizes comparable to nonstimulant medications. Conclusions: These innovations in ADHD care represent clinically significant new treatment options and opportunities for personalized care. Health care professionals should integrate these developments into clinical practice, mindful of individual patient and family needs and preferences. Future research should assess long-term outcomes, cost-effectiveness, and acceptability of these innovations.

Treatment Utilization Pattern of Preschool Children With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

The aim of this study was to identify patterns of ADHD care, including factors that guide selection and sequencing of treatments in a large nationwide sample of preschool-aged youth over the past 6 years.

METHOD

A retrospective cohort study utilizing a large electronic health record (TriNetX) of nearly 24,000 children ages 3 to 6 diagnosed with ADHD.

RESULTS

One in three preschoolers with ADHD were prescribed psychotropic medication, most commonly methylphenidate and guanfacine. One in 10 had at least one psychotherapy billing code during the entire assessment with most youth starting medication before psychotherapy. Rates of most treatments, including polypharmacy, increased with comorbid psychiatric disorders or sleep problems and over the course of the coronavirus pandemic.

CONCLUSION

Rates of treatment have increased over time but are still largely inconsistent with published care guidelines that advise therapy before medication. Clinicians appear to prioritize psychiatric comorbidity and sleep problems when selecting treatments.

Single and Combined Effects of Multiple Intensities of Behavioral Modification and Methylphenidate for Children with ADHD in the Home Setting

Behavioral treatment, stimulants, and their combination are the recommended treatments for childhood attention-deficit/hyperactivity disorder (ADHD). The current study utilizes within-subjects manipulations of multiple doses of methylphenidate (placebo, 0.15, 0.30, and 0.60 mg/kg/dose t.i.d.) and intensities of behavioral modification (no, low, and high intensity) in the summer treatment program (STP) and home settings. Outcomes are evaluated in the home setting. Participants were 153 children (ages 5-12) diagnosed with ADHD. In alignment with experimental conditions implemented during the STP day, parents implemented behavioral modification levels in three-week intervals, child medication status varied daily, and the orders were randomized. Parents provided daily reports of child behavior, impairment, and symptoms and self-reported parenting stress and self-efficacy. At the end of the study, parents reported treatment preferences. Stimulant medication led to significant improvements across all outcome variables with higher doses resulting in greater improvement. Behavioral treatment significantly improved child individualized goal attainment, symptoms, and impairment in the home setting and parenting stress and self-efficacy. Effect sizes indicate that behavioral treatment combined with a low-medium dose (0.15 or 0.30 mg/kg/dose) of medication results in equivalent or superior outcomes compared to a higher dose (0.60 mg/kg/dose) of medication alone. This pattern was seen across outcomes. Parents overwhelmingly reported preferring treatment with a behavioral component as a first-choice treatment (99%). Results underscore the need to consider dosing as well as parent preference when utilizing combined treatment approaches. This study provides further evidence that combining behavioral treatment and stimulant medication may reduce the stimulant dose needed for beneficial effects.

Effects of a Primary Care-Based Engagement Intervention for Improving Use of ADHD Treatments

INTRODUCTION

Uptake of attention deficit hyperactivity disorder (ADHD) treatments is low in primary care. A quasi-experimental study assessed the impact of a primary care-based engagement intervention to improve ADHD treatment use.

METHOD

Families of children with ADHD from four pediatric clinics were invited to participate in a two-stage intervention. The first step was an assessment battery to assess functioning and identify goals, followed by an in-office engagement session run by primary care staff.

RESULTS

Of the 636 invited families, 184 (28.9%) completed ratings, with 95 (51%) families completing the engagement session. ADHD office visits varied based on the number of steps completed (0-2). ADHD prescriptions decreased over time in families completing neither step but increased for children previously unmedicated whose parents completed either step. Families completing both steps had the highest rates of nonmedication ADHD treatments.

DISCUSSION

A brief two-step engagement intervention was associated with increased uptake of ADHD treatments.

Editorial: Can Too Much Positive Emotion Be Bad for You?

There has been increasing focus on the assessment and treatment of irritability over the past decade in recognition of the impairment produced by abnormally persistent or excessive displays of negative emotions. However, emotional dysregulation may not be valence specific, and the impact of excessive or abnormally persistent displays of positive affect has received little attention. In their review in this issue of the Journal, Vogel et al.¹ argue that it should receive more attention. They do an admirable job synthesizing the developmental and clinical literature to support the potential value of assessing the capacity to regulate positive affect in an attempt to determine if too much of good thing can in fact be bad for you.

Systematic Review and Meta-analysis: Pharmacological and Nonpharmacological Interventions for Persistent Nonepisodic Irritability

OBJECTIVE

This meta-analysis examined the efficacy of available pharmacological and nonpharmacological interventions for irritability among youth with autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), disruptive behavior disorders (DBD), disruptive mood dysregulation disorder (DMDD), and/or severe mood dysregulation (SMD).

METHOD

Literature searches were conducted in October 2020, resulting in 564 abstracts being reviewed to identify relevant papers, with 387 articles being reviewed in full. A random effects model was used for the meta-analysis, with subgroup meta-regressions run to assess effects of study design, intervention type, medication class, and clinical population.

RESULTS

A total of 101 studies were included (80 pharmacological, 13 nonpharmacological, 8 combined). Despite high heterogeneity in effects (I2 = 94.3%), pooled posttreatment effect size for decreasing irritability was large (Hedges' g = 1.62). Large effects were found for pharmacological (g = 1.85) and nonpharmacological (g = 1.11) interventions; moderate effects were found for combined interventions relative to monotherapy interventions (g = 0.69). Antipsychotic medications provided the largest effect for reducing irritability relative to all other medication classes and nonpharmacological interventions. A large effect was found for youth with ASD (g = 1.89), whereas a medium effect was found for youth with ADHD/DMDD/DBD/SMD (g = 0.64).

CONCLUSION

This meta-analysis provides a comprehensive review of interventions targeting persistent nonepisodic irritability among youth with various psychiatric disorders. Strong evidence was found for medium-to-large effects across study design, intervention type, and clinical populations, with the largest effects for pharmacological interventions, particularly antipsychotic medications and combined pharmacological interventions, and interventions for youth with ASD.

Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them

OBJECTIVE

Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking.

METHOD

The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis.

RESULTS

Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses.

CONCLUSION

Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

Adolescent Suicide Risk Screening: A Secondary Analysis of the SHIELD Randomized Clinical Trial

OBJECTIVE

To evaluate the effectiveness of adolescent suicide risk screening to increase initiation of mental health services via a secondary analysis using data from the SHIELD (Screening in High Schools to Identify, Evaluate and Lower Depression) randomized clinical trial, which evaluated school-based screening for major depressive disorder (MDD).

STUDY DESIGN

Students in 14 Pennsylvania high schools were randomized by grade to either the usual school practice of targeted referral for behavior raising a concern for suicide risk or universal screening using the Patient Health Questionnaire-9 (PHQ-9), with any response >0 to item 9 regarding suicide risk considered positive. Students identified in either arm were referred to the Student Assistance Program (SAP), which is mandated in all Pennsylvania schools. The SAP determined follow-up. Study groups were compared using mixed-effects logistic regression.

RESULTS

The participants comprised 12 909 students, with 6473 (50.1%) randomized to universal screening. The study group was 46% female and 43% Hispanic or non-Hispanic Black. Adolescents in the universal screening arm had 7.1-fold greater odds (95% CI, 5.7-8.8) of being identified as at risk for suicide, 7.8-fold greater odds (95% CI, 4.6-13.1) of follow-up needs, and 4.0-fold greater odds (95% CI, 2.0-7.9) of initiating mental health treatment.

