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Objective: To conduct qualitative analysis of interviews to understand phenomenology, daily life impact, and treatment considerations of sluggish cognitive tempo (SCT) behaviors in children and adolescents. Method: Youth with elevated SCT symptoms ( N = 15, ages 9–16 years) and their parents completed interviews focused on their perception and daily life impact of SCT behaviors. Parents were also asked about intervention targets. Results: Parents and youth had both negative and positive perceptions of SCT, with SCT fostering creativity/imagination and a break from stressors while also negatively impacting daily functioning. The domains most frequently selected by parents as SCT intervention targets were academics, emotions, mind wandering, morning routines, and self-esteem. Conclusion: Children and their parents share negative and positive views of SCT behaviors, while also detailing specific ways that SCT negatively impacts day-to-day functioning. This study offers insights into possible intervention targets as provided by youth and parents directly impacted by SCT.

There remains critical need for community-based approaches to HIV prevention which center youth voices and needs.We established an adolescent health working group (AHWG) to convene youth, parents, providers, and advocates in agenda-setting for interventions to increase pre-exposure prophylaxis uptake in Durham.Our three study phases included six AHWG meetings from 2019 to 2020, youth-only meetings guided by a participatory engagement framework (Youth Generate and Organize), and interviews (n=13) and surveys with youth in the community (N=87). We also developed materials such as an AHWG mission statement, a list of themes and informational needs, and documented strategies about pivoting the project during the onset of the COVID-19 global pandemic.Lessons Learned/Conclusions: Engaging adults in youth-focused HIV prevention differs greatly to engaging youth themselves. Creating spaces to promote adolescent sexual Health requires trust building, breaking down sensitivities and stigma to, and flexibility to navigate both virtual and in-person spaces to do so.

Objective: Eveningness diurnal preference is common in psychiatric conditions, including attention-deficit/hyperactivity disorder (ADHD) and internalizing disorders. Little is known about how diurnal preference relates to sluggish cognitive tempo (SCT)—a distinct clinical construct associated with functional impairment—in clinical samples. Method: Adult outpatients ( n = 65; 43 with ADHD, 22 with internalizing/adjustment disorders) self-reported on SCT symptoms (total symptoms; slow/daydreamy, sleepy/sluggish, and low initiation/persistence factors) and diurnal preference. Results: Greater eveningness was associated with overall SCT severity and sleepy/sluggish symptoms in the full sample. Relationships between eveningness and overall SCT severity and slow/daydreamy symptoms were stronger for those with internalizing/adjustment disorders compared to ADHD. The relationship between eveningness and sleepy/sluggish symptoms was uniform across groups. Conclusion: Findings suggest a potential role of eveningness preference in adult SCT presentation. Future studies should investigate underlying mechanisms linking these two constructs and the efficacy of circadian interventions in the treatment of SCT among adult outpatients.

This study tested whether early and developmentally atypical substance use mediates risk for adult substance use among children with attention-deficit/hyperactivity disorder (ADHD), and whether that risk is substance-specific. Participants were children with ADHD previously enrolled in a randomized controlled trial (RCT), and a demographically similar non-ADHD group, assessed at 2 through 16 years after the original RCT baseline. Self-reports of heavy drinking, marijuana use, daily smoking, and other illicit drug use were collected at follow-ups to establish atypically early and frequent use. Models estimated statistically mediated effects of childhood ADHD on adult substance use via early substance involvement, with planned comparisons to evaluate substance specificity. Results supported the mediation hypothesis, showing that childhood ADHD was associated with more frequent adult substance use via early substance involvement for marijuana, cigarettes, illicit drugs, and to a lesser extent, alcohol. Mediation was not escalated by comorbid childhood conduct disorder or oppositional defiant disorder except for early use of nonmarijuana illicit drugs. Substance-specificity in the mediational pathway was largely absent except for cigarette use, where ADHD-related early smoking most strongly predicted adult daily smoking. Findings from this study provide new evidence that atypically early substance use associated with childhood ADHD signals important cross-drug vulnerability by early adulthood, but cigarette use at a young age is especially associated with increased risk for habitual (daily) smoking specifically. Efforts to prevent, delay, or reduce substance experimentation should occur early and focus on factors relevant to multiple drugs of abuse in this at-risk population. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Adolescents and young adults (AYA; 13-24 years-old) comprise 22% of new HIV infections in the United States (US), most of whom live in the South. We used the situated-Information, Motivation, Behavioral skills (sIMB) model to identify priorities for intervention on multi-level factors that influence HIV preventive care among Black AYA in Durham, North Carolina. We conducted two participatory workshops (ages 13-17, N = 6; ages 18-24, N = 7) to engage youth about how to discuss HIV. We also assessed sIMB constructs from a separate quantitative sample of youth to contextualize the workshop findings (N = 80). HIV knowledge was low overall, but lower among younger Black AYA, suggesting a need for comprehensive sexual education. Trusted adults provided sexual health information, motivation for health maintenance, and behavioral skills support. HIV prevention interventions should provide comprehensive sexual health education to Black AYA, be age-specific, and include social supporters like parents, teachers, and community members.

