Pharmacological and psychosocial treatments for adolescents with ADHD: An updated systematic review of the literature

Smith, Waschbusch, Willoughby, and Evans (2000) reviewed a small treatment literature on ADHD in adolescents and concluded that methylphenidate stimulant medication was a well-established treatment and behavior therapy (BT) demonstrated preliminary efficacy. This review extends and updates the findings of the prior one based on the previous 15 years of research. Studies published since 1999 were identified and coded using standard criteria and effect sizes were calculated where appropriate. Highlights of the last 15 years of research include an expansion of pharmacological treatment options and developmentally appropriate psychosocial treatment packages for adolescents with ADHD. Additionally, nonstimulant medications (e.g., atomoxetine) are now approved for the treatment of ADHD in adolescence. The review concludes that medication and BT produce a similar range of therapeutic effects on the symptoms of adolescents with ADHD. However, results suggest that BT may produce greater overall benefits on measures of impairment. There was no evidence that cognitive enhancement trainings, such as working memory training or neurofeedback improved the functioning of adolescents with ADHD. Whether to use medication, BT, or their combination to treat an adolescent with ADHD is complicated and we provide evidence-informed guidelines for treatment selection. The reviewed evidence does not support current American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry professional guidelines, which state that stimulant medication is the preferred treatment for adolescents with ADHD. Recommendations for assessment, practice guidelines, and future research are discussed.     

Aggressive, prosocial, and nonsocial behavior in hyperactive boys: dose effects of methylphenidate in naturalistic settings

Given the importance of interpersonal interactions for hyperactive children, we evaluated the impact of methylphenidate on specific categories of social behavior in 25 boys, aged 6-12, with attention deficit-hyperactivity disorder (ADHD). These children participated in a 3-week, double-blind, crossover trial with placebo and low (0.3 mg/kg) and moderate (0.6 mg/kg) dosages of methylphenidate during a naturalistic summer research program. Fifteen comparison boys, without problems in attention and behavior, were also observed. In addition to decreasing noncompliance, methylphenidate reduced a combined category of physical and verbal aggression for the ADHD boys, with a significant linear trend across dosages. The medication decreased aggression to levels comparable with those of the comparison boys. There were no medication effects on the frequency of nonsocial or prosocial behaviors. Results are discussed in light of the need to effect durable change in both the quantity and quality of social behavior for hyperactive children.     

Stress responsivity in children with externalizing behavior disorders

Patterns of lower autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) axis activity have been found in children with oppositional defiant disorder (ODD). The aim of the present study was to investigate whether children with attention-deficit/hyperactivity disorder (ADHD) differ from ODD children with (OD/AD) or without comorbid ADHD in ANS and HPA axis activity under baseline and stressful conditions. The effects of stress on cortisol, heart rate (HR), and skin conductance level (SCL) were studied in 95 children (26 normal control [NC] children and 69 child psychiatric patients referred for externalizing behavior problems [15 ODD, 31 OD/AD, and 23 ADHD]). No baseline differences were found in cortisol between the four groups. However, the ODD and OD/AD groups showed a significantly weaker cortisol response to stress compared to the ADHD and NC groups; the ADHD group had a similar cortisol response as the NC group. Within the ODD group this pattern of low cortisol responsivity was most clearly present in the more severely affected inpatients. With respect to HR, the ODD group had a significantly lower HR during baseline and stressful conditions. The higher HR levels in the OD/AD and ADHD groups were likely to be caused by methylphenidate. The externalizing groups had significantly lower SCL levels, and no differences were found between these groups. It was concluded that differences in cortisol responsivity during stress exposure are important in distinguishing within a group of children with externalizing behavior between those with ODD and ADHD.     