CONCLUSIONS

Although the PHQ-9 is a MDD screening tool, its use in universal screening increased identification and treatment initiation for adolescents at risk for suicide. This confirms the value of universal screening and suggests that a suicide-specific risk assessment would have even greater impact on treatment initiation for identified youth.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03716869.

Updates in Pharmacologic Strategies for Emotional Dysregulation in Attention Deficit Hyperactivity Disorder

Emotional dysregulation (ED) manifesting as irritability or aggression produces appreciable impairment in children with attention deficit hyperactivity disorder and a main reason why they present for treatment. Central nervous system (CNS) stimulants seem to be a safe and tolerable treatment of most youth with these presentations. Optimization of CNS stimulants dose in combination with psychosocial interventions led to reductions in ED. Randomized controlled trials support that addition of risperidone further reduces aggression when these treatments are not sufficient. There is evidence for the efficacy of divalproex, molindone and selective serotonin reuptake inhibitor improve these outcomes when used as adjunct to CNS stimulants.

Treatment Engagement Following a Positive Mental Health Screening Questionnaire

INTRODUCTION

Less than half of U.S. adolescents with major depressive disorder receive treatment. Despite the U.S. Preventive Services Task Force 2016 statement supporting primary care major depressive disorder screening, there is limited data examining whether positive screens prompt treatment engagement. This study evaluated treatment engagement following a positive Patient Health Questionnaire-Adolescent Version screen and assessed the impact of demographics, clinical variables, and provider recommendations on treatment engagement.

METHODS

This was a retrospective cohort study (analysis November 2021) of adolescents aged 11-18 years seen at a primary care clinic of an academic medical center from July 2017 to December 2018 and identified with a positive Patient Health Questionnaire-Adolescent Version (broadest definition score ≥10; ≥1 for Item 9 regarding suicidal thoughts; yes for unscored Items 1, 3, or 4; or very or extremely difficult for unscored Item 2). Positive screen by score ≥10 alone was also considered. The primary outcome was treatment engagement, defined as initiation of a psychotropic medication, or a behavioral health treatment session within 1 year of symptom identification.

RESULTS

Of the 1,315 eligible adolescents, 23.0% had a positive Patient Health Questionnaire-Adolescent Version (n=302) by the broadest criteria; 92/302 (30.5%) engaged in treatment. Patients whose providers recommended treatment had 7.32 times the odds (95% CI=3.76, 14.2, p<0.001) of treatment engagement. For those positive by Patient Health Questionnaire-Adolescent Version ≥10 (85/302, 28.1%), 37/85 (43.5%) engaged in treatment. The influence of provider recommendations was comparable (OR=6.96, 95% CI=3.56, 13.6, p<0.001).

CONCLUSIONS

Less than half of adolescents with a positive Patient Health Questionnaire-Adolescent Version at an academic primary care clinic engaged with treatment. Provider recommendation was an impactful intervention to improve mental healthcare treatment engagement.

The effect of stimulant medication on the learning of academic curricula in children with ADHD: A randomized crossover study

OBJECTIVE

Evaluate whether stimulant medication improves acquisition of academic material in children with attention deficit hyperactivity disorder (ADHD) receiving small-group, content-area instruction in a classroom setting.

METHOD

Participants were 173 children between the ages of 7 and 12 years old (77% male, 86% Hispanic) who met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for ADHD and were participating in a therapeutic summer camp. The design was a triple-masked, within-subject, AB/BA crossover trial. Children completed two consecutive phases of daily, 25-min instruction in both (a) subject-area content (science, social studies) and (b) vocabulary. Each phase was a standard instructional unit lasting for 3 weeks. Teachers and aides taught the material to small groups in a summer classroom setting. Each child was randomized to be medicated with daily osmotic-release oral system methylphenidate (OROS-MPH) during either the first or second of the instructional phases, receiving placebo during the other.

RESULTS

Medication had large, salutary, statistically significant effects on children's academic seatwork productivity and classroom behavior on every single day of the instructional period. However, there was no detectable effect of medication on learning the material taught during instruction: Children learned the same amount of subject-area and vocabulary content whether they were taking OROS-MPH or placebo during the instructional period.

CONCLUSIONS

Acute effects of OROS-MPH on daily academic seatwork productivity and classroom behavior did not translate into improved learning of new academic material taught via small-group, evidence-based instruction. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Predictors of Changes in Height, Weight, and Body Mass Index After Initiation of Central Nervous System Stimulants in Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE

To identify predictors of changes in height, weight, and body mass index (BMI) in children with attention deficit hyperactivity disorder (ADHD) starting central nervous system (CNS) stimulants.

STUDY DESIGN

There were 230 medication-naïve children aged 5-12 years with ADHD who participated in a randomized trial evaluating the impact of CNS stimulants on growth over 30 months. This observational analysis focused on the 141 participants using study medication for 65 or more days in the first 6-months after starting medication. Biometric variables, ADHD, and oppositional defiant disorder symptom scores at medication initiation, and medication use over the study were examined as predictors of changes in standardized (z) height, weight, and BMI.

RESULTS

Mean changes in z-BMI, z-weight. and z-height were negative throughout the study. The most consistent predictors of change in z-BMI, z-weight, and z-height were percent days medicated and total medication exposure. Children with lower z-height and z-weight at medication initiation experienced greater z-BMI and z-weight decreases over the first 6 months on medication. Greater appetite suppression during dose optimization predicted greater decreases in z-weight over the entire study and a greater decrease in z-height over the first 6 months on medication. z-weight change correlated with z-height change. Behavioral symptoms did not predict changes in z-BMI, z-weight, or z-height.

CONCLUSIONS

How much and how often CNS stimulants are used predicts changes in z-BMI, z-weight, and z-height in children. Even smaller and lighter children may be at risk for decreases in z-weight and z-BMI. Parent ratings of appetite during dose titration may serve as feasible indicators of future weight and height change in children using CNS stimulants.

TRIAL REGISTRATION

Clinicialtrials.gov: NCT01109849.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Screening in High Schools to Identify, Evaluate, and Lower Depression Among Adolescents: A Randomized Clinical Trial

IMPORTANCE

Adolescent major depressive disorder (MDD) prevalence has nearly doubled in the past decade. The US Preventive Services Task Force endorses universal adolescent MDD screening in primary care; however, most adolescents lack preventive health care, resulting in worsening disparities in MDD screening and treatment.

OBJECTIVE

To evaluate the effectiveness of universal adolescent MDD screening in the school setting in an effort to reduce disparities and improve MDD identification and treatment initiation.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial, conducted from November 6, 2018, to November 20, 2020, compared the usual school practice of targeted or selected screening based on observable behaviors of concern with universal MDD screening. Students within an identified school were randomized by grade to 1 of the 2 study groups. Study groups were compared using mixed-effects logistic regression. Participants included students in grades 9 through 12 enrolled at 1 of the 14 participating Pennsylvania public high schools.

INTERVENTIONS

In targeted screening, students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up recommendations. In universal screening, all students completed the Patient Health Questionnaire-9 (PHQ-9); students with positive scores proceeded to SAP. The universal screening group could also have targeted referral to SAP for concerning behavior independent of the PHQ-9.

MAIN OUTCOMES AND MEASURES

The primary outcome was initiation of MDD treatment or services based on data collected by school SAP teams during the academic year.

