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Sluggish cognitive tempo (SCT) and daytime sleepiness are both common in individuals with attention-deficit/hyperactivity disorder (ADHD). There appears to be considerable overlap between the tired and lethargic aspects of SCT and behaviors frequently exhibited by individuals with daytime sleepiness. However, no studies have examined the degree to which these constructs overlap and whether or not they are empirically distinct. In Study 1, a confirmatory factor analysis with the SCT subscale of the Barkley Adult ADHD Rating Scale-IV (BAARS-IV) and the Epworth Sleepiness Scale (ESS) was conducted in a sample of 768 college students. Results demonstrated that SCT and daytime sleepiness exhibit considerable overlap but are empirically distinct. In Study 2, we examined the relation between SCT and daytime sleepiness and also the impact of comorbid SCT and sleepiness on the functioning of 58 college students rigorously diagnosed with ADHD. Regression analyses in both Study 1 and Study 2 showed that SCT predicts daytime sleepiness above and beyond symptoms of ADHD, anxiety, and depression. The 2 constructs were significantly related (r = .51), with the highest correlations occurring between the SCT tired and lethargic items with daytime sleepiness. College students with ADHD + SCT and daytime sleepiness were significantly more impaired than college students diagnosed with ADHD without SCT or daytime sleepiness. Together, these results fill an important gap in the literature by confirming SCT to be overlapping but empirically distinct from daytime sleepiness and demonstrating that SCT and daytime sleepiness are associated with functioning in college students with ADHD.

Objectives The purposes of the present studies were to (a) examine the factor structure of sluggish cognitive tempo (SCT) and attention-deficit/hyperactivity disorder (ADHD) in college students and (b) examine the associations between SCT and academic functioning and internalizing symptoms in college students with and without ADHD. Method In Study 1, a confirmatory factor analysis of the Barkley Adult ADHD Rating Scale-IV (BAARS-IV) was conducted in a sample of 768 college students (aged 17–34 years, 68% female). In Study 2, we examined the relation of SCT to academic functioning and internalizing symptoms in a sample of 72 college students rigorously diagnosed with ADHD (aged 17–35 years, 44% female). Results Study 1 results supported the factor structure of the BAARS-IV, with the optimal model comprising 4 correlated but distinct factors: SCT, Inattention, Hyperactivity, and Impulsivity. After controlling for correlated demographic variables and ADHD symptoms, SCT was significantly related to academic impairment (including grade point average), anxiety, and depression. In Study 2, SCT again contributed unique variance to internalizing symptoms and academic impairment after controlling for correlated participant characteristics (i.e., sex, age, race, parent education level, family income, ADHD medication use, and mental health service utilization) and ADHD symptom severity. Conclusions These results fill an important gap in the literature by (a) confirming SCT to be distinct from ADHD in emerging adulthood, (b) demonstrating SCT to be strongly linked to college student adjustment, and (c) providing support for the hypothesis that SCT is associated with psychosocial functioning in both individuals with and without ADHD.

The purpose of the study was to evaluate the relation between ratings of Executive Function (EF) and academic functioning in a sample of 94 middle-school-aged youth with Attention-Deficit/Hyperactivity Disorder (ADHD; Mage = 11.9; 78 % male; 21 % minority). This study builds on prior work by evaluating associations between multiple specific aspects of EF (e.g., working memory, inhibition, and planning and organization) as rated by both parents and teachers on the Behavior Rating Inventory of Executive Function (BRIEF), with multiple academic outcomes, including school grades and homework problems. Further, this study examined the relationship between EF and academic outcomes above and beyond ADHD symptoms and controlled for a number of potentially important covariates, including intelligence and achievement scores. The EF Planning and Organization subscale as rated by both parents and teachers predicted school grades above and beyond symptoms of ADHD and relevant covariates. Parent ratings of youth's ability to transition effectively between tasks/situations (Shift subscale) also predicted school grades. Parent-rated symptoms of inattention, hyperactivity/impulsivity, and planning and organization abilities were significant in the final model predicting homework problems. In contrast, only symptoms of inattention and the Organization of Materials subscale from the BRIEF were significant in the teacher model predicting homework problems. Organization and planning abilities are highly important aspects academic functioning for middle-school-aged youth with ADHD. Implications of these findings for the measurement of EF, and organization and planning abilities in particular, are discussed along with potential implications for intervention.

Objective: This study examined the feasibility and effectiveness of a behavioral parent training (BPT) group intervention implemented in an outpatient mental health setting in reducing child impairments and increasing parenting confidence in managing child behavior. Method: Parents of 241 children with ADHD participated in the eight-session parent group program, completing the Impairment Rating Scale (IRS) and a measure of parenting confidence at the first and last session. Results: Parents reported improvements in child behavior across all domains of the IRS, with the largest improvements in terms of overall impairment, parent–child relationship, and impact of child behavior on the family. Parents also reported increased confidence in managing their child’s behavior. Conclusion: These findings suggest that brief BPT group programs administered to a diverse range of attendees in a typical outpatient setting result in improvements in functional impairments comparable with those produced in controlled studies, as well as improved parenting confidence.

Objective: The primary objective of this study was to evaluate the prevalence of multiple types of sleep problems in young adolescents with ADHD. Method: Adolescents comprehensively diagnosed with ADHD (N = 262) and their caregivers completed well-validated measures of sleep problems and daytime sleepiness. Participants also completed measures related to medication use, comorbidities, and other factors that could predict sleep problems. Results: Daytime sleepiness was by far the most common sleep problem, with 37% of adolescents meeting the clinical threshold according to parent report and 42% according to adolescent report. In contrast, prevalence rates for specific nighttime sleep problems ranged from 1.5% to 7.6%. Time spent in bed, bedtime resistance, ADHD inattentive symptoms, and Sluggish Cognitive Tempo (SCT) symptoms were significant in the final model predicting daytime sleepiness. Conclusion: Adolescents with ADHD commonly experience problems with daytime sleepiness that may significantly affect their functioning, but this may not be directly attributable to specific sleep problems.