Cannabis use alters sperm DNA methylation, but the potential reversibility of these changes is unknown. Semen samples from cannabis users and non-user controls were collected at baseline and again following a 77-day period of cannabis abstinence (one spermatogenic cycle). Users and controls did not significantly differ by demographics or semen analyses. Whole-genome bisulfite sequencing identified 163 CpG sites with significantly different DNA methylation in sperm between groups (P

Parental cannabis use has been associated with adverse neurodevelopmental outcomes in offspring, but how such phenotypes are transmitted is largely unknown. Using reduced representation bisulphite sequencing (RRBS), we recently demonstrated that cannabis use is associated with widespread DNA methylation changes in human and rat sperm. Discs-Large Associated Protein 2 (DLGAP2), involved in synapse organization, neuronal signaling, and strongly implicated in autism, exhibited significant hypomethylation (p

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.

Background Despite young African American adults (ages 18–24) being among the highest risk groups for HIV infection, little is known about their awareness of HIV pre-exposure prophylaxis (PrEP) – a once daily pill shown to be > 90% effective in preventing HIV. To explore awareness and acceptability of PrEP among college students in this demographic, we conducted a survey of attendees at two large historically Black universities (HBCU) in North Carolina. Methods We administered a 14-item questionnaire to students at two HBCUs in North Carolina between February and April 2018. Questions were formatted in a yes/no or multiple choice format. Questionnaire items specifically addressed PrEP awareness and acceptability. Surveys were administered to students at a campus health fair and while transiting the campus student union via iPad. Response to all questions was optional. We fit a logistic regression model to determine association of key demographic determinants with PrEP acceptability and awareness. Statistical analyses were conducted using SAS 9.4 (SAS, Cary, NC). Results Overall, 210 students participated in the survey, of which 60 completed all survey items as presented. The survey cohort was 75% female, 89% heterosexual and 39% freshmen. The mean age of respondents was 19.8 years (SD: 1.8). Fifty-two percent of survey respondents reported that they were aware of PrEP prior to the time of survey administration. Only 3% of respondents reported that they were on PrEP. The most common sources of information on PrEP were campus health services (24%) and non-social media advertising (15%). Of respondents who were aware of PrEP, 61% reported that they had heard about in the 6 months prior to survey administration, while only 19% say they were aware of it for more than a year. Regarding acceptability of PrEP, 58% of respondents reported that they would take a once a day pill for HIV if they were at risk. Our logistic regression analysis found no statistically significant associations between key demographic factors and PrEP awareness. However, persons who perceived themselves to be at risk for HIV acquisition were more likely to find once daily oral PrEP (relative risk 2.66 (95% CI 1.31–5.42)) as an acceptable prevention strategy than the rest of the survey cohort. Conclusions African American HBCU students are becoming aware of PrEP, and generally perceive the intervention as acceptable and worth consideration.