RESULTS

A total of 12 909 students were included (median age, 16 years [range, 13-21 years]; 6963 male [53.9%]), of whom 2687 (20.8%) were Hispanic, 2891 (22.4%) were non-Hispanic Black, 5842 (45.3%) were non-Hispanic White, and 1489 (11.5%) were multiracial or of other race or ethnicity. A total of 6473 students (50.1%) were randomized to universal screening, and 6436 (49.9%) were randomized to targeted screening. Adolescents in the universal screening group had 5.92 times higher odds (95% CI, 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of SAP confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of initiating MDD treatment. No differences were identified in initiation for planned subgroup analyses by sex or race and ethnicity.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, universal school-based MDD screening successfully increased identification of MDD symptoms and treatment initiation among adolescents, confirming the value of this approach to address this rising public health concern.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03716869.

Impact of CNS Stimulants for Attention-Deficit/Hyperactivity Disorder on Growth: Epidemiology and Approaches to Management in Children and Adolescents

Central nervous system stimulants are established treatments for pediatric attention-deficit/hyperactivity disorder with robust efficacy data. Reductions in appetite, weight, and growth velocity are some of the most common concerns regarding the long-term use of central nervous system stimulants in developing children. They are associated with suppression of weight and body mass index in childhood. However, both weight and body mass index often progressively increase over adolescence at rates faster than those seen in non-attention-deficit/hyperactivity disorder youth to the degree that attention-deficit/hyperactivity disorder is associated with elevated body mass index by the end of adolescence regardless of medication use. The capacity of central nervous system stimulants to slow growth was identified 50 years ago. Recent work has established that the growth deficits accumulate during the first 2 years of use and may persist provided medication is used. Early initiation coupled with persistent use through adolescence is most likely to be associated with clinical impactful growth suppression. There has been limited formal investigation of treatments for stimulant-associated reductions in weight and height. The most robust evidence exists for drug holidays improving weight gain. Observational studies suggest that limiting lifetime exposure or discontinuing medication is associated with greater adult height. Additional research is needed to identify the causal mechanisms driving the observed slowing in growth as well as the identification of predictors of clinically impactful growth suppression.

Baseline performance moderates stimulant effects on cognition in youth with ADHD

Attention-deficit/hyperactivity disorder is associated with impaired cognitive functioning and increased delay discounting (i.e., a stronger preference for immediate reward). At the group level, stimulant medication improves cognition and delay discounting, yet not all children exhibit problems in these domains, and previous work has not examined whether stimulant-induced improvements are moderated by baseline performance. To address this question in the current study, 82 children with attention-deficit/hyperactivity disorder (9-12 years old) attended a week-long research camp. On the baseline day (Monday), participants completed tasks of inhibitory control, visuospatial working memory, reaction time variability, and delay discounting. Children then completed a 3-day, randomized, double-blind, placebo-controlled trial of ∼1 mg/kg and 2 mg/kg long-acting methylphenidate (mean doses = 39.1 and 74.3 mg, respectively), during which they were readministered the battery of tasks. Cognitive composites (mean of inhibitory control, working memory, and reaction time variability performance) were created for the baseline and medication evaluation phases. As predicted, the extent to which cognition was improved with medication compared with placebo and with 2 mg/kg compared with 1 mg/kg was greatest among children with poorer baseline cognitive function. Children with stronger baseline cognition exhibited less improvement with methylphenidate compared with placebo and did not benefit from the 2 compared with the 1 mg/kg dose. In contrast, medication-related improvement in delay discounting was unrelated to baseline discounting. Given that improving cognitive function is one potential mechanisms by which stimulants exert their therapeutic effects, this study has significant implications for understanding how and for whom stimulant medication works. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Review of the Evidence Base for Psychosocial Interventions for the Treatment of Emotion Dysregulation in Children and Adolescents

Many children with a range of psychiatric diagnoses manifest impaired levels of emotion dysregulation (ED). Over the past decade, there has been increasing examination of psychosocial interventions for ED. We found preliminary evidence of positive effects for a wide range of psychosocial treatments that were associated with improvements in emotion recognition, emotional reactivity, and emotion regulation. More studies are needed because results are limited by the small number of controlled trials, heavy reliance on parent ratings, and heterogeneity of the samples.

Parent Views on School-Based Depression Screening: Findings From a National Survey

PURPOSE

This study explored parent views on school involvement in screening and identification of adolescent depression.

METHODS

This was a cross-sectional Internet-based survey with the C.S. Mott Children's Hospital National Poll on Children's Health. Of 2,004 parents (63.4% response rate), 770 had a middle/high school student and were eligible for this module. Poststratification weights were generated by survey vendor Ipsos. Descriptive and bivariate results were calculated; multinomial logistic regression models controlled for parent sex, race/ethnicity, education, employment status, and school level.

RESULTS

Parent respondents were 54.8% female, 57.5% white, 64.3% above a high school education, and 79.7% employed; 76.2% were answering based on a high school student. Most parents supported school-based depression screens starting in sixth (46.7%) or seventh (15.1%) grades, although 15.9% responded no screening should be done. Among parent respondents, 93.2% wished to be informed of a positive screen. Regression analysis found parents of middle school students were 4.18 times more likely to prefer sixth versus 9th to 12th grade to start screening.

CONCLUSIONS

Most parents support middle school depression screening but overwhelmingly wished to be informed of a positive result. Guidelines for maintaining adolescent confidentiality in a school-based depression screening program will require careful consideration.

The Impact of Persistent Irritability on the Medication Treatment of Paediatric Attention Deficit Hyperactivity Disorder

This study compares the efficacy and tolerability of central nervous system (CNS) stimulants in children with attention deficit hyperactivity disorder (ADHD) with and without prominent irritability (IRR) over the course of 30 months. This is a secondary analysis of a study examining growth patterns in medication naïve children with ADHD subsequently treated with CNS stimulants (predominantly OROS-Methylphenidate, up to 54 mg per day) for 30 months. Participants had to meet full diagnostic criteria for ADHD and been treated with CNS stimulants for under 30 days. Children were classified as IRR if they were rated as pretty much or very much on either of the "often angry" or easily annoyed" items plus "lose temper," items of the Disruptive Behavior Disorders Rating Scale (DBDRS). Structured ratings of ADHD symptoms, impairment, side effects, and symptoms of oppositional defiant disorder (ODD) were collected every 2-12 weeks for the duration of the study. Medication use was measured by pill count and parent report. The IRR group comprised 28% of all participants. The IRR group had significantly higher levels of ADHD and ODD symptoms, impairment, and side effects ratings at baseline. In the IRR group, ODD symptoms, emotional lability, and impairment significantly decreased for participants with higher medication use. Total side effects increased for non-IRR participants with higher medication use. Emotional side effects decreased for IRR participants with higher medication use. Central nervous system stimulants were a tolerable and efficacious treatment in treatment naïve youth with ADHD with irritability. Clinical Trials Registration: NCT01109849.

A Randomized Controlled Trial of Interventions for Growth Suppression in Children With Attention-Deficit/Hyperactivity Disorder Treated With Central Nervous System Stimulants

OBJECTIVE

To examine the impact of central nervous system (CNS) stimulants on the growth of children with attention-deficit/hyperactivity disorder (ADHD), and to assess the efficacy and feasibility of weight recovery interventions on growth.

METHOD

A total of 230 children aged 5 to 12 years with ADHD with no history of chronic CNS stimulant use were randomly assigned to receive daily CNS stimulants (78%, primarily osmotic release oral system-methylphenidate [OROS-MPH]) or behavioral treatment (22%) for 30 months. After 6 months, children evidencing a decline in body mass index (BMI) of >0.5 z-units were randomized to 1 of 3 weight recovery treatments (WRTs): monthly monitoring of height/weight (MON) plus continued daily medication; drug holidays (DH) with medication limited to school days; or daily caloric supplementation (CS) with a 150-kcal supplement plus daily medication.