Sleep disturbances are significantly more common in youth with ADHD in comparison to youth without ADHD (Owens, 2009). Estimated prevalence rates for sleep disturbances in youth with ADHD range from 25 – 50% (Sung et al., 2008; Yoon et al., 2012). The most commonly cited sleep difficulties in youth with ADHD include problems with sleep latency, bedtime resistance, and daytime sleepiness (Chaing et al., 2010; Hvolby et al., 2009; Wiebe, et al., 2012). Importantly, significantly higher levels of sleep disturbance have been documented in youth with ADHD not taking psychotropic medications (Cohen-Zion & Ancoli-Israel, 2004; Stein, Weiss, & Hlavaty, 2012), suggesting that the high prevalence of sleep problems in this population is not simply an artifact of stimulant medication use. Although it is clear that youth with ADHD experience higher than expected rates of sleep disturbances, it is unknown whether these disturbances result in increased functional impairment. One domain where the clinical implications of sleep disturbances are particularly relevant is academic functioning. In non-ADHD samples, sleep disturbances are associated with worse cognitive performance, higher rates of internalizing and externalizing behavior problems (Astill et al., 2012), and impairment in academic functioning (Drake et al., 2003; Perez-Chada et al., 2007). Youth with ADHD exhibit considerable impairment with academic performance and achievement, including significantly lower school grades and achievement scores in comparison to their same-aged peers (Frazier et al., 2007). Interestingly, the mechanisms thought to underlie the academic impairments of youth with ADHD, namely inattention and deficits in executive function, are very similar to the deficits thought to lead to poor school performance in youth with sleep disturbances (Beebe, 2011). Specifically, both symptoms of inattention (Langberg et al., 2011) and deficits in executive function (Miller, Nevado-Montenegro, & Hinshaw, 2012) have been shown to predict the academic achievement of youth with ADHD. Despite these similarities, almost no research has been conducted examining whether sleep disturbances predict academic functioning in samples of youth with ADHD above and beyond symptoms of inattention. Mayes and colleagues (2008) evaluated the relative impact of ADHD symptoms, sleep, IQ, and neuropsychological functioning on academic achievement in a sample of 412 elementary-age children. In this study, children were not formally evaluated for ADHD however; parent ratings of ADHD symptoms were collected. Sleep was measured using scores generated from a full-night polysomnography (e.g. sleep latency, sleep efficiency, awakenings) and also with subscale scores from the parent-rated Pediatric Behavior Scale (PBS; e.g., difficulty falling asleep, daytime sleepiness, parasomnias). The authors reported that objective (i.e. polysomnography) and subjective (i.e. rating scale) measures of sleep were not significant in the final models predicting math and reading achievement. Intelligence, ADHD symptom ratings and neuropsychological task performance were associated with achievement, with IQ being the single best predictor (Mayes et al., 2008). In theMayes et al. (2008) study, academic functioning was defined as performance on a standardized achievement test, and the relationship between sleep and achievement was examined in an elementary school age sample. It has been argued that sleep problems are less likely to be detrimental to performance on standardized achievement tests because these tests are administered in one-to-one, controlled environments, where test administrators work to minimize the impact of inattention and to promote motivation (Beebe et al., 2010). Further, the middle childhood period is particularly important for the study of sleep disturbances given that adolescents have more autonomy over sleep behaviors and often have greater sleep restriction on school nights and report higher rates of daytime sleepiness (Beebe, 2011; Drake et al., 2003). Accordingly, it has been suggested that additional research is needed with adolescent samples, and that future research focus on the impact of sleep disturbances on school grades and parent- and teacher-rated academic performance, which are more likely to be impacted by daytime sleepiness (Beebe, 2011). Measurement of daytime sleepiness is considered particularly important because assessment of sleep problems (e.g. parasomnias and sleep-disordered breathing), and hours slept per night, does not fully account for problems with daytime sleepiness (Drake et al., 2003) and therefore, may not entirely capture associated problems with academic functioning (Carskadon et al., 1998; Owens et al., 2000). As such, the goal of this paper was to examine the relative contribution of hours slept per night and daytime sleepiness to the academic functioning of adolescents with ADHD. We hypothesized that sleep disturbances would have a detrimental impact on school grades and ratings of academic performance above and beyond symptoms of ADHD and relevant demographic variables.

Previous research has failed to find a consistent relation between Sluggish Cognitive Tempo (SCT) and executive function (EF) in youth with Attention-Deficit/Hyperactivity Disorder (ADHD) when laboratory-based neuropsychological tasks of EF are used, whereas recent research with youth and adults suggests a significant relation between SCT and ratings of EF. The purpose of this study was to examine ADHD dimensions and SCT symptoms in relation to ratings of EF in adolescents with ADHD. Fifty-two adolescents (ages 12-16; 70 % male) participated in this study. Parents and teachers completed validated measures of SCT, ADHD symptoms, and EF in daily life. Adolescents' intelligence and academic achievement were also assessed. ADHD and SCT symptoms were significantly correlated with ratings of EF. Regression analyses demonstrated that, as hypothesized, ADHD hyperactive-impulsive symptoms were strongly associated with behavioral regulation EF deficits, with ADHD inattentive and SCT symptoms unrelated to behavioral regulation EF when hyperactive-impulsivity symptoms were included in the model. The parent-reported SCT Slow scale measuring motivation, initiative, and apathy predicted both parent- and teacher-reported metacognitive EF deficits above and beyond youth characteristics and ADHD symptoms. In contrast, teacher-reported ADHD inattention was most clearly associated with teacher-reported metacognitive EF deficits. This study provides preliminary evidence for the importance of SCT symptoms in relation to metacognitive EF deficits among adolescents with ADHD and the need to further investigate the overlap and distinctiveness of SCT/ADHD. Further research is needed to replicate and extend these findings.

Attention Deficit Hyperactivity Disorder (ADHD)-related deficits in working memory, attention, and inhibitory control have been well documented on neuropsychological tests (see Hervey et al., 2004 & Willcutt et al., 2005 for meta-analytic reviews). In addition to these cognitive deficits, children with ADHD have higher levels of intra-individual variability in reaction times than typically-developing children (De Zeeuw et al., 2008; Epstein et al., 2011a; Klein, Wendling, Huettner, Ruder, & Peper, 2006; Vaurio, Simmonds, & Mostofsky, 2009). Researchers have proposed that reaction time (RT) variability may be a potential endophenotype for ADHD (Castellanos & Tannock, 2002), particularly since heritability of RT variability is high (Kuntsi & Stevenson, 2001; Andreou et al., 2007). Most studies have demonstrated increased RT variability using RT standard deviation (RTSD). However, more recent studies have used ex-Gaussian estimates and fast Fourier transform analyses to demonstrate that children with ADHD are not consistently slower or always more variable than typical children, but that children with ADHD tend to exhibit intermittent long reaction times during task performance (Hervey et al., 2006; Leth-Steensen, Elbaz, & Douglas, 2000; Vaurio et al., 2009). In addition, these instances of long reaction times in children with ADHD may be predictably periodic (Castellanos et al., 2005; Johnson et al., 2007; Vaurio et al., 2009). Although these analyses help to better describe the patterns of RT variability among children with ADHD, it remains unclear what these intermittent periods of long reaction times signify (Tamm et al., 2012). Multiple hypotheses exist postulating what RT variability represents in children with ADHD, including slower cognitive processing, deviant time perception (Kalff et al., 2005) and problems with state regulation (Sergeant, 2005). Several investigators have also posited that periods of long reaction times are indicative of lapses in attention (Leth-Steensen et al., 2000; Hervey et al., 2006), although this remains unsubstantiated. In an attempt to better understand RT variability, researchers have begun to examine its behavioral correlates. For example, does RT variability relate specifically to inattention? Studies examining differences between children with ADHD-Combined Type and children with ADHD-Predominantly Inattentive Type have shown that both groups have slower mean reaction times and greater RT variability than control groups, but have not indicated substantial differences between the two subtypes (Epstein et al., 2011a; Nigg, Blaskey, Huang-Pollock, & Rappley, 2002; Pasini, Paloscia, Alessandrelli, Porfirio, & Curatolo, 2007, Solanto et al., 2007). Correlational studies examining associations between RT variability and parent- and teacher-reported ADHD symptom domains have found that RT variability is related to composite scores of inattention more so than to hyperactivity/impulsivity (Nigg, 1999; Wahlstedt, 2009). However, a study examining relations between RT variability and individual ADHD symptoms found that RT variability was related to specific symptoms in both ADHD symptom domains (Epstein et al., 2003). Examining behavioral correlates of RT variability using parent- or teacher reports of ADHD behaviors may be limited as behavioral ratings provide general summaries of behavior over an extended period of time (e.g., last week) rather than temporally-specific, moment-by-moment, information about behavioral variability. Observational methods with temporal coding of inattentive behavior may better relate to RT variability than parent or teacher ratings. Indeed, using behavioral observations, children with ADHD exhibit more off-task behavior than controls (see Kofler, Rapport, & Alderson, 2008 for a meta-analytic review). Further, children with ADHD appear to exhibit greater within-subject variability in their off-task behavior than controls (Abikoff, Gittelman-Klein, & Klein, 1977; Lauth, Heubeck, & Mackowiak, 2006; Kofler et al., 2008). Using a continuous coding strategy, Rapport, Kofler, Alderson, Timko, and DuPaul (2009) found that compared with controls, children with ADHD stay on-task for shorter periods of time and exhibit greater variability in visual attention during academic assignment completion in the classroom. There is a limited literature examining relations between continuously observed ADHD behavior and neuropsychological indicators (Weis & Totten, 2004; Solanto et al., 2001). No study to date has examined neuropsychological-behavioral relations using RT variability as a neuropsychological indicator. Given the magnitude of between-group differences on RT variability outcomes (Epstein et al., 2011a) and the supposition that RT variability may be indicative of attentional lapses (Hervey et al., 2006; Leth-Steenson, et al., 2000), an examination of the behavioral correlates of RT variability using continuous behavioral observations provides the opportunity to increase our understanding of RT variability. The current study sought to build on the results reported by Epstein et al. (2011a). In this study, children with and without ADHD completed five computerized tasks, which tapped into various aspects of executive functioning. Analyses focused on group differences for a variety of reaction time performance indicators from these five tasks. Results indicated that children with ADHD had greater values of Ex-gaussian tau and the coefficient of variation (RTSD ÷ RT mean) than controls across all five tasks. In addition, group differences in accuracy were found on some of the tasks. No group differences were found for mu or sigma on any of the tasks (all ps ≤ .05). Along with completing the computerized tasks, participants also completed a math test, during which they were video-recorded. examined the relationship between indicators of RT variability on five neuropsychological tests and on-task behavior during an analogue math task among children with and without ADHD. We also included additional alternative neuropsychological indicators in order to examine whether the relationship between neuropsychological functioning and observed behavior was specific to RT variability.