Background Research on the psychometric properties of the Persian self-report form of the Pediatric Quality of Life Inventory Version 4.0 (PedsQL 4.0) in adolescents has several gaps (e.g., convergent validity) that limit its clinical application and therefore the cross-cultural impact of this measure. This study aimed at investigating the psychometric properties of the PedsQL 4.0 and the effects of gender and age on quality of life in Iranian adolescents. Method The PedsQL 4.0 was administered to 326 adolescents (12–17 years). A subsample of 115 adolescents completed the scale two weeks after the first assessment. Confirmatory Factor Analysis (CFA), correlation of the PedsQL 4.0 with the Weiss Functional Impairment Rating Scale-Self-report (WFIRS-S), and Item Response Theory (IRT) analysis were conducted to examine validity. Cronbach’s alpha, McDonald’s Omega, and Intra class correlation (ICC) were calculated as well to examine reliability. Gender and age effects were also evaluated. Results Internal consistency and test–retest reliability of the total PedsQL 4.0 scale was .92 and .87, respectively. The PedsQL 4.0 scores showed negative moderate to strong correlations with the WFIRS-S total scale. The four-factor model of the PedsQL 4.0 was not fully supported by the CFA—the root mean square error of approximation and the comparative fit index showed a mediocre and poor fit, respectively. IRT analysis indicated that all items of the PedsQL 4.0 fit with the scale and most of them showed good discrimination. The items and total scale provided more information in the lower levels of the latent trait. Males showed significantly higher scores than females in physical and emotional functioning, psychosocial health, and total scale. Adolescents with lower ages showed better quality of life than those with higher ages in all scores of the PedsQL 4.0. Conclusion The PedsQL 4.0 showed good psychometric properties with regard to internal consistency, test–retest reliability, and convergent validity in Iranian adolescents, which supports its use in clinical settings among Persian-speaking adolescents. However, factor structure according to our CFA indicates that future work should address how to improve fit. In addition, studies that include PedsQL 4.0 should consider gender and age effects were reported.

OBJECTIVE: Sluggish Cognitive Tempo (SCT) symptoms uniquely contribute to psychiatric and functional outcomes in child samples; however, the psychometric properties of SCT measures among adult outpatients are unknown. METHOD: Adults (n=124) presenting for an attention-deficit/hyperactivity disorder (ADHD) evaluation provided self- and collateral report of SCT symptoms. RESULTS: The SCT scale had good internal consistency and yielded three factors across raters: Slow/Daydreamy, Sleepy/Sluggish, and Low Initiation/Persistence. SCT scores exhibited convergent validity with ADHD symptoms across raters. Individuals with ADHD received higher SCT ratings than those without ADHD via collateral report, a pattern that was similar when comorbidity was considered. SCT was associated with poorer functioning after accounting for ADHD symptoms with some differential effects based on reporting source. CONCLUSION: Findings support the internal consistency and validity of a three-factor SCT scale among adult outpatients. Differential results between self- and collateral report demonstrate the importance of multiple reporters of SCT in clinical settings.

Introduction Children with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for smoking cigarettes, but there is little longitudinal research on the array of smoking characteristics known to be prognostic of long-term smoking outcomes into adulthood. These variables were studied into early adulthood in a multisite sample diagnosed with ADHD combined type at ages 7-9.9 and followed prospectively alongside an age- and sex-matched local normative comparison group (LNCG). Methods Cigarette smoking quantity, quit attempts, dependence, and other characteristics were assessed in the longitudinal Multimodal Treatment Study of Children with ADHD (MTA) eight times to a mean age of 24.9 years: ADHD n = 469; LNCG n = 240. Results In adulthood, the ADHD group had higher rates of daily cigarette smoking, one or more quit attempts, shorter time to first cigarette of the day, and more severe withdrawal than the LNCG. The ADHD group did not appear to have better smoking cessation rates despite a higher proportion quitting at least once. Smoking quantity and nicotine dependence did not differ between groups. The ADHD group reported younger daily smoking onset and faster progression from smoking initiation to daily smoking across assessments. Finally, ADHD symptom severity in later adolescence and adulthood was associated with higher risk for daily smoking across assessments in the ADHD sample. Conclusions This study shows that ADHD-related smoking risk begins at a young age, progresses rapidly, and becomes resistant to cessation attempts by adulthood. Prevention efforts should acknowledge the speed of uptake; treatments should target the higher relapse risk in this vulnerable population. Implications Although childhood ADHD predicts later smoking, longitudinal studies of this population have yet to fully characterize smoking behaviors into adulthood that are known to be prognostic of long-term smoking outcome. The current study demonstrates earlier and faster progression to daily smoking among those with a childhood ADHD diagnosis, as well as greater risk for failed quit attempts. Prevention efforts should address speed of smoking uptake, while treatments are needed that address smoking relapse risk. The current study also demonstrates ADHD symptom severity over development increases daily smoking risk, implicating the need for continuous ADHD symptom management.