RESULTS

Before WRT assignment, medication was associated with significant reductions in standardized weight and height (p values <.01). Adherence to CS and DH during WRT was high, with significant increases in daily caloric intake and decreases in weekly medication exposure (p values <.05). Across all WRT participants (n = 71), weight velocity increased significantly after WRT randomization (β₂ = 0.271, SE = 0.027, p < .001).When analyzed by what parents did (versus what they were assigned to), CS (p < .01) and DH (p < .05) increased weight velocity more than MON. No increase in height velocity was seen after randomization to any WRT. Over the entire study, WRT participants declined in standardized weight (-0.44 z-units) and height (-0.20 z-units).

CONCLUSION

Drug holidays, caloric supplementation, and increased monitoring all led to increased weight velocity in children taking CNS stimulants, but none led to increased height velocity.

CLINICAL TRIAL REGISTRATION INFORMATION

Novel Approach to Stimulant Induced Weight Suppression and Its Impact on Growth; https://clinicaltrials.gov/; NCT01109849.

Psychometric Properties of Parent Ratings on the Inventory of Callous-Unemotional Traits in a Nationally Representative Sample of 5- to 12-Year-Olds

The psychometric properties of the parent-report version of the Inventory of Callous-Unemotional Traits (ICU) in school-aged children requires further examination. In a nationally representative sample of U.S. children (N = 1,064, M age = 8.42, 51.7% boys), the current study examined the factor structure, measurement invariance, and the moderating role of parent rated ICU scores on conduct problems. Results supported (a) a two-factor model consisting of a CU factor and a limited prosocial emotions (LPE) factor; (b) an invariant structure of the ICU across child sex, as well as (to a lesser extent) across child age and parent sex; and (c) the moderating role of the LPE factor on the relationship between conduct problems and relevant outcomes (i.e., impairment, need for treatment). Normative data on the parent-report version of the ICU for elementary-aged school children in the United States were also presented. Clinical implications regarding use of the parent-report version of the ICU for school-aged children are discussed.

Development of a Child and Adolescent Tele-Partial Hospitalization Program (tele-PHP) in Response to the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic prevented a group-based partial hospitalization program (PHP) from running in-person care due to social distancing guidelines. However, the crisis also simultaneously increased stress on families while decreasing their desire to hospitalize youth for a nonmedical issue. Hence, the need for a PHP remained high. Health care organizations worked diligently to create a secure telehealth platform (tele-PHP) to be delivered to patients in their home environments. This article describes the development and implementation of child and adolescent tele-PHPs in response to the COVID-19 pandemic. These new programs were started in mid-March 2020, and changes were implemented over the next 3 to 4 weeks. Overall, patients and families have been receptive to behavioral health services delivered through telemedicine. While tele-PHPs are the most plausible solution to continue behavioral health care for these patients, some challenges were observed during this process. Besides procedural and technological challenges associated with creating a virtual setup, other difficulties include variable patient engagement, specific treatment-related challenges, and system-related changes. These challenges are addressed through psychoeducation, provision of online measures to assess treatment outcomes, and efforts to optimize parent engagement prior to treatment initiation for better treatment adherence. Initial experiences during a time of crisis suggest that tele-PHP services can be a viable long-term treatment option in the future during both a disaster and routine times to improve access for those who otherwise cannot take advantage of such services. Long-term effectiveness of these interventions still needs to be explored.

Initial Investigation of the Psychometric Properties of the Limited Prosocial Emotions Questionnaire (LPEQ)

Callous-unemotional traits, which include lack of remorse or guilt, callousness/lack of empathy, unconcern about performance, and shallow/deficient affect, were included as a specifier of conduct disorder in the current (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders under the rubric Limited Prosocial Emotions (LPEs). The purpose of this study was to examine the psychometric properties of a new rating scale, the Limited Prosocial Emotions Questionnaire (LPEQ). Caregivers (n = 1,050) of children (M_age = 8.42, SD = 2.31) completed the LPEQ and other measures. Results provide support for a single factor model of the LPEQ, with measurement invariance supported across child and informant sex. Both the reliability and validity of the LPEQ as a measure of LPEs were also well supported. Children identified with LPE had significantly greater average impairment and need for treatment relative to children without LPE. Children with conduct problems (i.e., conduct disorder or oppositional defiant disorder), as well those without conduct problems, had significantly more impairment if they were identified as having LPE. Our findings fit with the mounting evidence of the clinical utility of assessing LPEs in children. Future research should look to replicate our findings in clinical samples of youth.

Symptom scores and medication treatment patterns in children with ADHD versus autism

Most children with autism have ADHD, and children with ADHD-Combined and children with autism have high rates of irritable, oppositional, and aggressive behavior. Despite similar symptoms, prescribing practices may differ between autism and ADHD, which has not been examined in a single study. 1407 children with autism and 1036 with ADHD without autism, 2-17 years, were compared with 186 typical peers. Symptom scores were maternal Pediatric Behavior Scale ratings in eight areas (ADHD, oppositional/aggressive, irritable/angry, anxious, depressed, and social, writing, and learning problems). Psychotropics were prescribed to 38.0% with ADHD-Combined, 33.3% with autism, and 20.2% with ADHD-Inattentive, most often an ADHD medication (22.1% stimulant, 2.3% atomoxetine), antipsychotic (7.8%), SSRI (5.5%), and alpha agonist (4.9%). ADHD medications were more often prescribed than other medications in all diagnostic groups. Compared to autism, children with ADHD-Combined were more likely to be prescribed an ADHD medication, whereas antipsychotics and SSRIs were more likely to be prescribed in autism than in ADHD-Combined. Children with ADHD-Inattentive were least impaired and least likely to be medicated. More severely impaired children were more often medicated regardless of diagnosis. Symptom scores were far worse for treated and untreated children with ADHD and with autism than for typical peers.

The Role of Parental Knowledge and Attitudes about ADHD and Perceptions of Treatment Response in the Treatment Utilization of Families of Children with ADHD

The present study examined the impact of parental knowledge and attitudes about attention-deficit/hyperactivity disorder (ADHD), and parental perceptions of treatment response on the utilization of behavioral and pharmacological ADHD treatments, using data from a longitudinal treatment study designed to assess physical growth in children with ADHD. It also explored if these relations were moderated by race/ethnicity. Participants include 230 (74% Hispanic) families of treatment naïve children with ADHD (M age = 7.56, SD = 1.94; 73% male). Families were randomly assigned to receive behavior therapy (BT) or stimulant medication (MED; which also included low dose BT). After 6 months, families whose children still showed at least moderate impairment had access to either treatment for a total of 30 months. Utilization was measured using the number of BT sessions attended and total mg of MED taken over the study period. Families who reported more willingness to use medication for their child's ADHD at baseline were more likely to use MED and less likely to use BT, regardless of race/ethnicity. Parental knowledge about ADHD was only important in predicting BT utilization for White non-Hispanic families. Greater reduction in ADHD symptoms and impairment significantly predicted more MED utilization for Hispanic families. Results highlight the need to explore multiple parent (e.g., medication willingness) and child (e.g., symptom severity) factors when considering treatment utilization. Results also highlight ethnic differences in which factors affect treatment utilization.