Adolescents with Sluggish Cognitive Tempo (SCT) exhibit symptoms of slowness, mental confusion, excessive daydreaming, low motivation, and drowsiness/sleepiness. Although many symptoms of SCT reflect internalizing states, no study has evaluated the clinical utility of self-report of SCT in an attention-deficit/hyperactivity disorder (ADHD) sample. Furthermore, it remains unclear whether SCT is best conceptualized as a unidimensional or multidimensional construct. In a sample of 262 adolescents comprehensively diagnosed with ADHD, the present study used adolescent- and parent reports of SCT to evaluate the predictive utility of a general SCT factor from a bifactor modeling approach compared the utility of three specific SCT factors (slow, sleepy, and daydreamer) for predicting academic impairment and internalizing psychopathology. Overall, a multidimensional framework of SCT was supported, with the three SCT factors differentially predicting impairment and in one case (school grades), predicting impairment when the general factor did not. Consistent with prior research, SCT slow behaviors appear to be most strongly associated with impairment, predicting both academic impairment and internalizing psychopathology. Parent report of SCT was most useful for predicting academic functioning, whereas youth self-report was important for predicting anxiety and depression. Implications of the findings for the assessment and potential treatment of SCT are discussed.

BACKGROUND: The quality of care for children with attention-deficit/hyperactivity disorder (ADHD) delivered in community-based pediatric settings is often poor. Interventions have been developed to improve community-based ADHD care but have not demonstrated that better care results in improved patient outcomes. The objective of this study was to determine whether an ADHD quality improvement (QI) intervention for community-based pediatric practices improves patient outcomes. METHODS: A cluster randomized controlled trial was conducted in which 50 community-based pediatric primary care practices (213 providers) were randomized either to receive a technology-assisted QI intervention or to a control condition. The intervention consisted of 4 training sessions, office flow modification, guided QI, and an ADHD Internet portal to assist with treatment monitoring. ADHD treatment processes and parent- and teacher-rated ADHD symptoms over the first year of treatment were collected for 577 patients. RESULTS: Intent-to-treat analyses examining outcomes of all children assessed for ADHD were not significant (b = –1.97, P = .08). However, among the 373 children prescribed ADHD medication, there was a significant intervention effect (b = –2.42, P = .04) indicating greater reductions in parent ratings of ADHD symptoms after treatment among patients treated by intervention physicians compared with patients treated at control practices. There were no group differences on teacher ratings of ADHD symptoms. ADHD treatment care around medication was significantly better at intervention practices compared with control practices. CONCLUSIONS: A technology-assisted QI intervention improved some ADHD care quality and resulted in additional reductions in parent-rated ADHD symptoms among patients prescribed ADHD medications.

The primary goals of this study were to evaluate the dimensionality of the Penny et al. Sluggish Cognitive Tempo Scale and to compare model fits for parent- and youth self-report versions. Participants were 262 young adolescents (ages 10-15) comprehensively diagnosed with attention-deficit/hyperactivity disorder. Both confirmatory factor analysis (CFA) and bifactor modeling were used to determine if the proposed three-factor structure previously identified through exploratory factor analysis could be confirmed. Results showed that although the three-factor CFA had better fit statistics than a one- or two-factor CFA, the bifactor model was the best-fitting model for both parent report and self-report. This implies that Sluggish Cognitive Tempo Scale is best conceptualized as having an underlying general factor, with three specific factors that may represent different etiologies. Importantly, results also showed low-to-moderate correlations between raters and equivalent or better fit statistics for self-report in comparison with parent report.

The purposes of the present study were to: (1) describe rates of peer victimization in young adolescents with attention-deficit/hyperactivity disorder, (2) evaluate the association between types of peer victimization (i.e., physical, relational, and reputational) and internalizing problems (i.e., anxiety, depression, and self-esteem), and (3) examine whether associations between victimization and internalizing problems differ for males or females. Participants were 131 middle-school students (ages 11–15 years, 73 % male, 76 % White) diagnosed with ADHD who completed ratings of victimization, anxiety, depression, and self-esteem. Over half of the participants (57 %) reported experiencing at least one victimization behavior at a rate of once per week or more, with higher rates of relational victimization (51 %) than reputational victimization (17 %) or physical victimization (14 %). Males reported experiencing more physical victimization than females, but males and females did not differ in rates of relational or reputational victimization. Whereas relational and physical victimization were both uniquely associated with greater anxiety for both males and females, relational victimization was associated with greater depressive symptoms and lower self-esteem for males but not females. These findings indicate that young adolescents with ADHD frequently experience peer victimization and that the association between victimization and internalizing problems among young adolescents with ADHD differs as a result of victimization type, internalizing domain, and sex.

It is well established that children and adolescents with attention-deficit/hyperactivity disorder (ADHD) frequently experience co-occurring mental health problems in addition to difficulties in their peer relationships. Although substantial research has focused on the extent to which peer functioning contributes to subsequent co-occurring mental health problems, much less research has considered how co-occurring mental health problems affect peer functioning domains. Therefore, the purpose of this review is to examine the effect of co-occurring mental health problems on the peer functioning of youth with ADHD. The impact of co-occurring externalizing (i.e., oppositional defiant disorder, conduct disorder) and internalizing (i.e., anxiety, depression) symptoms are reviewed, with a focus on whether these co-occurring symptoms exacerbate, attenuate, or have no effect across peer domains of social skills/competence, peer status, and friendship among youth with ADHD. Drawing from a developmental psychopathology framework, this review then draws attention to relevant causal processes and developmental cascades (including social-cognitive, affective, and family and parenting factors) in offering promising avenues for future work.