Background Mindfulness-based interventions improve a variety of clinical outcomes. Executive functioning (EF) and emotion dysregulation are among the proposed transdiagnostic mechanisms that such interventions are proposed to target. The aim of the current study was to evaluate the impact of mindfulness meditation training on EF and emotion dysregulation in a sample of female adolescents with elevations in attention-deficit/hyperactivity disorder (ADHD) symptoms against a waitlist control condition. Method This study adopted a mixed 2 (treatment group, waitlist control group) × 2 (pre-test, post-test) design. Adolescent females (13–15 years old) exhibiting elevations in ADHD symptoms according to multiple informants were randomly assigned to a mindfulness treatment group (n = 15) or a waitlist control group (n = 15). Results Among EF laboratory tasks, planning and inhibition were higher in the treatment group relative to the control group with large effect sizes at post-treatment. The treatment group also exhibited lower scores in self-reported emotion dysregulation (total, nonacceptance of emotional responses, and impulse control difficulties) in comparison to the waitlist control group with large effect sizes at post-treatment. Within group pre-test and post-test comparisons indicated improvement on particular facets of EF and emotion dysregulation only for the treatment group. Conclusions Mindfulness meditation training improved particular facets of EF and emotion dysregulation in adolescent females with elevations in ADHD symptoms. Treatment development efforts should target clinical populations that exhibit difficulties in these transdiagnostic mechanisms.

Abstract. The goal of the present investigation was to expand the literature on impulsivity and Cluster B personality disorders (PDs) by conceptualizing impulsivity in a multidimensional manner. Two separate undergraduate samples (n = 223; n = 204) completed measures of impulsivity and Cluster B dimensions. Impulsivity was indeed predictive of Cluster B dimensions and, importantly, each PD scale exhibited a unique impulsivity profile. Findings for borderline PD scores were highly consistent across samples and strongly and positively associated with urgency and lack of perseverance, as expected. Findings for the other PD dimensions also exhibited a fair amount of consistency. Implications of these findings for diagnostic classification and treatment are discussed.

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.

Childhood attention-deficit/hyperactivity disorder (ADHD) is prospectively linked to substance use and disorder. Depression emerging in adolescence is an understudied risk factor that may explain some of this risk. In the present study, we considered mediating and moderating roles of adolescent depression in explaining this association by using longitudinal data from the prospective 16-year follow-up of the Multimodal Treatment Study of ADHD (MTA). Participants were 547 children diagnosed with DSM-IV ADHD Combined Type, and 258 age- and sex-matched comparison children. In adolescence, depressive symptoms did not exacerbate effects of childhood ADHD on any substance use. For both groups, time-varying and average depressive symptoms were associated with more frequent use of all substances. Prospectively, we found no evidence of depression mediation to adult substance use. However, adolescent depression moderated the association between childhood ADHD and adult marijuana use. Although adults without ADHD histories used marijuana more frequently if they had elevated depressive symptoms in adolescence, marijuana use by adults with ADHD histories was independent of their adolescent depression. In adulthood, depression diagnoses and ADHD persistence continued to operate as independent, additive correlates of substance use risk. Our findings suggest a circumscribed role for depression in substance use risk that adds to, but does not alter or explain, ADHD-related risk.

The present study tested the hypothesis that low behavioral approach system (BAS) sensitivity is associated with social anxiety in combat veterans.Self-report measures of reinforcement sensitivity, combat exposure, social interaction anxiety, and social observation anxiety were administered to 197 Iraq/Afghanistan combat veterans.As expected, combat exposure, behavioral inhibition system (BIS) sensitivity, and fight-flight-freeze system (FFFS) sensitivity were positively associated with both social interaction anxiety and social observation anxiety. In contrast, BAS sensitivity was negatively associated with social interaction anxiety only. An analysis of the BAS subscales revealed that the Reward Responsiveness subscale was the only BAS subscale associated with social interaction anxiety. BAS-Reward Responsiveness was also associated with social observation anxiety.The findings from the present research provide further evidence that low BAS sensitivity may be associated with social anxiety over and above the effects of BIS and FFFS sensitivity.

The objective of the present research was to examine the association between ADHD symptoms and nonsuicidal self-injury (NSSI) in male Iraq/Afghanistan-era veterans with and without PTSD. Approximately 25% of veterans screened positive for clinically-significant levels of ADHD. Male veterans with PTSD were significantly more likely to report ADHD symptoms than male veterans without PTSD. In addition, as expected, ADHD was strongly associated with NSSI, even after accounting for the effects of demographic variables, PTSD, depression, and alcohol use disorder. Future work aimed at replicating and extending these findings in longitudinal studies of veterans is needed.