Irritability and Limited Prosocial Emotions/Callous-Unemotional Traits in Elementary-School-Age Children

Affective traits, including irritability and limited prosocial emotions/callous-unemotional traits (LPE/CU), each explain significant variance in youth conduct problems but few studies have examined these constructs simultaneously. This study examined whether irritability, LPE/CU, or their combination explained significant variance in measures of internalizing or externalizing psychopathology, aggression, peer problems, impairment, or parenting. Participants were 219 elementary-school-age children, including 178 with attention-deficit/hyperactivity disorder, oppositional defiant disorder, and/or conduct disorder and 41 typically developing children. Results of analyses showed that irritability and LPE/CU had significant and sometimes unique associations with measures of child behavior, impairment, and parenting. There was also evidence that the interaction between irritability and LPE/CU was significantly associated with aggression and impairment. These findings suggest that irritability and LPE/CU should be examined together when assessing and treating conduct problems in youth.

A Commercial Insurance Claims Analysis of Correlates of Behavioral Therapy Use Among Children With ADHD

OBJECTIVE

The study examined factors associated with uptake of behavioral therapy among children with attention-deficit hyperactivity disorder (ADHD).

METHODS

Insurance claims data from 2008-2014 (MarketScan) were reviewed to examine associations between behavioral therapy use and demographic, patient, family, and provider factors. The association between ADHD medication use and future uptake of behavioral therapy was examined with logistic regression adjusted for covariates found to affect behavioral therapy use.

RESULTS

Among 827,396 youths with ADHD, under 50% received any billable behavioral therapy services over the 7 years. ADHD severity, gender, region of residence, assessment year, comorbid behavioral disorders, and behavioral therapy use by siblings were significantly associated with behavioral therapy use (p<0.001). Parent psychopathology and sibling medication use was not. Children prescribed ADHD medication were 2.5 times less likely than those not prescribed medication to use behavioral therapy, even after adjustment for severity of behavioral health symptoms and other covariates (odds ratio [OR]= 0.41, 95% confidence interval [CI]=.40-.41, p<0.001). Effects of medication use were stronger for future uptake of behavioral therapy (OR=0.25, 95% CI =0.24-0.25, p<.001). The impact of medication use on behavioral therapy use was equally strong for children under age 6 and for older children and did not weaken after release of 2011 guidelines recommending behavioral therapy as the initial ADHD treatment for young children.

CONCLUSIONS

Multiple systems, family, patient and provider factors affected behavioral therapy uptake. ADHD medication was a robust and potentially modifiable factor. It may be advisable to engage families in behavioral therapy prior to initiation of ADHD medication.

Effectiveness of Universal School-Based Screening vs Targeted Screening for Major Depressive Disorder Among Adolescents: A Trial Protocol for the Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) Randomized Clinical Trial

Importance

The prevalence of annual major depressive disorder (MDD) episodes among adolescents in the United States rose from 8.3% in 2008 to 12.8% in 2016. Despite the US Preventive Services Task Force 2009 endorsement and 2016 reaffirmation of universal adolescent MDD screening in primary care, many adolescents are missed, as more than 60% lack annual preventive health visits and MDD screening remains inconsistent.

Objective

To compare the effectiveness of universal school-based screening for adolescent MDD vs the existing process of targeted screening based on observable behavior.

Design, Setting, and Participants

Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) is a randomized clinical trial that will take place in at least 8 Pennsylvania public high schools among at least 9650 students enrolled in 9th through 12th grade. Students will be randomized by grade to either targeted screening (current process) or universal screening (intervention). Students in the targeted screening arm will complete mandated school health screenings, which do not include an MDD screening. These students will be observed through the academic year for referral to the Student Assistance Program (SAP), required in all Pennsylvania schools. If a student exhibits behavior concerning for MDD raised by any contact (eg, teacher, parent, peer, or self-referral), SAP will triage the student and provide follow-up recommendations. Students in the universal screening arm will complete the validated Patient Health Questionnaire-9 (PHQ-9) from September through December of the academic year. The PHQ-9 includes 9 close-ended questions and is scored from 0 to 27. Students with a positive result (ie, score >10) will proceed to SAP triage. Students in the intervention arm will also be observed for behavior concerning for MDD during the school year, potentially prompting SAP triage referral. The primary outcome will be the proportion of adolescents referred to SAP triage who are recommended for additional MDD-related services and successfully engage with at least 1 SAP recommendation. Observers will not be blinded to patient groups, and an intention-to-treat analysis will be used.

Discussion

The SHIELD trial began with 3 schools during the 2018-2019 academic year. Screening in the intervention arm with the PHQ-9 is currently underway for the remaining schools, with a goal of completion of all PHQ-9 screenings by December 2019. This trial addresses the US Preventive Services Task Force call for large, high-quality randomized clinical trials to better understand the effects of MDD screening and quantify the proportion of adolescents with screen-detected MDD successfully referred and treated.

Trial Registration

ClinicalTrials.gov identifier: NCT03716869.

Randomized Trial of First-Line Behavioral Intervention to Reduce Need for Medication in Children with ADHD

A study conducted in an analogue summer treatment setting showed that when concurrently receiving behavioral intervention, many children with Attention-Deficit Hyperactivity Disorder (ADHD) did not need medication or maximized responsiveness at very low doses. The present study followed participants in that summer study into the subsequent school year to investigate whether the same pattern would extend to the natural school and home settings. There were 127 unmedicated children with ADHD between the ages of 5 and 13 who were randomly assigned to receive or not receive behavioral consultation (BC) at the start of the school year. Children were evaluated by teachers and parents each week to determine if central nervous system stimulant treatment was needed. Children who received BC were approximately half as likely those who did not (NoBC) to initiate medication use each week at school or home and used lower doses when medicated at school. This produced a 40% reduction in total methylphenidate exposure over the course of the school year. BC and NoBC groups did not significantly differ on end-of-year teacher or parent ratings of behavior, which were positive. Moreover, BC and NoBC groups did not significantly differ in cost of treatment; although children in the BC condition accrued additional costs via the BC, these costs were offset by the associated delay and reduction in medication use. Results add to a growing literature suggesting that the use of low-intensity behavioral intervention as a first-line treatment reduces or eliminates the need for medication in children with ADHD.

Demographic Differences in Disruptive Mood Dysregulation Disorder Symptoms in ADHD, Autism, and General Population Samples

OBJECTIVE

Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) disruptive mood dysregulation disorder (DMDD) is a controversial new diagnosis. No studies have investigated DMDD symptoms (irritable-angry mood and temper outbursts) and demographics in general population and psychiatric samples.

METHOD

Maternal ratings of DMDD symptoms and diagnoses, age, gender, IQ, race, and parent occupation were analyzed in general population ( n = 665, 6-12 years) and psychiatric samples ( n = 2,256, 2-16 years).

RESULTS

Percentage of school-age children with DMDD symptoms were 9% general population, 12% ADHD-I, 39% ADHD-C, and 43% autism. Male, nonprofessional parent, and autism with IQ > 80 were associated with increasing DMDD symptoms, but demographics together explained only 2% to 3% of the DMDD score variance.

CONCLUSION

Demographics contributed little to the presence of DMDD symptoms in all groups, whereas oppositional defiant disorder (ODD) explained most of the variance. Almost all children with DMDD symptoms had ODD suggesting that DMDD may not be distinct from ODD.

Sex and Pubertal Status Moderate the Association Between ADHD and Depression Symptoms: An Examination From Preadolescence Through Late Adolescence

OBJECTIVE

This study examines the effects of sex and pubertal status on the association between attention-deficit/hyperactivity disorder (ADHD) and depression symptoms in preadolescence through late adolescence.