The purpose of the study was to evaluate the Homework, Organization, and Planning Skills (HOPS) intervention for middle school students with Attention-Deficit/Hyperactivity Disorder (ADHD) as implemented by school mental health (SMH) providers using a randomized trial design. Seventeen SMH providers from five school districts implemented the HOPS intervention. Forty-seven middle school students with ADHD (grades 6-8) were randomly assigned to receive the HOPS intervention or to a waitlist comparison group. Parent and teacher ratings of organizational skills and homework problems were collected pre- and post-intervention and at a 3-monoth follow-up, and school grades were also collected. Intervention participants demonstrated significant improvements relative to the waitlist comparison across parent-rated organized action (d = .88), materials management (d = .63), planning (d = 1.05), and homework completion behaviors (d = .85). Intervention participants did not make significant improvements relative to the comparison group according to teacher ratings. SMH providers were able to implement the HOPS intervention with fidelity despite the fact that no formal ongoing consultation was provided.

Youth with Attention-Deficit/Hyperactivity Disorder (ADHD) frequently experience academic impairment, including lower grades than their peers and elevated risk for grade retention and school dropout. Medication is the most commonly used treatment for youth with ADHD, and it is therefore essential to understand the extent to which medication use improves long-term academic functioning. This paper reviews the literature on the relation between long-term medication use and the academic outcomes of youth with ADHD. A systematic literature search was conducted to identify pertinent studies published since 2000 that followed youth with ADHD for 3 or more years. Academic outcomes of interest included school grades, achievement test scores, and grade retention. Nine studies were identified reporting on eight distinct longitudinal samples (N across studies = 8,721). These studies demonstrate that long-term medication use is associated with improvements in standardized achievement scores. However, the magnitude of these improvements is small and the clinical or educational significance is questionable. Evidence for long-term improvements in school grades and grade retention is less compelling. This review highlights methodological considerations in providing directions for future research. The importance of using multiple sources to gather information about medication adherence is discussed, including use of methodologies such as electronic monitors, rather than relying solely on parent report or chart review. Future research should also examine a range of medication adherence definitions in order to determine whether age of onset, duration of use, dose, and/or consistency of use moderates the relation between long-term medication use and academic outcomes.

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in childhood,1 and primary care physicians (PCPs) are frequently involved in the evaluation and diagnosis of youth with ADHD.2,3 Coexisting mental health problems in children with ADHD is the norm rather than the exception,4 with approximately three-quarters of children with ADHD meeting criteria for another psychiatric disorder.5 Indeed, the American Academy of Pediatrics (AAP) guidelines which provide primary care physicians with evidence-based recommendations for the assessment and diagnosis of children with ADHD emphasize the importance of simultaneously evaluating common comorbid mental health problems.6 Still, over half of pediatricians remain uncertain as to whether they have the requisite training for assessing ADHD comorbidities.7 In 2002, the AAP and the National Initiative for Children’s Healthcare Quality (NICHQ) jointly published a toolkit to be used in the assessment and treatment of ADHD in primary care settings (available at www.nichq.org). This toolkit includes a standardized measure of ADHD symptoms, the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS).8 In addition to items corresponding to the ADHD diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the VADPRS includes symptom screens for three common comorbidities: oppositional defiant disorder (ODD), conduct disorder (CD), and anxiety/depression (ANX/DEP).8 Screenings for each domain contain a select group of behaviors for each comorbidity (the ODD and CD screens include DSM-IV-based symptoms, whereas the ANX/DEP screen consists of items modified from another pediatric scale). Further, VADPRS scoring algorithms provide recommended scoring thresholds which may indicate the possible presence of these comorbid disorders. While the VADPRS has strong psychometric properties for the assessment of ADHD8,9 and is frequently used by physicians,10 the comorbidity screening scales have not received adequate attention regarding their clinical utility,11,12 that is, the extent to which the dimensional scales of the VADPRS are useful for detecting the presence or absence of corresponding DSM-IV- based diagnoses. Promising evidence to date shows the VADPRS comorbidity screening scales to be reliable8 and broadly correlated with corresponding diagnoses of a structured diagnostic interview.13 However, the cutoff recommendations for the VADPRS comorbidity screening scales provided in the AAP/NICHQ ADHD toolkit have not been thoroughly evaluated for their clinical utility. Therefore, the purposes of the present study were to (1) evaluate the clinical utility of the cutoff recommendations for the VADPRS comorbidity screening scales provided in the AAP/NICHQ ADHD toolkit, and (2) establish whether alternative cutoff recommendations may improve clinical utility.

OBJECTIVE: To determine the effectiveness of a quality improvement program to improve pediatricians' adherence to existing, evidence-based, attention-deficit/hyperactivity disorder (ADHD) practice guidelines. METHODS: Forty-nine community-based pediatricians at 8 practices participated in a cluster-randomized trial. Practices were matched according to the numbers of pediatricians and the proportions of patients receiving Medicaid. The medical charts for a random sample of patients with ADHD for each of the participating pediatricians were examined at baseline and 6 months. All practices participated in 4 sessions of training, including didactic lectures and office flow modification workshops. Practices were then given access to an ADHD Internet portal that allowed parents, teachers, and pediatricians to input information (eg, rating scales) about patients, after which information was scored, interpreted, and formatted in a report style that was helpful for assessment and treatment of patients with ADHD. Physicians evaluated their practice behaviors quarterly and addressed underperforming areas. RESULTS: Pediatricians in the intervention group, compared with those in the control group, demonstrated significantly higher rates of many American Academy of Pediatrics–recommended ADHD care practices, including collection of parent (Cohen's d = 0.69) and teacher (d = 0.68) rating scales for assessment of children with ADHD, use of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria (d = 0.85), and use of teacher rating scales to monitor treatment responses (d = 1.01). CONCLUSION: A quality improvement intervention that can be widely disseminated by using Internet-based information technology significantly improved the quality of ADHD care in community-based pediatric settings.

Objective: The purpose of the research study was to examine the manifestation of variability in reaction times (RT) in children with attention deficit hyperactivity disorder (ADHD) and to examine whether RT variability presented differently across a variety of neuropsychological tasks, was present across the two most common ADHD subtypes, and whether it was affected by reward and event rate (ER) manipulations. Method: Children with ADHD-combined type (n = 51), ADHD-predominantly inattentive type (n = 53), and 47 controls completed five neuropsychological tasks (Choice Discrimination Task, Child Attentional Network Task, Go/No-Go task, Stop Signal Task, and N-back task), each allowing trial-by-trial assessment of RTs. Multiple indicators of RT variability including RT standard deviation, coefficient of variation and ex-Gaussian tau were used. Results: Children with ADHD demonstrated greater RT variability than controls across all five tasks as measured by the ex-Gaussian indicator tau. There were minimal differences in RT variability across the ADHD subtypes. Children with ADHD also had poorer task accuracy than controls across all tasks except the Choice Discrimination task. Although ER and reward manipulations did affect children's RT variability and task accuracy, these manipulations largely did not differentially affect children with ADHD compared to controls. RT variability and task accuracy were highly correlated across tasks. Removing variance attributable to RT variability from task accuracy did not appreciably affect between-groups differences in task accuracy. Conclusions: High RT variability is a ubiquitous and robust phenomenon in children with ADHD. (PsycINFO Database Record (c) 2011 APA, all rights reserved). Language: en

The purpose of the study was to modify, test, and refine the Homework, Organization, and Planning Skills (HOPS) intervention for adolescents with ADHD for use by school mental health (SMH) providers. Ten SMH providers from three school districts implemented the HOPS intervention with 11 middle school students with ADHD. Parent and teacher ratings of materials organization and homework management were collected pre- and post-intervention and treatment fidelity was assessed. SMH providers and teachers participated in focus groups and provided feedback on ways to improve the feasibility and usability of the HOPS intervention. Students made large improvements in organizational skills (d = 1.8) and homework problems (d = 1.6) according to parent ratings; however, no improvements were observed on teacher ratings. Qualitative data generated from coding the focus groups and audio-recorded HOPS sessions were combined with the quantitative results to systematically refine the HOPS intervention for further evaluation of intervention effectiveness and disseminability.

