Search

Objective: To Explore whether subtypes and comorbidities of attention-deficit hyperactivity disorder (ADHD) induce distinct biases in cognitive components involved in information processing. Method: Performance on the Integrated Visual and Auditory Continuous Performance Test (IVA-CPT) was compared between 150 children (aged 7 to 10) with ADHD, grouped by DSM-5 presentation (ADHD-C, ADHD-I) or co-morbid diagnoses (anxiety, oppositional defiant disorder [ODD], both, neither), and 60 children without ADHD. Diffusion decision modeling decomposed performance into cognitive components. Results: Children with ADHD had poorer information integration than controls. Children with ADHD-C were more sensitive to changes in presentation modality (auditory/visual) than those with ADHD-I and controls. Above and beyond these results, children with ADHD+anxiety+ODD had larger increases in response biases when targets became frequent than children with ADHD-only or with ADHD and one comorbidity. Conclusion: ADHD presentations and comorbidities have distinct cognitive characteristics quantifiable using DDM and IVA-CPT. We discuss implications for tailored cognitive-behavioral therapy.

Objective: Recent studies suggest attention-deficit/hyperactivity disorder (ADHD) may emerge post-childhood. We integrate qualitative methods to systematically characterize contextual factors that may (a) delay identification of ADHD in childhood and (b) inform why ADHD symptoms emerge post-childhood. Method: Suspected late-onset ADHD cases from the local normative comparison group of the Multimodal Treatment Study of ADHD completed a qualitative interview (14 young adults and 7 caregivers). Interviews were qualitatively analyzed. Results: We identified five themes. Three themes may attenuate or delay identification of childhood ADHD: external factors (e.g., supportive adults), internal factors (e.g., strong intellectual functioning), and other factors (e.g., dismissive attitudes toward ADHD). Two themes may accompany an increase in ADHD symptoms post-childhood: external factors (e.g., increased external demands) and internal factors (e.g., perceived stress). Conclusion: Clinicians should probe these factors in suspected late-onset cases to address (a) whether, how, and to what extent ADHD was attenuated in childhood and (b) why symptoms emerge post-childhood.

Objective: Qualitative interviews with 183 young adults (YA) in the follow-up of the Multimodal Treatment Study of Children With and Without ADHD (MTA) provide rich information on beliefs and expectations regarding ADHD, life’s turning points, medication use, and substance use (SU). Method: Participants from four MTA sites were sampled to include those with persistent and atypically high SU, and a local normative comparison group (LNCG). Respondents were encouraged to “tell their story” about their lives, using a semistructured conversational interview format. Results: Interviews were reliably coded for interview topics. ADHD youth more often desisted from SU because of seeing others going down wrong paths due to SU. Narratives revealed very diverse accounts and explanations for SU-ADHD influences. Conclusion: Qualitative methods captured the perspectives of YAs regarding using substances. This information is essential for improving resilience models in drug prevention and treatment programs and for treatment development for this at-risk population.

Objective: Although substance use (SU) is elevated in ADHD and both are associated with disrupted emotional functioning, little is known about how emotions and SU interact in ADHD. We used a mixed qualitative–quantitative approach to explore this relationship. Method: Narrative comments were coded for 67 persistent (50 ADHD, 17 local normative comparison group [LNCG]) and 25 desistent (20 ADHD, 5 LNCG) substance users from the Multimodal Treatment Study of Children with ADHD (MTA) adult follow-up (21.7-26.7 years-old). Results: SU persisters perceived SU positively affects emotional states and positive emotional effects outweigh negative effects. No ADHD group effects emerged. Qualitative analysis identified perceptions that cannabis enhanced positive mood for ADHD and LNCG SU persisters, and improved negative mood and ADHD for ADHD SU persisters. Conclusion: Perceptions about SU broadly and mood do not differentiate ADHD and non-ADHD SU persisters. However, perceptions that cannabis is therapeutic may inform ADHD-related risk for cannabis use.