METHODS

Participants were 472 youth from the Multimodal Treatment Study of Children With ADHD. The study sample included 308 youth with DSM-IV ADHD, recruited from 1993 through 1996, and 164 comparison youth who were recruited approximately 2 years later. Self-reported depression symptoms from the Children's Depression Inventory and pubertal status from the Tanner Self-Report Scale were collected, along with combined parent-teacher reports of ADHD. Regression analyses examined the impact of ADHD, sex, pubertal status, and their interactions on total depression symptoms and related subscales (ie, negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem) in preadolescence. Next, path models examined associations between ADHD, sex, and pubertal status on depression symptoms into middle and late adolescence.

RESULTS

In preadolescence, significant ADHD × sex × puberty interactions emerged for total depression symptoms and anhedonia (P < .05). Higher levels of ADHD severity were associated with higher levels of depression in early maturing girls and later maturing boys. Effects appear to be driven by anhedonia. Longitudinal effects emerged showing that total depression symptoms and anhedonia in preadolescence predicted levels of each respective outcome into late adolescence.

CONCLUSIONS

Sex and pubertal status meaningfully impact the association between ADHD and depression symptoms in youth and should be considered in future work and treatment.

Editorial: Does an Attention-Deficit/Hyperactivity Disorder Pill a Day Keep Failing Grades Away?

Numerous studies have found that attention-deficit/hyperactivity disorder (ADHD) significantly impairs academic functioning. Observed impairments span diverse outcomes, from grade point average (GPA) and standardized test scores to grade retention and dropout. The impact of treating ADHD on academic functioning has received appreciable attention but remains a topic of debate because of the mixed and somewhat underwhelming results to date. The best evidence for effect is the capacity of central nervous system (CNS) stimulants to decrease problematic behaviors in the classroom.¹ However, it is not clear whether improved behavior translates into better academic functioning. In fact, there is evidence that parents might be less likely to follow through on behavioral interventions after medication has been initiated, even when parents report persistent impairment from ADHD.².

How do stimulant treatments for ADHD work? Evidence for mediation by improved cognition

BACKGROUND

Stimulant medications such as methylphenidate (MPH) are the frontline treatment for Attention-Deficit/Hyperactivity Disorder (ADHD). Despite their well-documented efficacy, the mechanisms by which stimulants improve clinical outcomes are not clear. The current study evaluated whether MPH effects on classroom behavior were mediated by improved cognitive functioning.

METHODS

Children with ADHD (n = 82; 9-12 years old) participated in a week-long summer research camp, consisting of cognitive testing, classroom periods, and recreational activities. After a baseline day, participants completed a 3-day randomized, double-blind, placebo-controlled trial of MPH (at doses approximating 0.3 and 0.6 mg/kg of immediate-release MPH dosed TID). Cognitive domains included inhibitory control (Stop Signal Task and prepulse inhibition of startle), attention (Continuous Performance Task and reaction time variability), and working memory (forward and backward spatial span). Clinical outcomes included math seatwork productivity and teacher-rated classroom behavior. A within-subjects path-analytic approach was used to test mediation. MPH-placebo and dose-response contrasts were used to evaluate drug effects.

RESULTS

Methylphenidate improved seatwork productivity and teacher ratings (ds = 1.4 and 1.1) and all domains of cognition (ds = 0.3-1.1). Inhibitory control (Stop Signal Task, SST) and working memory backward uniquely mediated the effect of MPH (vs. placebo) on productivity. Only working memory backward mediated the impact of MPH on teacher-rated behavior. The dose-response (0.6 vs. 0.3 mg/kg) effects were more modest for clinical outcomes (ds = 0.4 and 0.2) and cognition (ds = 0-0.3); there was no evidence of cognitive mediation of the clinical dose-response effects.

CONCLUSIONS

These findings are novel in demonstrating that specific cognitive processes mediate clinical improvement with stimulant treatment for ADHD. They converge with work on ADHD theory, neurobiology, and treatment development in suggesting that inhibitory control and working memory may be mechanisms of stimulant treatment response in ADHD. More work is necessary to evaluate the degree to which these findings generalize to chronic treatment, a broader array of clinical outcomes, and nonstimulant treatments.

Behavioral Observations of Parents With ADHD During Parent Training

OBJECTIVE

Several studies suggest that parental ADHD impedes behavioral parent training (BPT) outcomes. Parental ADHD symptoms exhibited during BPT may interfere with the acquisition of new skills. This study explored the observed behavior of parents with ADHD during BPT.

METHOD

Parents of children with ADHD attending group BPT completed self-ratings of their ADHD symptoms. Parents indicating a moderate level of ADHD symptoms were administered a clinical interview, and 37.3% of parents met ADHD criteria based on Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) clinician-rated symptom counts.

RESULTS

Parents with high ADHD symptoms displayed more total and off-task violations compared with parents with low ADHD symptoms, although no significant differences emerged for other behaviors (i.e., working quietly, using materials appropriately, and remaining in seat), absences, or tardiness.

CONCLUSION

Parental ADHD symptoms were manifested during BPT. Future research should clarify the nature of parental behavior in BPT as a possible mechanism explaining the relation between parental ADHD and impaired BPT outcomes.

Parent-Reported Improvements in Family Functioning in a Randomized Controlled Trial of Lisdexamfetamine for Treatment of Parental Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

This study examines the effects of parental stimulant medication treatment on parent ratings of parent-child functioning. Ratings of parent-child functioning in the home setting and immediately following a laboratory-based parent-child interaction were collected.

METHOD

Participants were 20 parents who along with their children (ages 5-12 years) were diagnosed with Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) attention-deficit/hyperactivity disorder (ADHD). Parents completed an open-label titration to determine their optimal dose of lisdexamfetamine (30, 50, or 70 mg/day) and then completed a month-long double-blind randomized pharmacological intervention for parental ADHD. Effects of parental stimulant medication administered for an extended duration were assessed by parent ratings of parent-child functioning in the home setting and immediately following a laboratory parent-child interaction task conducted at an academic mental health center. Data were collected from September 2010 to June 2013.

RESULTS

Stimulant medication versus placebo was associated with larger reductions in parental ADHD (d = 1.01-1.09), impairment (d = 0.67-0.82), and executive dysfunction (d = 0.74-0.94) in the home setting. No significant benefits of stimulant medication emerged in measures of parenting or child behavior at home. In the laboratory setting, parents treated with stimulant medication versus placebo reported fewer ADHD symptoms (d = 1.01-1.05) and their interaction was more successful (d = 0.83) and pleasant (d = 0.92). Several additional trends emerged showing beneficial effects of stimulant medication on parent-child functioning.

CONCLUSION

Parents treated with stimulant medication evidenced some improvements in parent-child functioning, which support the use of pharmacological intervention to improve functioning in families with parent-child ADHD.

CLINICAL TRIALS REGISTRATION

NCT01127607.

The association between Disruptive Mood Dysregulation Disorder symptoms and sleep problems in children with and without ADHD

BACKGROUND

Many youth experience persistent irritability and recurrent temper outbursts, conceptualized by DSM-5 as Disruptive Mood Dysregulation Disorder (DMDD). Sleep deprivation impairs emotion regulation which could increase rates of DMDD symptoms, especially in those with preexisting regulatory impairments, as seen with ADHD. However, there has been little examination of the relationship between chronic sleep problems and DMDD symptoms.