This study examined the relationship between the developmental trajectories of neuropsychological functioning and ADHD symptomatology in a longitudinal sample of children ages 9 to 14. Participants and measures were derived from the Multimodal Treatment Study for ADHD including 534MTA participants and 254 normal controls. Despite improvement over time, MTA participants continued to receive higher ratings of ADHD symptomatology and exhibit greater difficulties across the majority of neuropsychological outcomes. No relations were found between improvements in neuropsychological functioning and ADHD symptomatology over time. Findings provide support for the persistence of neuropsychological functioning and ADHD symptomatology. Findings did not support the hypothesized relation between improvements in frontally-mediated neuropsychological functioning and ADHD symptomatology possibly due to the brief 1-year lag and limited assessment battery. Findings are discussed in relation to neuropsychological development including recommendations for future research.

OBJECTIVE: The goal was to examine the clinical utility of using the Vanderbilt Attention-Deficit/Hyperactivity Disorder (ADHD) Rating Scale (VARS) to determine when to refer children with ADHD for learningdisorder (LD) evaluations. METHODS: A total of 128 stimulant-naive children with ADHD, 7 to 11 years of age, were included in the study. The parents and teachers of 128 children with diagnosed ADHD completed the VARS. The reading, numerical operations, and spelling subtests from the Wechsler Individual Achievement Test, Second Edition, were used to identify children with a comorbid LD. We examined the predictive validity and clinical utility of the VARS performance items for ruling in/out the presence of a comorbid LD. RESULTS: Thirty-eight percent of the samples met the criteria for a comorbid LD. A cutoff score of 7.5 for the sum of the VARS parent and teacher reading items had excellent clinical utility for ruling out both reading and spelling LDs. Cutoff scores of 4 for the VARS teacher reading and writing items had excellent utility for ruling out comorbid reading and spelling LDs, respectively. None of the VARS performance items effectively identified or ruled out math LDs. CONCLUSION: The VARS performance items should be used with an interview about school functioning and a review of school records to rule out the presence of a comorbid reading or spelling LD for children with diagnosed ADHD.

The long-term sustainability of a quality improvement project was examined. The ADHD Collaborative was designed to assist community-based pediatricians in adhering to the American Academy of Pediatrics evidence-based assessment and treatment guidelines for attention deficit hyperactivity disorder (ADHD). Patient chart reviews were completed out to 2 years post training for 14 practices (N = 38 pediatricians), who received the ADHD Collaborative intervention to assess whether improvements made immediately post training were sustained. Pediatricians maintained significant improvements in their use of evidence-based assessment and treatment practices for a period of 2 years. The majority of the improvements occurred quickly, within 6 months of training. Pediatricians focused most of their continuous quality improvement (CQI) efforts on improving follow-up care for their patients with ADHD. Systematic monitoring and follow up of ADHD patients who were prescribed medication improved considerably from pre-train...

Parent-report of child homework problems was examined as a treatment outcome variable in the MTA-Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (ADHD). Five hundred seventy-nine children ages 7.0 to 9.9 were randomly assigned to either medication management, behavioral treatment, combination treatment, or routine community care. Results showed that only participants who received behavioral treatment (behavioral and combined treatment) demonstrated sustained improvements in homework problems in comparison to routine community care. The magnitude of the sustained effect at the 10-month follow-up assessment was small to moderate for combined and behavioral treatment over routine community care (d = .37, .40, respectively). Parent ratings of initial ADHD symptom severity was the only variable found to moderate these effects.

Attention-deficit/hyperactivity disorder (ADHD) is a commonly occurring behavioral disorder among children. Community-based physicians are often the primary providers of services for children with ADHD. A set of consensus guidelines has been published by the American Academy of Pediatrics that provides best-practice diagnostic procedures for primary-care physicians. These recommendations emphasize the importance of using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria as the basis for making an ADHD diagnosis and conducting systematic follow-up, including the collection of parent and teacher ratings scales to quantitatively assess response to treatment. Although these recommendations have been widely disseminated and their adoption actively promoted, guideline adherence, in general, is known to be poor. Two types of intervention models, ancillary service and office systems modification, have been proposed to promote adoption of evidence-based ADHD practice in primary-care settings. The present article reviews the efficacy of these intervention models, and discusses the cost and sustainability of each model as related to feasibility of intervention dissemination.

Mothers and fathers often disagree in their ratings of child behavior, as evidenced clinically and as supported by a substantial literature examining parental agreement on broadband rating scales. The present study examined mother—father agreement on Diagnostic and Statistical Manual—based symptom-specific ratings of Attention-Deficit/Hyperactivity Disorder (ADHD), as compared to agreement on broadband ratings of externalizing behavior. Based on mother and father ratings of 324 children who participated in the Multimodal Treatment Study of Children with ADHD (MTA), parental agreement was computed and patterns of disagreement examined. Mother—father ratings were significantly correlated; however, a clear pattern of higher ratings by mothers was present. Agreement on attention-deficit/hyperactivity disorder symptom-specific ratings was significantly lower than that for broadband externalizing behaviors and oppositional defiant disorder symptoms. Of several moderator variables tested, parental stress was the only one that predicted the discrepancy in ratings. Disagreement between parents is clinically significant and may pose complications to the diagnostic process.

OBJECTIVES. The goals were to implement and to test a quality-improvement intervention aimed at improving community-based primary care providers’ adherence to the American Academy of Pediatrics, evidence-based diagnostic and treatment guidelines for attention-deficit/hyperactivity disorder. METHODS. Nineteen practices (with 84 primary care providers) from a large urban community were trained by using quality-improvement methods with some academic detailing. Pretraining and posttraining adherence to evidence-based practices was assessed through review of patient charts. RESULTS. Preintervention rates of guideline usage were uniformly low. After the intervention, primary care providers showed substantial improvement in their use of the guidelines for the assessment and treatment of elementary school-aged patients with newly diagnosed attention-deficit/hyperactivity disorder. Use of parent and teacher assessment rating scales increased from levels of 52% to 55% to levels of nearly 100%. Systematic monitoring of responses to medication improved from a baseline level of 9% to 40%. CONCLUSIONS. Quality-improvement interventions such as the one used in this study seem quite effective in improving primary care providers’ practices at offices that express interest in improving the quality of care for attention-deficit/hyperactivity disorder. The design of the intervention, problems associated with improving and sustaining treatment monitoring, and issues related to generalizability of the intervention model are discussed.