Little is known about the reproductive effects of paternal cannabis exposure. We evaluated associations between cannabis or tetrahydrocannabinol (THC) exposure and altered DNA methylation in sperm from humans and rats, respectively. DNA methylation, measured by reduced representation bisulfite sequencing, differed in the sperm of human users from non-users by at least 10% at 3,979 CpG sites. Pathway analyses indicated Hippo Signaling and Pathways in Cancer as enriched with altered genes (Bonferroni p

BackgroundPre-exposure prophylaxis (PrEP) provides a strong preventative benefit to individuals at risk for HIV. While PrEP adherence is highly correlated with its efficacy, adherence rates are variable both across and within persons. ObjectiveThe objective of this study was to develop and pilot-test a smartphone-based intervention, known as mSMART, that targets PrEP adherence. mSMART provides contingency management in the form of monetary incentives for daily PrEP adherence based on a real-time adherence assessment using a camera-based medication event-monitoring tool as well as medication reminders, PrEP education, individualized behavioral strategies to address PrEP adherence barriers, and medication adherence feedback. MethodsThis was a 4-week open-label, phase I trial in a community sample of young men who have sex with men already on PrEP (N=10). ResultsAlthough adherence composite scores corresponding to PrEP biomarkers indicated that 90% (9/10) of the sample already had an acceptable baseline adherence in the protective range, by the end of the 4-week period, the scores improved for 30% (3/10) of the sample—adherence did not worsen for any participants. Participants reported mean PrEP adherence rates of 91% via daily entries in mSMART. At the end of the 4-week period, participants indicated acceptable ratings of satisfaction, usability, and willingness to recommend mSMART to others. There were no technical difficulties associated with smartphone compatibility, user misunderstandings about mSMART features that interfered with daily use, or study attrition. ConclusionsThis study is the first to apply contingency management to PrEP adherence. Findings indicated that mSMART is feasible and acceptable. Such an adherence intervention administered via a user-friendly smartphone app can allow for widespread dissemination. Future efficacy trials are needed. Trial RegistrationClinicalTrials.gov NCT02895893; https://clinicaltrials.gov/ct2/show/NCT02895893 (Accessed by Webcite at http://www.webcitation.org/72JskjDJq)

This chapter describes the long-term outcomes in the Multimodal Treatment study of ADHD (MTA), which began in 1994 and ended in 2014. First, we provide a short history of the origin of the MTA. Second, we review the design as a 14-month randomized clinical trial and the transition to a long-term follow-up. Third, we present findings from 12 key publications describing outcomes in four stages of the MTA from childhood to adulthood. Fourth, we discuss how the final adult assessments of the MTA address critical issues about symptomatic persistence of ADHD, functional outcomes outside the parental home, and cost-benefit analyses of residual effects of treatment with medication.

Background Inconsistent findings exist regarding long-term substance use (SU) risk for children diagnosed with attention-deficit/hyperactivity disorder (ADHD). The observational follow-up of the Multimodal Treatment Study of Children with ADHD (MTA) provides an opportunity to assess long-term outcomes in a large, diverse sample. Methods Five hundred forty-seven children, mean age 8.5, diagnosed with DSM-IV combined-type ADHD and 258 classmates without ADHD (local normative comparison group; LNCG) completed the Substance Use Questionnaire up to eight times from mean age 10 to mean age 25. Results In adulthood, weekly marijuana use (32.8% ADHD vs. 21.3% LNCG) and daily cigarette smoking (35.9% vs. 17.5%) were more prevalent in the ADHD group than the LNCG. The cumulative record also revealed more early substance users in adolescence for ADHD (57.9%) than LNCG (41.9%), including younger first use of alcohol, cigarettes, marijuana, and illicit drugs. Alcohol and nonmarijuana illicit drug use escalated slightly faster in the ADHD group in early adolescence. Early SU predicted quicker SU escalation and more SU in adulthood for both groups. Conclusions Frequent SU for young adults with childhood ADHD is accompanied by greater initial exposure at a young age and slightly faster progression. Early SU prevention and screening is critical before escalation to intractable levels.