METHODS

Associations between DMDD symptoms and sleep parameters in children were assessed using parent-report and objective measures of sleep in a general population sample (N = 665) and an ADHD sample (N = 784). Irritability, temper outbursts, sleep problems and other psychological problems were assessed with the Pediatric Behavior Scale. The general population study also completed overnight polysomnography (PSG).

RESULTS

DMDD symptoms were reported in 9.2% of the community sample and 31.4% of the ADHD sample. In both samples, children with DMDD symptoms had significantly higher parent-reported sleep problems than children without DMDD symptoms. Children with sleep problems had significantly higher DMDD scores than children without sleep problems. However, DMDD symptoms were most strongly associated with oppositional behavior. Sleep problems were not a significant contributor. Hyperactivity-impulsivity was most strongly associated with sleep problems, and DMDD was not a significant contributor. Children with and without DMDD symptoms did not differ significantly on any PSG parameter.

CONCLUSIONS

Associations between parent-reported sleep problems and DMDD symptoms were due to their shared relationship with other behavioral problems. Therefore, chronic sleep problems do not appear to be a primary source of DMDD symptoms in children with or without ADHD.

Does Childhood Attention-Deficit/Hyperactivity Disorder (ADHD) Predict Levels of Depressive Symptoms during Emerging Adulthood?

Little is known about the development and course of depressive symptoms through emerging adulthood among individuals with a childhood history of attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to examine if a history of ADHD in childhood significantly predicted depressive symptoms during emerging adulthood (i.e., ages 18-25 years), including the initial level of depressive symptoms, continued levels of depressive symptoms at each age year, and the rate of change in depressive symptoms over time. 394 participants (205 with ADHD and 189 without ADHD; 348 males and 46 females) drawn from the Pittsburgh ADHD Longitudinal Study (PALS) completed annual self-ratings of depressive symptoms between the ages of 18 and 25 years. Childhood history of ADHD significantly predicted a higher initial level of depressive symptoms at age 18, and higher levels of depressive symptoms at every age year during emerging adulthood. ADHD did not significantly predict the rate of change in depressive symptoms from age 18 to age 25. Childhood history of ADHD remained a significant predictor of initial level of depressive symptoms at age 18 after controlling for comorbid psychiatric diagnoses, but not after controlling for concurrent ADHD symptoms and psychosocial impairment. Participants with childhood histories of ADHD experienced significantly higher levels of depressive symptoms than non-ADHD comparison participants by age 18 and continued to experience higher, although not increasing, levels of depressive symptoms through emerging adulthood. Clinical implications and directions for future research are discussed.

Reinforcement and Stimulant Medication Ameliorate Deficient Response Inhibition in Children with Attention-Deficit/Hyperactivity Disorder

This study examined the degree to which reinforcement, stimulant medication, and their combination impact response inhibition in children with Attention-Deficit/Hyperactivity Disorder (ADHD). Across three studies, participants with ADHD (n = 111, 25 girls) and typically-developing (TD) controls (n = 33, 6 girls) completed a standard version of the stop signal task (SST) and/or a reinforcement-manipulation SST with performance-contingent points. In two of these studies, these tasks were performed under placebo or 0.3 and 0.6 mg/kg methylphenidate (MPH) conditions. Cross-study comparisons were conducted to test hypotheses regarding the separate and combined effects of reinforcement and methylphenidate on response inhibition among children with ADHD relative to TD controls. Baseline response inhibition was worse among children with ADHD compared to controls. MPH produced dose-related improvements in response inhibition in children with ADHD; compared to non-medicated TD controls, 0.3 mg/kg MPH normalized deficient response inhibition, and 0.6 mg/kg MPH resulted in better inhibition in children with ADHD. Reinforcement improved response inhibition to a greater extent for children with ADHD than for TD children, normalizing response inhibition. The combination of MPH and reinforcement improved response inhibition among children with ADHD compared to reinforcement alone and MPH alone, also resulting in normalization of response inhibition despite repeated task exposure. Deficient response inhibition commonly observed in children with ADHD is significantly improved with MPH and/or reinforcement, normalizing inhibition relative to TD children tested under standard conditions.

Comparative Cost Analysis of Sequential, Adaptive, Behavioral, Pharmacological, and Combined Treatments for Childhood ADHD

We conducted a cost analysis of the behavioral, pharmacological, and combined interventions employed in a sequential, multiple assignment, randomized, and adaptive trial investigating the sequencing and enhancement of treatment for children with attention deficit hyperactivity disorder (ADHD; Pelham et al., 201X; N = 146, 76% male, 80% Caucasian). The quantity of resources expended on each child's treatment was determined from records that listed the type, date, location, persons present, and duration of all services provided. The inputs considered were the amount of physician time, clinician time, paraprofessional time, teacher time, parent time, medication, and gasoline. Quantities of these inputs were converted into costs in 2013 USD using national wage estimates from the Bureau of Labor Statistics, the prices of 30-day supplies of prescription drugs from the national Express Scripts service, and mean fuel prices from the Energy Information Administration. Beginning treatment with a low-dose/intensity regimen of behavior modification (large-group parent training) was less costly for a school year of treatment ($961) than beginning treatment with a low dose of stimulant medication ($1,669), regardless of whether the initial treatment was intensified with a higher "dose" or if the other modality was added. Outcome data from the parent study (Pelham et al., 201X) found equivalent or superior outcomes for treatments beginning with low-intensity behavior modification compared to intervention beginning with medication. Combined with the present analyses, these findings suggest that initiating treatment with behavior modification rather than medication is the more cost-effective option for children with ADHD.

The Effectiveness and Tolerability of Central Nervous System Stimulants in School-Age Children with Attention-Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder Across Home and School

OBJECTIVE

This study examines the effectiveness and tolerability of stimulants in children with attention-deficit/hyperactivity disorder (ADHD) and disruptive mood dysregulation disorder (DMDD).

METHODS

To be eligible, participants had to meet Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV) criteria for the combined subtype of ADHD and National Institute of Mental Health (NIMH) severe mood dysregulation criteria. The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V) DMDD criteria were retrospectively assessed after the study was completed. An open-label medication trial lasting up to 6 weeks was completed to optimize the central nervous system (CNS) stimulant dose. Measures of affective symptoms, ADHD symptoms and other disruptive behaviors, impairment, and structured side effect ratings were collected before and after the medication trial.

RESULTS

Optimization of stimulant medication was associated with a significant decline in depressive symptoms on the Childhood Depression Rating Score-Revised Scale (p<0.05, Cohen's d=0.61) and Mood Severity Index score (p<0.05, Cohen's d=0.55), but not in manic-like symptoms on the Young Mania Rating Scale. There was a significant reduction in ADHD (p<0.05, Cohen's d=0.95), oppositional defiant disorder (ODD) (p<0.05, Cohen's d=0.5), and conduct disorder (CD) symptoms (p<0.05, Cohen's d=0.65) as rated by parents. There was also a significant reduction in teacher-rated ADHD (p<0.05, Cohen's d=0.33) but not in ODD symptoms. Medications were well tolerated and there was no increase in side effect ratings seen with dose optimization. Significant improvement in functioning was reported by clinicians and parents (all p's<0.05), but youth still manifested appreciable impairment at end-point.

CONCLUSIONS

CNS simulants were well tolerated by children with ADHD comorbid with a diagnosis of DMDD. CNS stimulants were associated with clinically significant reductions in externalizing symptoms, along with smaller improvements in mood. However, most participants still exhibited significant impairment, suggesting that additional treatments may be needed to optimize functioning.