Attention-deficit/hyperactivity disorder (ADHD) is a commonly occurring behavioral disorder among children. Community-based physicians are often the primary providers of services for children with ADHD. A set of consensus guidelines has been established that provides best practice diagnostic procedures for primary care physicians. These assessment recommendations emphasize the importance of collecting parent and teacher rating scales, using Diagnostic and Statistical Manual of Mental Disorders IV criteria as the basis for making an ADHD diagnosis, and evaluating for comorbid conditions. The ADHD diagnostic process is complicated by several factors including the subjectivity of the ADHD diagnosis, differential diagnosis with comorbid conditions, and the inconsistent manifestation of ADHD symptomatology across development. The present article provides recommendations for addressing these complex diagnostic issues. ADHD assessment methods and tools, the process of assessing for comorbid conditions and making differential diagnosis, and when to make a referral to specialists are reviewed.

There is considerable evidence that externalizing disorders such as attention deficit/hyperactivity disorder (ADHD) put youth at risk for a range of adverse academic outcomes. It is importantly to note that some youth avoid these negative outcomes, yet there is a gap in our understanding of these resilient youth. The purpose of this study was to longitudinally evaluate social acceptance and social skills as potential protective factors of the associations between inattentive, hyperactive/impulsive, and oppositional defiant behaviors with academic outcomes. Participants included a sample of 93 middle school students comprehensively diagnosed with ADHD. Parents and adolescents completed ratings of social skills and perceived social acceptance. School grades and teacher-rated academic impairment were assessed 18 months later as longitudinal academic functioning outcomes. Inattention and social acceptance were associated with academic outcomes 18 months later. Regression analyses revealed that parent- and adolescent-rated social acceptance demonstrated promotive effects for grades and against teacher-rated academic impairment. Further, social acceptance significantly interacted with inattention in predicting school grades, such that high parent- and adolescent-rated social acceptance significantly attenuated the relationship between inattention and poor grades, even after controlling for baseline grades and intelligence. The presence of social acceptance was especially critical for adolescents with high levels of inattention. Specifically, adolescents with high inattention and high social acceptance had a mean grade point average of 2.5, and adolescents with high inattention and low social acceptance had a mean grade point average of 1.5. These findings demonstrate that social acceptance may be an important intervention target for improving academic outcomes among adolescents with ADHD.

Objective: This study compared practitioner self-report of ADHD quality of care measures with actual performance, as documented by chart review. Method: In total, 188 practitioners from 50 pediatric practices completed questionnaires in which they self-reported estimates of ADHD quality of care indicators. A total of 1,599 charts were reviewed. Results: The percentage of patients for whom practitioners self-reported that they used evidence-based care was higher in every performance category when compared with chart review, including higher use of parent and teacher rating scales during assessment and treatment compared with chart review. Self-reported use of Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria during assessment was also higher than by chart review. The actual number of days until the first contact after starting medication was nearly three times longer than self-report estimates. Conclusion: Practitioners overreport performance on quality of care indicators. These differences were large and consistent across ADHD diagnostic and treatment monitoring practices. Practitioner self-report of ADHD guideline adherence should not be considered a valid measure of performance.

Students with attention-deficit/hyperactivity disorder (ADHD) often experience a host of negative academic outcomes, and deficits in reading and mathematics abilities contribute to these academic impairments. Students with ADHD may also have difficulties with written expression, but there has been minimal research in this area and it is not clear whether written expression abilities uniquely contribute to the academic functioning of students with ADHD. The current study included a sample of 104 middle school students diagnosed with ADHD (Grades 6-8). Participants were followed longitudinally to evaluate whether written expression abilities at baseline predicted student grade point average (GPA) and parent ratings of academic impairment 18 months later, after controlling for reading ability and additional relevant covariates. Written expression abilities longitudinally predicted both academic outcomes above and beyond ADHD and oppositional defiant disorder symptoms, medication use, reading ability, and baseline values of GPA and parent-rated academic impairment. Follow-up analyses revealed that no single aspect of written expression was demonstrably more impactful on academic outcomes than the others, suggesting that writing as an entire process should be the focus of intervention. (PsycINFO Database Record

The Challenging Horizons After School Program is one of the only psychosocial interventions developed specifically for adolescents with attention-deficit/hyperactivity disorder (ADHD) that has demonstrated efficacy in multiple randomized controlled trials. To date, however, all research with the intervention has evaluated outcomes at the group level, and it is unclear whether all adolescents respond similarly, or if the intervention is particularly well suited for certain adolescents with ADHD. This type of information is needed to guide stakeholders in making informed choices as part of dissemination and implementation efforts. The purpose of this study was to evaluate trajectories of response to intervention for a large sample of middle-school age adolescents with ADHD (grades 6-8) who received the after-school intervention (N=112). An additional goal of the study was to evaluate potential predictors of response trajectories, focusing on determining what factors best distinguished between intervention responders and nonresponders. Latent trajectory analyses consistently revealed four or five distinct classes. Depending on the outcome, between 16% and 46% of participants made large improvements, moving into the normal range of functioning, and between 26% and 65% of participants made small or negligible improvements. Multivariate predictor analyses revealed that a strong counselor/adolescent working alliance rated from the adolescent perspective and lower levels of parenting stress and parent-adolescent conflict consistently predicted an increased likelihood of intervention response. Implications of these findings for disseminating the after school intervention and for further intervention development are discussed.

This study examined the efficacy of an after-school program, the Challenging Horizons Program (CHP), that met four days a week and focused on improving organization, academic skills, and classroom behavior. The CHP was compared with a community control that included involvement in a district-run after-school program that met one to three days a week and focused on preparation for standardized testing. Participants were 48 middle-school youth, referred as experiencing a combination of learning and behavior problems, randomly assigned to either the CHP or the control. Parent and teacher ratings of behavioral and academic functioning were collected at the beginning of the academic year and again after one semester of intervention. Relative to the control, participants in the CHP made significant improvements in parent-rated academic progress, self-esteem, and overall severity of problem. While teacher ratings did not reach significance, CHP participants made medium effect size improvements in academ...

Objective To conduct the first meta-analysis evaluating the internal and external validity of the sluggish cognitive tempo (SCT) construct as related to or distinct from attention-deficit/hyperactivity disorder (ADHD) and as associated with functional impairment and neuropsychological functioning. Method Electronic databases were searched through September 2015 for studies examining the factor structure and/or correlates of SCT in children or adults. The search procedures identified 73 papers. The core SCT behaviors included across studies, as well as factor loadings and reliability estimates, were reviewed to evaluate internal validity. Pooled correlation effect sizes using random effects models were used to evaluate SCT in relation to external validity domains (i.e., demographics, other psychopathologies, functional impairment, and neuropsychological functioning). Results Strong support was found for the internal validity of the SCT construct. Specifically, across factor analytic studies including more than 19,000 individuals, 13 SCT items loaded consistently on an SCT factor as opposed to an ADHD factor. Findings also support the reliability (i.e., internal consistency, test–retest reliability, interrater reliability) of SCT. In terms of external validity, there is some indication that SCT may increase with age ( r = 0.11) and be associated with lower socioeconomic status ( r = 0.10). Modest (potentially negligible) support was found for SCT symptoms being higher in males than females in children ( r = 0.05) but not in adults. SCT is more strongly associated with ADHD inattention ( r = 0.63 in children, r = 0.72 in adults) than with ADHD hyperactivity-impulsivity ( r = 0.32 in children, r = 0.46 in adults), and it likewise appears that SCT is more strongly associated with internalizing symptoms than with externalizing symptoms. SCT is associated with significant global, social, and academic impairment ( r = 0.38–0.44). Effects for neuropsychological functioning are mixed, although there is initial support for SCT being associated with processing speed, sustained attention, and metacognitive deficits. Conclusion This meta-analytic review provides strong support for the internal validity of SCT and preliminary support for the external validity of SCT. In terms of diagnostic validity, there is currently not enough evidence to describe SCT in diagnostic terms. Key directions for future research are discussed, including evaluating the conceptualization of SCT as a transdiagnostic construct and the need for longitudinal research.