This study assessed quality of life, emotional and behavioral problems, prosocial behavior, and functional impairment in a sample of Iranian children based on their attention and behavioral control skills. The sample consisted of 280 male and female children aged between 6 and 12 years old who were divided into strong, moderate, and weak groups based on parental ratings of attention and behavioral control skills on the strengths and weaknesses of ADHD symptom and normal behavior rating scale (SWAN). In addition, parents completed the pediatric quality of life inventory version 4.0 generic core scales (PedsQL 4.0), the strengths and difficulties questionnaire, and the Weiss functional impairment rating scale-parent report (WFIRS-P). The strong group generally showed better quality of life than the weak group. The strong group was better than the moderate group, and the moderate group was better than the weak group on school functioning. The weak group had more conduct problems and hyperactivity/inattention and less prosocial behavior than the moderate group and the strong group. The moderate group had more hyperactivity/inattention than the strong group. The weak group showed more impairment than the moderate group and the strong group on all subscales and the total scale of the WFIRS-P. The quality of life, behavioral problems, prosocial behavior, and functional impairment can be different in children based on their attention and behavioral control skills.

BACKGROUND Pre-exposure prophylaxis (PrEP) provides a strong preventative benefit to individuals at risk for HIV. While PrEP adherence is highly correlated with its efficacy, adherence rates are variable both across and within persons. OBJECTIVE The objective of this study was to develop and pilot-test a smartphone-based intervention, known as mSMART, that targets PrEP adherence. mSMART provides contingency management in the form of monetary incentives for daily PrEP adherence based on a real-time adherence assessment using a camera-based medication event-monitoring tool as well as medication reminders, PrEP education, individualized behavioral strategies to address PrEP adherence barriers, and medication adherence feedback. METHODS This was a 4-week open-label, phase I trial in a community sample of young men who have sex with men already on PrEP (N=10). RESULTS Although adherence composite scores corresponding to PrEP biomarkers indicated that 90% (9/10) of the sample already had an acceptable baseline adherence in the protective range, by the end of the 4-week period, the scores improved for 30% (3/10) of the sample—adherence did not worsen for any participants. Participants reported mean PrEP adherence rates of 91% via daily entries in mSMART. At the end of the 4-week period, participants indicated acceptable ratings of satisfaction, usability, and willingness to recommend mSMART to others. There were no technical difficulties associated with smartphone compatibility, user misunderstandings about mSMART features that interfered with daily use, or study attrition. CONCLUSIONS This study is the first to apply contingency management to PrEP adherence. Findings indicated that mSMART is feasible and acceptable. Such an adherence intervention administered via a user-friendly smartphone app can allow for widespread dissemination. Future efficacy trials are needed. CLINICALTRIAL ClinicalTrials.gov NCT02895893; https://clinicaltrials.gov/ct2/show/NCT02895893 (Accessed by Webcite at http://www.webcitation.org/72JskjDJq)

Diagnostic guidelines differ between DSM attention-deficit/hyperactivity disorder (ADHD) and ICD hyperkinetic disorder (HKD). Only 145 of 579 children age 7–9 in the Multimodal Treatment Study of ADHD (the MTA) with combined-type DSM-IV ADHD met criteria for ICD-10 HKD, because major internalizing comorbidities and more stringent symptom count/pervasiveness requirements excluded most. The 145 HKD had significantly better 14-month medication response than the rest. We explored whether HKD had greater adult symptom persistence and/or impairment than other ADHD. Multi-informant assessments were done for 16 years. We used the 12/14/16-year assessments, in young adulthood. The post-attrition 109 with baseline HKD had no greater adult persistence of ADHD symptoms/impairment than 367 without HKD, but had more cumulative stimulant use, more job losses, lower emotional lability, and fewer car crashes. However, those excluded for internalizing comorbidity but otherwise meeting HKD criteria had significantly more persistence. Only 6 of the 109 (5.5%) with baseline HKD met ICD-10 criteria for HKD in adulthood, compared to 25 of 367 (6.8%) without a childhood HKD diagnosis. Despite greater initial symptom severity, HKD had no worse 16-year young adult outcome than others, except for job losses, balanced by less emotional lability and fewer crashes. Comorbid internalizing disorder seems to have worse prognosis than initial severity/pervasiveness of ADHD symptoms.

Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder that regularly persists into adulthood and is associated with a number of maladaptive functional outcomes. Cognitive-behavioral therapy (CBT) is an empirically based treatment that has demonstrated effects on core ADHD symptoms and related impairments in adult samples. One manualized CBT in particular is proposed to target both core symptoms of ADHD and underlying executive functioning (EF) deficits. Targeting underlying dysfunction is important to ongoing treatment development efforts and may enhance efficacy. This manualized CBT was developed for groups. The aims of this case study were twofold. First, we adapted a manualized group-based CBT for adult ADHD for an individual format. Second, we discuss a case study to exemplify how clinicians can measure and track EF symptoms in a clinic setting using a multi-method approach. Self-report and collateral-report questionnaire data provided initial support for adaptation of Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction to an individual format. Outcome data were more limited with cognitive test scores. The discrepancy between questionnaire and cognitive test data along with the complications observed at 2-month follow up are discussed.

Research examining nonpharmacological interventions for adults diagnosed with attention-deficit/hyperactivity disorder (ADHD) has expanded in recent years and provides patients with more treatment options. Mindfulness-based training is an example of an intervention that is gaining promising preliminary empirical support and is increasingly administered in clinical settings. The aim of this review is to provide a rationale for the application of mindfulness to individuals diagnosed with ADHD, describe the current state of the empirical basis for mindfulness training in ADHD, and summarize a treatment approach specific to adults diagnosed with ADHD: the Mindful Awareness Practices (MAPs) for ADHD Program. Two case study examples are provided to demonstrate relevant clinical issues for practitioners interested in this approach. Directions for future research, including mindfulness meditation as a standalone treatment and as a complementary approach to cognitive-behavioral therapy, are provided.

Clinicians who conduct cognitive-behavioral therapy (CBT) targeting attention-deficit/hyperactivity disorder (ADHD) in adulthood have noted that their patients sometimes verbalize overly positive automatic thoughts and set overly optimistic goals. These cognitions are frequently related to failure to engage in compensatory behavioral strategies emphasized in CBT. In this paper, we offer a functional analysis of this problematic pattern, positively-valenced cognitive avoidance, and suggest methods for addressing it within CBT for adult ADHD. We propose that maladaptive positive cognitions function to relieve aversive emotions in the short-term and are therefore negatively reinforced but that, in the long-term, they are associated with decreased likelihood of active coping and increased patterns of behavioral avoidance. Drawing on techniques from Behavioral Activation (BA), we offer a case example to illustrate these concepts and describe step-by-step methods for clinicians to help patients recognize avoidant patterns and engage in more active coping.

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.

Adolescents and young adults without childhood attention deficit hyperactivity disorder (ADHD) often present to clinics seeking stimulant medication for late-onset ADHD symptoms. Recent birth-cohort studies support the notion of late-onset ADHD, but these investigations are limited by relying on screening instruments to assess ADHD, not considering alternative causes of symptoms, or failing to obtain complete psychiatric histories. The authors address these limitations by examining psychiatric assessments administered longitudinally to the local normative comparison group of the Multimodal Treatment Study of ADHD.Individuals without childhood ADHD (N=239) were administered eight assessments from comparison baseline (mean age=9.89 years) to young adulthood (mean age=24.40 years). Diagnostic procedures utilized parent, teacher, and self-reports of ADHD symptoms, impairment, substance use, and other mental disorders, with consideration of symptom context and timing.Approximately 95% of individuals who initially screened positive on symptom checklists were excluded from late-onset ADHD diagnosis. Among individuals with impairing late-onset ADHD symptoms, the most common reason for diagnostic exclusion was symptoms or impairment occurring exclusively in the context of heavy substance use. Most late-onset cases displayed onset in adolescence and an adolescence-limited presentation. There was no evidence for adult-onset ADHD independent of a complex psychiatric history.Individuals seeking treatment for late-onset ADHD may be valid cases; however, more commonly, symptoms represent nonimpairing cognitive fluctuations, a comorbid disorder, or the cognitive effects of substance use. False positive late-onset ADHD cases are common without careful assessment. Clinicians should carefully assess impairment, psychiatric history, and substance use before treating potential late-onset cases.