Treatment Sequencing for Childhood ADHD: A Multiple-Randomization Study of Adaptive Medication and Behavioral Interventions

Behavioral and pharmacological treatments for children with attention deficit/hyperactivity disorder (ADHD) were evaluated to address whether endpoint outcomes are better depending on which treatment is initiated first and, in case of insufficient response to initial treatment, whether increasing dose of initial treatment or adding the other treatment modality is superior. Children with ADHD (ages 5-12, N = 146, 76% male) were treated for 1 school year. Children were randomized to initiate treatment with low doses of either (a) behavioral parent training (8 group sessions) and brief teacher consultation to establish a Daily Report Card or (b) extended-release methylphenidate (equivalent to .15 mg/kg/dose bid). After 8 weeks or at later monthly intervals as necessary, insufficient responders were rerandomized to secondary interventions that either increased the dose/intensity of the initial treatment or added the other treatment modality, with adaptive adjustments monthly as needed to these secondary treatments. The group beginning with behavioral treatment displayed significantly lower rates of observed classroom rule violations (the primary outcome) at study endpoint and tended to have fewer out-of-class disciplinary events. Further, adding medication secondary to initial behavior modification resulted in better outcomes on the primary outcomes and parent/teacher ratings of oppositional behavior than adding behavior modification to initial medication. Normalization rates on teacher and parent ratings were generally high. Parents who began treatment with behavioral parent training had substantially better attendance than those assigned to receive training following medication. Beginning treatment with behavioral intervention produced better outcomes overall than beginning treatment with medication.

Disruptive mood dysregulation disorder: current insights

Disruptive mood dysregulation disorder (DMDD) was introduced as a new diagnostic entity under the category of depressive disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It was included in DSM-5 primarily to address concerns about the misdiagnosis and consequent overtreatment of bipolar disorder in children and adolescents. DMDD does provide a home for a large percentage of referred children with severe persistent irritability that did not fit well into any DSM, Fourth Edition (DSM-IV) diagnostic category. However, it has been a controversial addition to the DSM-5 due to lack of published validity studies, leading to questions about its validity as a distinct disorder. In this article, the authors discuss the diagnostic criteria, assessment, epidemiology, criticism of the diagnosis, and pathophysiology, as well as treatment and future directions for DMDD. They also review the literature on severe mood dysregulation, as described by the National Institute of Mental Health, as the scientific support for DMDD is based primarily on studies of severe mood dysregulation.

Impact of Attention-Deficit Hyperactivity Disorder on School Performance: What are the Effects of Medication?

Attention-deficit hyperactivity disorder (ADHD) affects an estimated 5-7 % of schoolchildren worldwide. School functioning and academic achievement are frequently impaired by ADHD and represent one of the main reasons children start ADHD medication. Multiple potential causal pathways exist between ADHD and impaired school performance. In this review, we decompose school performance into three components and assess the impact of ADHD and its treatments on academic performance (assessed by grade point average [GPA], time on-task, percentage of work completed as well as percent completed correctly), academic skills (as measured by achievement tests and cognitive measures), and academic enablers (such as study skills, motivation, engagement, classroom behavior and interpersonal skills). Most studies examined only the short-term effects of medication on school performance. In these, ADHD medications have been observed to improve some aspects of school performance, with the largest impact on measures of academic performance such as seatwork productivity and on-task performance. In a subset of children, these benefits may translate into detectable improvements in GPA and achievement testing. However, limited data exists to support whether these changes are sustained over years. Optimizing medication effects requires periodic reassessment of school performance, necessitating a collaborative effort involving patients, parents, school staff and prescribers. Even with systematic reassessment, behavioral-based treatments and additional school-based services may be needed to maximize academic performance for the many youth with ADHD and prominent impairments in school performance.

Reinforcement enhances vigilance among children with ADHD: comparisons to typically developing children and to the effects of methylphenidate

Sustained attention and reinforcement are posited as causal mechanisms in Attention-Deficit/Hyperactivity Disorder (ADHD), but their interaction has received little empirical study. In two studies, we examined the impact of performance-based reinforcement on sustained attention over time, or vigilance, among 9- to 12-year-old children. Study 1 demonstrated the expected vigilance deficit among children with ADHD (n = 25; 12% female) compared to typically developing (TD) controls (n = 33; 22% female) on a standard continuous performance task (CPT). During a subsequent visit, reinforcement improved attention more among children with ADHD than controls. Study 2 examined the separate and combined effects of reinforcement and acute methylphenidate (MPH) on CPT performance in children with ADHD (n = 19; 21% female). Both reinforcement and MPH enhanced overall target detection and attenuated the vigilance decrement that occurred in no-reinforcement, placebo condition. Cross-study comparisons suggested that the combination of MPH and reinforcement eliminated the vigilance deficit in children with ADHD, normalizing sustained attention. This work highlights the clinically and theoretically interesting intersection of reinforcement and sustained attention.

Effects of behavioral and pharmacological therapies on peer reinforcement of deviancy in children with ADHD-only, ADHD and conduct problems, and controls

OBJECTIVE

This study compared the unique and combined effects of evidence-based treatments for ADHD-stimulant medication and behavior modification-on children's rates of reinforcement for deviant peer behavior (RDPB).

METHOD

Using a within-subjects design, 222 elementary school-age children attending a summer treatment program, including 151 children with ADHD (127 male), with and without comorbid conduct problems, and 71 control children (57 male), received varying combinations of behavior modification (no, low-intensity, and high-intensity) and methylphenidate (placebo, 0.15 mg/kg, 0.30 mg/kg, and 0.60 mg/kg). RDPB was measured through direct observation and compared across all behavior modification and medication conditions.

RESULTS

Children with ADHD reinforced the deviant behavior of their peers at a significantly higher rate than control children in the absence of either intervention. However, that difference largely disappeared in the presence of both behavior modification and medication. Both low and high-intensity behavior modification, as well as medium (0.30 mg/kg) and high (0.60 mg/kg) doses of methylphenidate, significantly reduced the rate of ADHD children's RDPB to levels similar to the control group.

CONCLUSIONS

Results indicate that although untreated children with ADHD do engage in RDPB at a greater rate than their non-ADHD peers, existing evidence-based interventions can substantially decrease the presence of RDPB, thereby limiting potential iatrogenic effects in group-based treatment settings.

A pilot study of stimulant medication for adults with attention-deficit/hyperactivity disorder (ADHD) who are parents of adolescents with ADHD: the acute effects of stimulant medication on observed parent-adolescent interactions

OBJECTIVE

This study explores the use of stimulant medication for parents with attention-deficit/hyperactivity disorder (ADHD) who also have adolescents with ADHD.

METHODS

Five parents, diagnosed with ADHD, had their dose of lisdexamfetamine (LDX) titrated to optimal effect. Next, parents and their adolescents completed two interactions, once when parents were on placebo and once when parents were on optimal dose of LDX, to assess acute effects of parental medication on parenting during a neutral discussion (NeuDiss), a problem discussion (ProbDiss), and a homework task (HW).

RESULTS

Parents demonstrated a significant decrease in the ratio of commands to total verbalizations during the NeuDiss on LDX compared with placebo. Although no other statistically significant effects emerged at the p<0.05 level, moderate to large effects of medication on some aspects of parenting related to the amount and timing of speech (i.e., total verbalizations, total commands, ratio of commands to total verbalizations, and responsiveness) emerged and varied by task. Parental stimulant medication did not appear to impact the content of parents' speech (i.e., use of negative talk or praise).

CONCLUSIONS

These results add to a growing literature suggesting that treatment for parental ADHD may impact parenting performance, and suggest that attention to parental ADHD in treatment for adolescents with ADHD may possibly enhance family functioning.