Objective To describe the relationships between attention-deficit/hyperactivity disorder (ADHD) care practices and subsequent medication use. Method A retrospective cohort from a random sample of medical records in 50 pediatric practices with 188 providers, including 1,352 children who started ADHD medication, was studied. Independent variables included physician behaviors related to medication titration and monitoring of treatment response. Primary outcomes were number of days covered with ADHD medication during the first year of treatment and time from starting medicine to the first 30-day gap in medication supply. Multilevel modeling and Cox proportional hazards regression models were conducted. Results Children had an average medication supply of 217 days in the first year. Half experienced a 30-day gap in medication supply in the first 3 months. Nearly three-fourths had a medication adjustment in the first year with the first adjustment usually being a dosage change. The average time to the first medication adjustment was over 3 months. Physician's first contact with parents occurred in the first month of treatment for less than half, with the average time being over 2 months. Little variation related to ADHD care quality was accounted for at the physician level. Early titration and early contact were related to greater medication supply and continuity of treatment. Conclusion Earlier physician-delivered ADHD care (e.g., contact with parent after starting medication and medication adjustment) is related to greater medication supply and continuity. It remains to be determined whether interventions that improve the quality of titration and monitoring practices for children with ADHD would also improve medication continuity.

This paper describes the development of an after-school program for middle-school students that simultaneously addressed issues of efficacy and effectiveness in an effort to create an evidence-based intervention (EBI) that can be implemented in school settings. The topics highlighted in this case example are intended to address the growing concern that over-focusing on efficacy in well-controlled, grant-funded studies has resulted in a generation of EBI that are not acceptable, feasible, or sustainable in the majority of applied settings. Our case example focuses on six key issues highlighted in the published research literature: sustainability, recruitment, methodological design, flexibility, training, and meaningful outcomes. We briefly summarize each of these issues and relate them to our experiences conducting a successful pilot study. A summary of the pilot study results is also presented to lend support for the utilization of the EBI model of dissemination described in this paper.

The authors conduct an evaluation of a middle school-based treatment program for youth with ADHD during early stages of treatment development. The studies focus on interpreting outcome trends in preliminary data and identifying assessment issues that will be important to consider when conducting a clinical trial. Parent reports indicate that the majority of students benefit from improvements in academic, social, and overall functioning. Although teachers report beneficial effects for the majority of the participants in the program, there is little agreement about individual students. Measurement problems are associated with understanding normal change during a school year, accounting for normal behavior changes in December and May, and considerable disagreement between teachers. Suggestions to guide future work in this area are provided.

The effects of a set of behavioral and educational interventions provided in a middle-school-based mental health program on the behavior and academic performance of 7 students diagnosed with attention-deficit/hyperactivity disorder (ADHD) were studied. The treatments included educational, social skills and family interventions designed to target school functioning, peer relations, and family functioning. Dependent measures included parent and teacher ratings of ADHD symptoms, daily functioning, and academic grades. Large effect sizes were found on measures of inattention and school functioning. Grades and measures of family functioning and peer relations yielded small to moderate effect sizes. Description of the procedures is provided and implications for advancing school-based mental health care for adolescents with a diagnosis of ADHD are discussed.

Objective The development of attention-deficit/hyperactivity disorder (ADHD) care quality measurements is a prerequisite to improving the quality of community-based pediatric care of children with ADHD. Unfortunately, the evidence base for existing ADHD care quality metrics is poor. The objective of this study was to identify which components of ADHD care best predict patient outcomes. Method Parents of 372 medication-naive children in grades 1 to 5 presenting to their community-based pediatrician (N = 195) for an ADHD-related concern and who were subsequently prescribed ADHD medication were identified. Parents completed the Vanderbilt ADHD Parent Rating Scale (VAPRS) at the time ADHD was raised as a concern and then approximately 12 months after starting ADHD medication. Each patient's chart was reviewed to measure 12 different components of ADHD care. Results Across all children, the mean decrease in VAPRS total symptom score during the first year of treatment was 11.6 (standard deviation 10.1). Of the 12 components of ADHD care, shorter times to first contact and more teacher ratings collected in the first year of treatment significantly predicted greater decreases in patient total symptom scores. Notably, it was timeliness of contacts, defined as office visits, phone calls, or email communication, that predicted more ADHD symptom decreases. Office visits alone, in terms of number or timeliness, did not predict patient outcomes. Conclusion The magnitude of ADHD symptom decrease that can be achieved with the use of ADHD medications was associated with specific components of ADHD care. Future development and modifications of ADHD quality care metrics should include these ADHD care components.

The purpose of this study was to evaluate the degree with which Individualized Education Programs (IEPs) and 504 Plans prepared for middle school students with attention deficit/hyperactivity disorder (ADHD) conformed to best practices and included evidence-based services. Specifically, we examined the problem areas identified in the statement of students' present level of academic achievement and functional performance (PLAAFP) and targeted in the students' measurable annual goals and objectives (MAGOs). In addition, we compared services with lists of recommended services provided by the U.S. Department of Education (ED) and reviews of evidence-based practices. Participants were 97 middle school students with ADHD, 61.9% with an IEP, and 38.1% with a 504 Plan. Most (85%) IEP PLAAFP statements described nonacademic/behavior problems, but fewer than half had MAGOs targeting these areas of need. Services listed on IEPs and Section 504 Plans were frequently consistent with ED recommendations, but had little to no research supporting their effectiveness. In addition, services with evidence supporting benefit to students with ADHD were rarely included on IEPs or 504 Plans. Implications for special education policy and future directions are discussed.

The primary aim of this study was to evaluate whether alcohol consumption longitudinally predicts the adjustment, overall functioning, and grade point average (GPA) of college students with ADHD and to determine whether self-report of executive functioning (EF) mediates these relationships. Sixty-two college students comprehensively diagnosed with ADHD completed ratings at the beginning and end of the school year. Regression analyses revealed that alcohol consumption rated at the beginning of the year significantly predicted self-report of adjustment and overall impairment at the end of the year, above and beyond ADHD symptoms and baseline levels of adjustment/impairment but did not predict GPA. Exploratory multiple mediator analyses suggest that alcohol use impacts impairment primarily through EF deficits in self-motivation. EF deficits in the motivation to refrain from pursuing immediately rewarding behaviors in order to work toward long-term goals appear to be particularly important in understanding why college students with ADHD who consume alcohol have a higher likelihood of experiencing significant negative outcomes. The implications of these findings for the prevention of the negative functional outcomes often experienced by college students with ADHD are discussed. (PsycINFO Database Record

Objective: The purpose of this study was to evaluate aspects of emotion dysregulation (ED) that characterize young adolescents with ADHD, examine the effects of subtype and comorbidity, and determine the extent to which ED is related to aggression and rule-breaking and social impairment. Method: We examined which aspects of ED are most relevant to ADHD in 180 young adolescents (75% boys), as well as whether ED differs across ADHD subtypes or comorbid oppositional defiant disorder (ODD) status. We also examined the association between ED and aggression, rule-breaking, and social impairment. Results: Young adolescent females and males with ADHD exhibited various manifestations of ED, including behavioral dyscontrol in the presence of strong emotions and inflexibility/slow return to emotional baseline. ED did not differ as a function of ADHD subtype or comorbid ODD. Three aspects of ED, namely, low threshold for emotional excitability/impatience, behavioral dyscontrol in the face of strong emotions, and inflexibility/slow return to baseline, predicted three of six measured indices of parent- and self-reported social impairment, above and beyond comorbid ODD. Conclusions: ED is associated with ADHD among young adolescents, does not differ based on ADHD subtype or ODD status, and is associated with social impairment.