Objective: The clinical literature on ADHD in adults suggests that “overly positive” or optimistic cognitions may contribute to impairment and failure to use self-regulation skills in this population, yet the research literature on this topic is limited. We developed the ADHD Cognitions Scale (ACS), a brief self-report measure of ADHD-related thoughts, and evaluated its psychometric properties. Method: We collected self-report measures, inculding the ACS, from two large community samples ( Ns = 262, 304). Results: The measure demonstrated a one-factor solution that replicated in the second sample. Evidence of good internal consistency and also convergent and divergent validity was obtained for both samples. Scores on the ACS correlated with functional impairment, time management problems, and avoidant coping strategies. Conclusion: With additional study, the ACS may be useful to identify and track maladaptive ADHD-related cognitions during cognitive-behavioral treatment, and to further study the role of these thoughts in ADHD-related impairment.

Background Fueled by rapid technological advances over the past decade, there is growing interest in the use of smartphones to aid in smoking cessation. Hundreds of applications have been developed for this purpose, but little is known about how these applications are accessed and used by smokers or what features smokers believe would be most useful. Purpose The present study sought to understand the prevalence of smartphone ownership and patterns of use among smokers as well as the perceived utility of various smartphone application features for smoking cessation that are currently in development or already available. Methods Daily cigarette smokers (n = 224) reported on smartphone ownership, their patterns of smartphone usage, and perceived utility of features. Features were ranked according to perceived utility and differences in both perceived utility and general smartphone use patterns were examined as a function of demographic and smoking-related variables. Results Most smokers (80.4%) own a smartphone, but experience with smoking cessation applications is extremely rare (6.1%). Ownership and patterns of usage differed as a function of demographic and smoking-related variables. Overall, gain-framed features were rated as most useful, while loss-framed and interpersonal features were rated as least useful. Conclusions Mobile health interventions have the potential to reach a large number of smokers but are currently underutilized. Additional effort is needed to ensure parity in treatment access. Gain-framed messages may be especially useful for engaging smokers, even if other features ultimately drive treatment effects. Implications This study describes patterns of smartphone usage among smokers and identifies the smartphone application features smokers believe would be most useful during a quit attempt. Findings indicate which subgroups of smokers are most likely to be reached with mobile health interventions and suggests that inclusion of specific features may be helpful for engaging smokers in the smoking cessation process.

OBJECTIVE: This study examines the behavior beliefs, social supports, and turning points in individuals with/without Attention-Deficit/Hyperactivity Disorder (ADHD) related to their substance use/abuse (SU/A) decisions. METHOD: The coded interviews from sixty participants with/without ADHD were compared for their SU/A decisions and precipitants to these decisions among abstainers, persisters, and desisters. RESULTS: ADHD subjects reported fewer social advantages to avoid SU/A than non-ADHD subjects. Desisters and persisters reported more social advantages of using drugs than abstainers. Persisters reported both more negative and positive psychological/physiological effects of SU/A. ADHD subjects reported fewer positive role models in their lives. Non-ADHD patients reported more positive turning points than ADHD subjects, regardless of SU/A status. CONCLUSIONS: ADHD individuals face challenges in making healthy decisions about SU/A due to lack of positive role models. Reinforcing accurate behavioral beliefs may be important to change behaviors in individuals with SU/A or to prevent SU/A initiation in ADHD individuals.

The current study assessed antecedents and consequences of ad lib cigarette smoking in smokers diagnosed with attention-deficit/hyperactivity disorder (ADHD) using ecological momentary assessment (EMA). Adult smokers with ADHD (n = 17) completed 870 smoking and 622 nonsmoking electronic diary entries over a seven-day observation period of their naturalistic smoking behavior. Data collection occurred from 2011 to 2012. Generalized estimating equations indicated that ADHD smokers were more likely to smoke when urge to smoke, negative affect, boredom, stress, worry, and restlessness were elevated. In addition, participants were more likely to smoke in situations that elicited higher levels of nervousness and frustration. ADHD symptoms, in general, did not differ between smoking and nonsmoking contexts, though hyperactive-impulsive ADHD symptoms were elevated prior to smoking in frustrating situations. Additional situational antecedent variables were associated with smoking, including being in the presence of others smoking, being in a bar or restaurant, while outside, and while consuming caffeinated or alcoholic beverages. Participants also reported a significant improvement in urge to smoke, negative affect, stress, hunger, and ADHD symptoms after smoking a cigarette. Findings suggest certain contextual factors that may maintain ad lib cigarette smoking in smokers with ADHD and identify potential treatment targets in smoking cessation interventions for this at-risk group. Clinical implications and future research directions are discussed. Funding for this study was provided by the National Institute on Drug Abuse.