Executive functioning in children with attention-deficit/hyperactivity disorder: combined type with and without a stimulant medication history

Behavioral and neuropsychological functioning in unmedicated children with attention-deficit/hyperactivity disorder (ADHD) who have a history of medication treatment (Rx) versus those who are treatment na?ve (TN) has, to our knowledge, not been previously studied. Ninety-four children in four groups (ADHD/Rx, ADHD/TN, learning disabilities [LD], and controls) were evaluated, while unmedicated, on measures of achievement, neuropsychological functioning, and behavior. The ADHD/Rx group performed significantly better than the TN group on writing, Stroop interference, and measures of attention, and performed as well as the control group on executive functioning, verbal working memory, and academics. Behaviorally, the ADHD groups showed more difficulty with mood and externalizing behaviors compared with the LD and control groups, with the ADHD/TN performing the most poorly. Findings suggest that the ADHD/Rx group shows better executive and academic functioning even when unmedicated.     

Snoring, sleep quality, and sleepiness across attention-deficit/hyperactivity disorder subtypes

STUDY OBJECTIVES: To characterize the relationship between pediatric attention-deficit/hyperactivity disorder (ADHD) subtypes, chronic snoring, and indexes of sleep quality and daytime sleepiness. DESIGN: A cross-sectional design with planned comparisons of ADHD (all subtypes) versus general community controls; ADHD Predominantly Inattentive Type (ADHD-I) versus a group with both ADHD Predominantly Hyperactive/Impulsive Type (ADHD-HI) and ADHD Combined Type (ADHD-C); and ADHD-HI versus ADHD-C. SETTING: Subjects recruited from a pediatric clinic, a university psycholgy clinic, and the general community. PARTICIPANTS: Caretakers of 74 children (45 with ADHD, 29 community controls; 53 boys, 21 girls; mean age, 9.6 years; age range, 6 to 16 years). Thirty-two (71.1%) of the children with ADHD were taking stimulant medication and 7 (15.5%) were taking hypnotic medication. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Caretakers completed the Pediatric Sleep Questionnaire (PSQ) and the Children's Sleep-Wake Scale (CSWS). Only the ADHD-HI diagnosis was associated with an increased likelihood of chronic snoring. Sleep quality was poorer among children with ADHD than controls; however, there were no differences in sleep quality across ADHD subtypes. Sleepiness was greater in children with ADHD, especially the ADHD-I Type. CONCLUSIONS: Chronic snoring may be a correlated feature in only a subgroup of the ADHD population, possibly those more likely to be diagnosed with ADHD-HI. Although children with ADHD have poorer sleep quality and greater daytime sleepiness, these 2 features of ADHD are not closely related.     

Stimulant Medication and the Treatment of Aggression in Children With Attentional Deficits

Reviews evidence regarding the efficacy of stimulant medications in treating aggression and antisocial behavior in externalizing youngsters, particularly those with attention-deficit hyperactivity disorder (ADHD). Despite claims that stimulant medication is not efficacious with respect to aggression, recent investigations with behavioral observation methodologies in large-group settings have revealed clinically significant reductions of aggressive behavior with stimulant treatment. Furthermore, among youngsters with attentional problems, both aggressive and nonaggressive subgroups show a positive response to such medication. Discussion focuses on the need for multimodality interventions with externalizing children.     

Effects of medication, behavioral, and combined treatments on parents' and children's attributions for the behavior of children with attention-deficit hyperactivity disorder

Seventy-four mothers and 41 fathers and their 6 to 13 year old sons with attention-deficit hyperactivity disorder (ADHD) watched videos of child ADHD symptoms, compliance, and noncompliance. Participants were told either that the child was receiving medication, behavioral treatment, a combination of the two, or was not receiving treatment and were asked to rate the cause of the behavior. Parents attributed less control but greater stability to positive child behaviors when the child was receiving medication. However, for negative behaviors, medication increased attributions of control but diminished stability. With behavior management. compliance was seen as more external and stable and noncompliance as more controllable but less stable. For all treatments, boys reported increased control over ADHD symptoms and noncompliance. The implications of these treatment-related attributions for parenting and children's self-perceptions are discussed.     