Objective:To evaluate participants’ perceptions about frequent use and reasons for substance use (SU) in the qualitative interview study, an add-on to the multimodal treatment study of ADHD (MTA). Method: Using the longitudinal MTA database, 39 ADHD cases and 19 peers with Persistent SU, and 86 ADHD cases and 39 peers without Persistent SU were identified and recruited. In adulthood, an open-ended interview was administered, and SU excerpts were indexed and classified to create subtopics (frequent use and reasons for use of alcohol, marijuana, and other drugs). Results: For marijuana, the Persistent compared with Nonpersistent SU group had a significantly higher percentage of participants describing frequent use and giving reasons for use, and the ADHD group compared with the group of peers had a significantly higher percentage giving “stability” as a reason for use. Conclusion: Motivations for persistent marijuana use may differ for adults with and without a history of ADHD.

Objective: ADHD is associated with risky sexual behavior and early pregnancy, but few studies have examined mechanisms of risk linking childhood ADHD to early pregnancy. The present study utilized data from the Multimodal Treatment Study of ADHD to examine potential mechanisms that may account for the association between childhood ADHD and becoming pregnant or causing a pregnancy by age 18. Method: Participants were 579 children with ADHD and 289 comparison peers followed over 16 years. Results: Relative to the comparison group, those with childhood ADHD were at more than two times increased risk of early pregnancy. Univariately, persistence of ADHD symptoms, delinquency/substance use, and academic performance/achievement during adolescence each mediated the association between childhood ADHD and early pregnancy. When considered together, only delinquency/substance use remained a significant mediator of this relationship. Conclusion: Findings point toward specific targets of intervention for youth with ADHD to prevent early pregnancy.

Objective: Mothers raising a child with ADHD can experience high parenting stress. We evaluated if mothers’ personality traits and own ADHD symptoms could also affect parenting stress. Method: 430 biological mothers from the Multimodal Treatment Study of Children with ADHD (MTA mothers) and 237 of a local normative comparison group (LNCG mothers) were evaluated at baseline. Interactions were tested between mothers’ group and maternal personality/ADHD symptoms related to parenting stress. Results: Compared to LNCG, MTA mothers had higher parenting stress, self-reported ADHD, neuroticism, and lower conscientiousness and agreeableness. When personality and ADHD were evaluated together, ADHD symptoms interacted with mothers’ group: high maternal ADHD was positively associated with parenting stress for LNCG but not MTA mothers. Conclusion: Personality traits or ADHD characteristics do not appear operative for the high parenting stress of mothers of a child with ADHD. However, high maternal ADHD or low conscientiousness are associated with stress levels similar to raising a child with ADHD.

Objective: Preparing for a definitive randomized clinical trial (RCT) of neurofeedback (NF) for ADHD, this pilot trial explored feasibility of a double-blind, sham-controlled design and adherence/palatability/relative effect of two versus three treatments/week. Method: Unmedicated 6- to 12-year-olds with Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) ADHD were randomized to active NF versus sham-NF and to 2X versus 3X/week treatment frequency. Frequency switch was allowed after Treatment 24. Results: In two school years, 39 participants were recruited and 34 (87%) completed all 40 treatments. Child/parent guesses about assigned treatment were no better than chance. At Treatment 24, 38% chose 2X/week and 62% chose 3X/week. Both active NF and sham yielded large pre–post improvement on parent ratings but NF no more than sham. Conclusion: Blinding appears to work, and sham does not prevent recruitment/retention. Treatment frequency of 3X/week seems preferred over 2X/week and was as effective. A large double-blind RCT is feasible and necessary to test specific NF effectiveness.

Objective: Methylphenidate is a leading first-line treatment for ADHD (AD/HD). This stimulant has long been suspected to adversely affect sleeping patterns of treated individuals, especially children. There are few studies on the effects of recently developed longer-acting methylphenidate treatments, such as once-daily oral or transdermal formulations, on sleep. Method: The authors examined eight indices of sleep behavior among children treated with either of these two methylphenidate preparations or placebo in a randomized, double-blind, multicenter, parallel-group study. Results: The main predictor of sleep problems was baseline numbers or severity of preexisting sleep problems, whereas the different treatments and placebo varied little in their propensity to elicit such problems. There was no significant relationship between dosage and severity or frequency of sleep problems. Conclusion: The authors found little evidence that methylphenidate treatment (at least in sustained-release forms) was a significant cause of sleep problems in treated children who were carefully titrated to an optimal dose. (J. of Att. Dis. 2009; 12(4) 308-315)