Though the American Academy of Pediatrics has developed and disseminated clear evidence-based guidelines for ADHD care, community-based pediatricians often have difficulty implementing these guidelines. New strategies are needed to improve the quality of care received by children with ADHD and to improve utilization of the AAP consensus guidelines by pediatricians. An evidence-based quality improvement intervention has been developed that effectively improves the quality of ADHD care delivered by community-based pediatricians. In order to facilitative widespread dissemination of this intervention model, the entire intervention has been modified for online delivery. The intervention is called the myADHDportal.com Improvement Program. The full functionality of this online intervention is described including the collection of online ADHD rating scales from parents and teachers and online communication between parents, teachers, and physicians. In addition, the web portal integrates several innovative quality improvement features including an online wizard for mapping ADHD patient flow, an online report card for monitoring quality of care, and an online wizard for guiding practices through the Plan-Do-Study-Act (PDSA) cycle process. The combination of clinical utility and quality improvement tools facilitates delivery of quality ADHD care and reduces several of the obstacles to implementing AAP-recommended practice behaviors. Initial results with this intervention model are reviewed and goals for dissemination are described.

Objective: This study examined neurocognitive and behavioral predictors of math performance in children with and without ADHD. Method: Neurocognitive and behavioral variables were examined as predictors of (a) standardized mathematics achievement scores, (b) productivity on an analog math task, and (c) accuracy on an analog math task. Results: Children with ADHD had lower achievement scores but did not significantly differ from controls on math productivity or accuracy. N-back accuracy and parent-rated attention predicted math achievement. N-back accuracy and observed attention predicted math productivity. Alerting scores on the attentional network task predicted math accuracy. Mediation analyses indicated that n-back accuracy significantly mediated the relationship between diagnostic group and math achievement. Conclusion: Neurocognition, rather than behavior, may account for the deficits in math achievement exhibited by many children with ADHD.

This prospective longitudinal study evaluated the impact of daytime sleepiness on the school performance of 62 college students diagnosed comprehensively with attention deficit hyperactivity disorder. The primary goal of the study was to determine if self-reported daytime sleepiness rated at the beginning of the academic year could predict academic and overall functioning at the end of the academic year while also considering potentially important covariates, including symptoms of inattention, hyperactivity and impulsivity, medication status and whether or not students lived at home or on-campus. Self-reported daytime sleepiness predicted longitudinally school maladjustment, overall functional impairment and the number of D and F grades (i.e. poor and failing) students received in courses above and beyond both self- and parent-report of symptoms, but did not predict overall grade point average. Living at home served as a protective factor and was associated with less school maladjustment and overall impairment. Gender was the only significant predictor in the overall grade point average model, with female gender associated with higher overall grades. The implications of these findings for monitoring and treatment of sleep disturbances in college students with attention deficit hyperactivity disorder are discussed.

Disorganization (of time, tasks, and materials) is a core difficulty underlying the functional impairments associated with Attention-Deficit/Hyperactivity Disorder (ADHD). This chapter discusses the role of organizational deficits in ADHD symptomatology and reviews school-related interventions designed to target these organizational deficits in youth with ADHD, including evidence of their efficacy and limitations of existing studies. Common strategies among intervention programs include teaching youth to more effectively monitor their own behavior, reinforcing progress in organizational strategies, providing organizational instruction and skill-building, and the use of external organizational aids. Evidence suggests that these interventions are efficacious in improving organizational skills and acceptable to parents, teachers, and school staff involved with implementation. Areas for future research are discussed.

The purpose of the study was to evaluate the relation between Sluggish Cognitive Tempo (SCT) and academic functioning in a sample of 52 adolescents (40 males, 12 females) with Attention-Deficit/Hyperactivity Disorder (ADHD; M age = 13.75). This study builds on prior work by utilizing an empirically-based and psychometrically validated measure of SCT, collecting ratings of SCT from both parents and teachers, and examining associations with multiple domains of academic functioning from both the parent and teacher perspective as well as grade point average (GPA). Both SCT and DSM-IV symptoms of inattention were significantly correlated with domains of academic functioning. Multiple regression analyses demonstrated that the parent-rated SCT Slow subscale predicted overall academic functioning, organizational skills impairment, and homework problems above and beyond ADHD symptoms and child and demographic characteristics known to be associated with academics, including intelligence, academic achievement, and family income. The teacher-rated SCT Low Initiation/Persistence subscale also predicted homework problems and was the only SCT variable to predict school grades above and beyond ADHD symptoms and relevant covariates. Both the SCT Slow and Low Initiation/Persistence subscales include items related to youth seeming apathetic, unmotivated, and lacking initiative, behaviors that are strongly related to ADHD symptoms of inattention but not currently captured by the DSM-IV. Implications of these findings towards supporting the external validity of the SCT construct are discussed along with potential implications for intervention.

The purpose of the study was to evaluate predictors of response and mechanisms of change for the Homework, Organization, and Planning Skills (HOPS) intervention for middle school students with Attention-Deficit/Hyperactivity Disorder (ADHD). Twenty-three middle school students with ADHD (grades 6–8) received the HOPS intervention implemented by school mental health providers and made significant improvements in parent-rated materials organization and planning skills, impairment due to organizational skills problems, and homework problems. Predictors of response examined included demographic and child characteristics, such as gender, ethnicity, intelligence, ADHD and ODD symptom severity, and ADHD medication use. Mechanisms of change examined included the therapeutic alliance and adoption of the organization and planning skills taught during the HOPS intervention. Participant implementation of the HOPS binder materials organization system and the therapeutic alliance as rated by the student significantly predicted post-intervention outcomes after controlling for pre-intervention severity. Adoption of the binder materials organization system predicted parent-rated improvements in organization, planning, and homework problems above and beyond the impact of the therapeutic alliance. These findings demonstrate the importance of teaching students with ADHD to use a structured binder organization system for organizing and filing homework and classwork materials and for transferring work to and from school.

This study examined help-seeking and perceived barriers to children’s mental health service utilization in a large sample of parents living in rural communities who are at various stages in the help-seeking process. The goals were to (a) obtain a demographic profile of at-risk kindergarteners and their parents, (b) examine parent-reported help-seeking behaviors, and (c) assess barriers to mental health service use. Parent and teacher report of the Behavior Assessment System for Children, Second Edition, were used to screen children (N ¼ 597) at kindergarten entry and to identify their risk status. Parents also completed the Barriers to Participation Scale and reported the frequency of help-seeking behaviors related to their child’s problems. Using a cutoff score of 1.5 standard deviations above the mean, nearly half (51%) of children were identified as at-risk (76% low risk, 24% high risk) for emotional, behavioral, social, and adaptive problems. Barriers and help-seeking did not differ across parents of low and high risk children. Among parents of at-risk children, only 33% believed their child had a problem. Parents sought informal help more often than professional help; however, medical doctors and school staff were sought most among professionals. The majority of parents (61%) endorsed at least one barrier that would interfere with mental health service use. Results highlight the importance of early school mental health screening and the need for interventions to increase parent problem recognition and engagement in mental health service utilization.