A randomized controlled trial of cognitive therapy versus intensive behavior therapy in obsessive compulsive disorder

BACKGROUND: The study was designed to compare cognitive therapy (CT) with intensive behavior therapy (BT) in obsessive-compulsive disorder (OCD) and to study their change process. METHODS: Sixty-five outpatients with DSM-4 OCD were randomized into 2 groups for 16 weeks of individual treatment in 3 centers. Group 1 received 20 sessions of CT. Group 2 received a BT program of 20 h in two phases: 4 weeks of intensive treatment (16 h), and 12 weeks of maintenance sessions (4 h). No medication was prescribed. RESULTS: Sixty-two patients were evaluated at week 4, 60 at week 16 (post-test), 53 at week 26 and 48 at week 52 (follow-up). The response rate was similar in the 2 groups. The Beck Depression Inventory (BDI) was significantly more improved by CT (p = 0.001) at week 16. The baseline BDI and Obsessive Thoughts Checklist scores predicted a therapeutic response in CT, while the baseline BDI score predicted a response in BT. At week 16, only the changes in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and a scale measuring the interpretation of intrusive thoughts correlated in CT, while the changes in Y-BOCS, BDI, and interpretation of intrusive thoughts correlated in BT. Improvement was retained at follow-up without a between-group difference. The intent-to-treat analysis (last observation carried forward) found no between-group differences on obsessions, rituals and depression. CONCLUSIONS: CT and BT were equally effective on OCD, but at post-test CT had specific effects on depression which were stronger than those of BT. Pathways to improvement may be different in CT and BT. The outcomes are discussed in the light of an effect size analysis.     

重复经颅磁刺激联合认知行为训练治疗注意力缺陷伴多动障碍儿童的疗效

目的:观察重复经颅磁刺激(repetitive transcranial magnetic stimulation,rTMS)联合认知行为训练治疗注意力缺陷伴多动障碍(attention deficit hyperactivity disorder,ADHD)患儿的临床疗效.方法:60例ADHD患儿按随机数字表法分为对照组和实验组,每组30例.对照组常规采用认知行为治疗,实验组在采用认知行为训练基础上加用rTMS,治疗前后采用数字划消测试(Number Cancel Test,NCT)和Conners父母量表(Parents Symptom Questionnaire,PSQ)进行评估.结果:对照组治疗前后数字划消测试及Co n n e r s父母量表评分差异均有统计学意义(P<0.01),实验组治疗前后数字划消测试及Conners父母量表评分差异均有统计学意义(P<0.01).实验组与对照组治疗后数字划消测试划在对数、划漏数和净分三项评分差异亦均有统计学意义(均P<0.01),在Conners父母量表评分中学习问题和多动指数两项评分差异亦均有统计学意义(均P<0.05).结论:认知行为训练、rTMS联合认知行为训练治疗ADHD患者均有显著疗效.rTMS联合认知行为训练在治疗ADHD患者与单纯认知行为训练相比有疗效优势.     

The reliability, validity, and unique contributions of self-report by adolescents receiving treatment for attention-deficit/hyperactivity disorder

Participants were 36 adolescents diagnosed with attention-deficit/hyperactivity disorder (ADHD) who completed a summer treatment program. Self-report measures included the IOWA Conners Inattention/Overactivity and Oppositional/Defiant subscales, peer and staff interaction ratings, and a daily guess if the placebo or methylphenidate was given during a double-blind medication trial. Self-reports were reliable, and some of the self-report measures distinguished between placebo and methylphenidate conditions. However, the self-report measures exhibited weak correlations with observed frequencies of negative behavior and did not make a unique contribution beyond what was reported by adults. This study replicates previous findings that adolescents may be poor sources of information about ADHD symptoms, but adolescents receiving treatment for ADHD may be able to provide valid self-reports about negative social behavior.     