Objective: To review and provide details about the primary and secondary findings from the Multimodal Treatment study of ADHD (MTA) published during the past decade as three sets of articles. Method: In the second of a two part article, we provide additional background and detail required by the complexity of the MTA to address confusion and controversy about the findings outlined in part I (the Executive Summary). Results: We present details about the gold standard used to produce scientific evidence, the randomized clinical trial (RCT), which we applied to evaluate the long-term effects of two well-established unimodal treatments, Medication Management (MedMGT) and behavior therapy (Beh), the multimodal combination (Comb), and treatment “as usual” in the community (CC). For each of the first three assessment points defined by RCT methods and included in intent-to-treat analyses, we discuss our definition of evidence from the MTA, interpretation of the serial presentations of findings at each assessment point with a different definition of long-term varying from weeks to years, and qualification of the interim conclusions about long-term effects of treatments for ADHD based on many exploratory analyses described in additional published articles. Conclusions: Using a question and answer format, we discuss the possible clinical relevance of the MTA and present some practical suggestions based on current knowledge and uncertainties facing families, clinicians, and investigators regarding the long-term use of stimulant medication and behavioral therapy in the treatment of children with ADHD. (J. of Att. Dis. 2008; 12(1) 15-43)

Objective: This research evaluates effects of vestibular stimulation by Comprehensive Motion Apparatus (CMA) in ADHD. Method: Children ages 6 to 12 (48 boys, 5 girls) with ADHD were randomized to thrice-weekly 30-min treatments for 12 weeks with CMA, stimulating otoliths and semicircular canals, or a single-blind control of equal duration and intensity, each treatment followed by a 20-min typing tutorial. Results: In intent-to-treat analysis ( n = 50), primary outcome improved significantly in both groups ( p = .0001, d = 1.09 to 1.30), but treatment difference not significant ( p = .7). Control children regressed by follow-up (difference p = .034, d = 0.65), but overall difference was not significant ( p = .13, d = .47). No measure showed significant treatment differences at treatment end, but one did at follow-up. Children with IQ-achievement discrepancy ≥ 1 SD showed significantly more CMA advantage on three measures. Conclusion: This study illustrates the importance of a credible control condition of equal duration and intensity in trials of novel treatments. CMA treatment cannot be recommended for combined-type ADHD without learning disorder. (J. of Att. Dis. 2008; 11(5) 599-611)

Objective: This study investigated behavioral and emotional characteristics of children with convergence insufficiency (CI), before and after treatment with office-based vergence accommodative therapy (OBVAT). Method: Parents of 44 children ages 9 to 17 years with symptomatic CI completed the Conners 3 ADHD Index and the Child Behavior Checklist (CBCL) before and after OBVAT. Pre-treatment scores were compared with normative data and post-treatment scores were compared with baseline using the Wilcoxon sign rank test. Results: Following OBVAT, CI children showed a significant mean improvement ( p < .0001, effect size of 0.58) on the Conners 3 ADHD Index with the largest changes occurring in the 23 children who scored the highest at baseline. On the CBCL, anxious/depressed, somatic, and internalizing problems improved significantly ( p < .001, effect sizes of −0.36, −1.15, and −0.67, respectively). Conclusion: In an open trial, attention and internalizing problems improved significantly following treatment for CI.

Objective: This study extends previous research and examined if the longitudinal relation between self-perceived social acceptance and changes in adjustment was moderated by peer status and ADHD diagnosis. Method: A sample of children with ADHD and a normative comparison group (age 8-13 years) were assessed at baseline and one-year follow-up. Self-perceived social acceptance, peer status, and three areas of adjustment (depression symptoms, aggression/conduct problems, and social skills) were measured. Results: Moderation was found when predicting depression symptoms and aggression/conduct problems. Specifically, in children with ADHD only, higher perceived social acceptance protected against increases in depression symptoms for those with lower peer preference, but predicted greater aggression/conduct problems for those with higher peer preference. There was not evidence of significant moderation for predicting social skills; instead non-ADHD status, greater peer preference, and greater self-perceived social acceptance were each predictive of greater social skills. Conclusion: Results highlight the complex association between positive social self-perceptions and adjustment for children with ADHD and caution against a universal assumption that high self-perceptions are adaptive.