Neural Processing of Threat Cues in Young Children With Attention-Deficit/Hyperactivity Symptoms

A growing literature indicates that attention deficit/hyperactivity disorder (ADHD) involves difficulty processing threat-related emotion faces. This deficit is especially important to understand in young children, as threat emotion processing is related to the development of social skills and related behavioral regulation. Therefore, the current study aimed to better understand the neural basis of this processing in young children with ADHD symptoms. Forty-seven children between 4 and 7 years of age were included in the analysis, 28 typical developing and 19 with clinically significant levels of ADHD hyperactive/impulsive symptoms. Participants completed a passive affective face-viewing task. Event-related potentials were assessed for each emotion, and parental report of child behavior and emotion regulation abilities was assessed. Children with ADHD symptoms showed altered N170 modulation in response to specific emotion faces, such that the N170 was less negative in response to fearful compared to neutral faces, whereas typically developing children showed the opposite pattern. Groups did not differ in reactivity to anger or non-threat-related emotion faces. The N170 difference in fearful compared to neutral faces correlated with reported behavior, such that less fear reactivity predicted fewer prosocial behaviors. Abnormalities in the underlying neural systems for fear processing in young children with ADHD symptoms may play an important role in social and behavioral deficits within this population.     

Attention deficit hyperactivity disorder and sleep disturbances: consideration of parental influence

Parent report of sleep-related problems among children with attention deficit hyperactivity disorder (ADHD) is common and may stem from several different factors. This study examined the extent to which parental influence predicted sleep problems among 67 children, ages 5 to 12, meeting a research diagnosis of ADHD. The majority of parents/caregivers (73%) reported significant child sleep difficulties. Parental implementation of daily routines added to the explained variance in bedtime resistance after considering child and family characteristics (e.g., age, medication, and family income) but was not a significant predictor of sleep problems overall. Parenting stress was not a significant predictor of child sleep problems. Results suggest that implementation of consistent routines, especially those related to bedtime, may be a key factor in facilitating improved sleep among children who display behaviors consistent with ADHD.     

Upgrading the Science and Technology of Assessment and Diagnosis: Laboratory and Clinic-Based Assessment of Children With ADHD

Reviews the usefulness of clinic-based and laboratory-based instruments and paradigms for diagnosing attention deficit hyperactivity disorder (ADHD) and monitoring treatment effects. Extant literature examining the performance of normal children and those with ADHD on an extensive range of neurocognitive tests, tasks, and experimental paradigms indicates that particular types of instruments may be more reliable than others with respect to detecting between-group differences. We review task parameters that may distinguish the more reliable from less reliable instruments. The value of clinic-based and laboratory-based instruments for monitoring treatment response in children with ADHD is questionable when evaluated in the context of ecologically relevant variables such as classroom behavior and academic functioning. We present a general conceptual model to highlight conceptual issues relevant to designing clinic-based and laboratory-based instruments for the purposes of diagnosing and monitoring treatment effects in children with ADHD. Application of the model to currently conceptualized core variables indicates that attention and impulsivity-hyperactivity may represent correlative rather than core features of the disorder. We discuss implications of these findings for designing the next generation of clinic-based and laboratory-based instruments.     

Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents, 2016

The purpose of this study is to estimate the national prevalence of parent-reported attention deficit/hyperactivity disorder (ADHD) diagnosis and treatment among U.S. children 2–17 years of age using the 2016 National Survey of Children’s Health (NSCH). The NSCH is a nationally representative, cross-sectional survey of parents regarding their children’s health that underwent a redesign before the 2016 data collection. It included indicators of lifetime receipt of an ADHD diagnosis by a health care provider, whether the child currently had ADHD, and receipt of medication and behavioral treatment for ADHD. Weighted prevalence estimates were calculated overall and by demographic and clinical subgroups (n = 45,736). In 2016, an estimated 6.1 million U.S. children 2–17 years of age (9.4%) had ever received an ADHD diagnosis. Of these, 5.4 million currently had ADHD, which was 89.4% of children ever diagnosed with ADHD and 8.4% of all U.S. children 2–17 years of age. Of children with current ADHD, almost two thirds (62.0%) were taking medication and slightly less than half (46.7%) had received behavioral treatment for ADHD in the past year; nearly one fourth (23.0%) had received neither treatment. Similar to estimates from previous surveys, there is a large population of U.S. children and adolescents who have been diagnosed with ADHD by a health care provider. Many, but not all, of these children received treatment that appears to be consistent with professional guidelines, though the survey questions are limited in detail about specific treatment types received. The redesigned NSCH can be used to annually monitor diagnosis and treatment patterns for this highly prevalent and high-impact neurodevelopmental disorder.     

Treatment-related changes in objectively measured parenting behaviors in the multimodal treatment study of children with attention-deficit/hyperactivity disorder

The present study examined treatment outcomes for objectively measured parenting behavior in the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (ADHD). Five hundred seventy-nine ethnically and socioeconomically diverse children with ADHD-combined type (ages 7.0-9.9 years) and their parent(s) were recruited at 6 sites in the United States and Canada and randomly assigned to 1 of 4 treatment groups for 14 months of active intervention: medication management (MedMgt), intensive behavior therapy, combination of the 2 (Comb), or a community-treated comparison (CC). Baseline and posttreatment laboratory observations of parent-child interactions were coded by observers blind to treatment condition. Comb produced significantly greater improvements in constructive parenting than did MedMgt or CC, with effect sizes approaching medium for these contrasts. Treatment effects on child behaviors were not significant. The authors discuss the importance of changes in parenting behavior for families of children with ADHD and the need for reliable and objective measures in evaluating treatment outcome.     

Circadian motor activity affected by stimulant medication in children with attention‐deficit/hyperactivity disorder

Attention‐deficit/hyperactivity disorder (ADHD) is a highly prevalent disorder occurring in approximately 3–5% of school‐aged children. The core symptoms of ADHD are effectively treated with stimulant medications such as methylphenidate; however, there are also negative side effects, including insomnia. It has been suggested that administration of stimulant medication may alter the timing or regularity of circadian motor activity levels. This study aimed to investigate the impact of stimulant medication on the strength and timing of circadian rhythms in 16 stimulant medication‐naïve children with ADHD. Participants were monitored for changes in motor activity during a 3‐week blinded placebo‐controlled medication trial to examine the impact of immediate‐release methylphenidate hydrochloride. Motor activity was measured by actigraphy, and 24‐h activity profiles were analysed using cosinor analyses to identify measurable changes in circadian rhythms. The children in this sample demonstrated significant increases in motor activity during the sleep‐onset latency period. They also showed a significant reduction in relative circadian amplitude and a phase‐delay in the timing of the daily rhythm. Clinicians and parents of children being treated with stimulant medication for ADHD should be aware that stimulant medication may cause disruption of sleep/circadian rhythms. Behavioural strategies to improve sleep may be useful for children experiencing these negative effects from medication.     

Regional brain perfusion before and after treatment with methylphenidate may be associated with the G1287A polymorphism of the norepinephrine transporter gene in children with attention-deficit/hyperactivity disorder

The noradrenergic system modulates attention and arousal. Dysregulation of the noradrenergic system may be involved in the pathophysiology of attention-deficit/hyperactivity disorder (ADHD). This study intended to examine the differences in methylphenidate (MPH) treatment response and pre- and post-treatment cerebral perfusion associated with the G1287A and −3081(A/T) polymorphisms of the norepinephrine transporter (NET) gene in ADHD children. Thirty-seven drug-naïve ADHD children (8.9 ± 1.8 years old, M = 32, F = 5) were genotyped. Next, baseline single-photon emission computed tomography (SPECT) and clinical assessments were carried out for ADHD subjects. After 8 weeks of MPH treatment, SPECT and clinical assessment were repeated. There were no differences in baseline clinical assessments or cerebral perfusion based on genotype. However, after treatment, ADHD children with the G/G genotype at the G1287A polymorphism showed more improvement in symptoms than children without the G/G genotype as evaluated by the Clinical Global Impressions-Improvement scale (p = 0.022). Furthermore, ADHD children with the G/G genotype at the G1287A polymorphism showed hyperperfusion in the right inferior temporal gyrus (p < 0.001, uncorrected) and middle temporal gyrus (p = 0.001, uncorrected) compared to children without the G/G genotype. Although the results of this study should be interpreted cautiously, they suggest that polymorphisms of the NET gene may contribute to an intermediate phenotype. Further studies should clearly elucidate the relationship between treatment response and functional connectivity in the brain according to this genetic polymorphism.     

Methylphenidate improves deficient error evaluation in children with ADHD: an event-related brain potential study

Children with ADHD make more errors than control children in response-conflict tasks. To explore whether this is mediated by enhanced sensitivity to conflict or reduced error-processing, task-related brain activity (N2, Ne/ERN, Pe) was compared between 8- to 12-year-old children with ADHD and healthy controls during performance of a flanker task. Furthermore, effects of methylphenidate were investigated in ADHD children in a second study. ADHD children made more errors, especially in high-response-conflict conditions, without showing post-error slowing. N2 amplitudes were enhanced on trials resulting in an error response, Ne/ERN amplitude was unaffected and Pe amplitude was reduced in the ADHD group. Methylphenidate reduced errors in both low- and high-conflict conditions and normalized Pe amplitudes in children with ADHD. It was concluded that the inaccurate behaviour of ADHD children in conflict tasks might be related to reduced error-awareness and higher sensitivity to response conflict. Methylphenidate's ameliorating effects might be established through its influence on brain networks including posterior (parietal) cortex, enabling children with ADHD to allocate more attention to significant events.     

Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder

Despite the vast literature supporting the efficacy of stimulant medication in the treatment of attention-deficit/hyperactivity disorder (ADHD), several limitations of pharmacological treatments highlight the clear need for effective psychosocial treatments to be identified. A large evidence base exists for behavioral interventions, including parent training and school interventions, which has resulted in their classification as "empirically validated treatments." Additionally, social skills training with generalization components, intensive summer treatment programs, and educational interventions appear promising in the treatment of ADHD. Given the chronic impairment children with ADHD experience across multiple domains of functioning, multimodal treatments are typically necessary to normalize the behavior of these children. The state of the ADHD treatment literature is reviewed, important gaps are identified (e.g., treatment for adolescents), and directions for future research are outlined within a developmental psychopathology framework.     

Relation among marital conflict,child coping,and child adjustment

The goal of this study was to simultaneously examine maternal attributions, affect, and parenting in mothers of children with and without attention deficit hyperactivity disorder (ADHD) using a multimethod approach (vignettes, confederate child video clips, and video clips of mother's own child). Of the participants, 23 were 7- to 12-year-old children (19 boys, 4 girls) with ADHD and their mothers, and 29 were 7- to 12-year-old comparison children (21 boys, 8 girls) and their mothers. Results indicated that mothers of children with ADHD attributed inattentive-impulsive behavior to less controllable and intentional factors and reported more negative affect and power assertive parenting in response to it than comparison mothers. They also attributed this behavior to more internal factors than comparison mothers but only when viewing their own children and to more global/stable factors but only when viewing their own children or a confederate child. Interestingly, mothers of children with ADHD reported more positive parenting in response to prosocial behavior while attributing this behavior to less controllable and global/stable factors than comparison mothers; compliance also was seen as less controllable, global/stable, and intentional by mothers of children with ADHD.