Objective: The aim of this paper was to review all randomized published trials and unpublished conference presentations on the neurofeedback (NF) treatment of pediatric ADHD, and their relevance, strengths, and limitations. Method: Via PsychInfo and Medline searches and contacts with NF researchers 14 studies were identified and reviewed. Results: The majority were conducted from 1994 to 2010, with 5- to 15-year-olds, usually male and White with the combined type of ADHD. Most studies used theta/beta NF with a unipolar-electrode placement at Cz and demonstrated, where reported, an overall ADHD mean effect size of d = 0.69, a medium effect. Main study strengths, within some studies, include use of randomization, treatment control conditions, Diagnostic and Statistical Manual of Mental Disorders criteria, evidence-based assessment of ADHD, standard treatment outcome measures, multidomain assessment, and, for some studies, moderate sample size, some type of blind and the identification of medication as a concomitant treatment. Main study limitations (and directions for future research) include the lack of adequate blinding of participants, raters and NF trainers, a sham-NF/blinded control treatment condition, posttreatment follow-up, generalizability, specific details about delivery of NF, identification and control of comorbidity, and the identification, measurement, and control of concomitant treatments and potential side effects. Conclusion: Based on the results and methodologies of published studies, this review concludes that NF for pediatric ADHD can be currently considered as “probably efficacious.”

The vast parenting literature has shown differences in parenting practices across different ethnicities. However, parenting practices of parents of children with Attention-Deficit/Hyperactivity Disorder (ADHD) have primarily been studied in Caucasian middle-class families. Given that modifying parenting practices is often a primary target for psychosocial intervention for children with ADHD, ethnic differences in parenting may moderate treatment outcomes. Utilizing observations of 567 children with ADHD (ages 7–9) and their caregivers collected during the Multimodal Treatment Study of ADHD (MTA), the present study examined ethnic differences in observed parenting and child behavior at baseline and the moderating effects of ethnicity on the relationship between treatment and parenting and child behavior. The four MTA treatments were medication management, behavior therapy, combined medication management + behavior therapy, and community care. Baseline results indicated that both parenting practices and child behavior differed by ethnicity. However, ethnicity did not moderate the relationship between treatment and parenting and child behavior. Hence, children from different ethnicities did not differentially benefit from one treatment over another on observed ratings of parenting or child behavior. Implications for clinical care and future research are discussed.

Objective: To review the primary and secondary findings from the Multimodal Treatment study of ADHD (MTA) published over the past decade as three sets of articles. Method: In a two-part article—Part I: Executive Summary (without distracting details) and Part II: Supporting Details (with additional background and detail required by the complexity of the MTA)—we address confusion and controversy about the findings. Results: We discuss the basic features of the gold standard used to produce scientific evidence, the randomized clinical trial, for which was used to contrast four treatment conditions: medication management alone (MedMgt), behavior therapy alone (Beh), the combination of these two (Comb), and a community comparison of treatment “as usual” (CC). For each of the three assessment points we review three areas that we believe are important for appreciation of the findings: definition of evidence from the MTA, interpretation of the serial presentations of findings at each assessment point with a different definition of long-term, and qualification of the interim conclusions about long-term effects of treatments for ADHD. Conclusion: We discuss the possible clinical relevance of the MTA and present some practical suggestions based on current knowledge and uncertainties facing families, clinicians, and investigators regarding the long-term use of stimulant medication and behavioral therapy in the treatment of children with ADHD. (J. of Att. Dis. 2008; 12(1) 4-14)

Objective: Impaired peer relationships have long been recognized as one of the major functional problems of children with ADHD, but no specific guidelines on clinical levels of impairment in this domain exist. Method: This study used Receiver Operating Characteristics methodology to determine what aspects of peer functioning best discriminate between children with ADHD and their classmates. Optimal cutoffs indicative of clinical levels of impairment associated with ADHD diagnosis were determined for all variables. The participants were 165 children with AD/HD who were part of the Multimodal Treatment Study of Children With ADHD and their 1,298 classmates. Results: Variables that best discriminated between children with ADHD and their classmates included peer rejection and negative imbalance between given and received liking ratings (i.e., children with ADHD liked others more than they were liked). Conclusion: Peer rejection and negative imbalance show most promise for identifying clinically significant levels of peer relationship impairment in children with ADHD. (J. of Att. Dis. 2009; 12(4) 372-380)