Upgrading the science and technology of assessment and diagnosis: laboratory and clinic-based assessment of children with ADHD

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

Interventions to Address the Academic Impairment of Children and Adolescents with ADHD

There exists a strong link between ADHD and academic underachievement. Both the core behavioral symptoms of ADHD and associated executive functioning deficits likely contribute to academic impairment. Current evidence-based approaches to the treatment of ADHD (i.e., stimulant medication, clinical behavior therapy and classroom behavioral interventions) have demonstrated a robust impact on behavioral variables such as attention and disruptive behavior within classroom analogue settings; however, their efficacy in improving academic outcomes is much less clear. Although surprisingly few treatment outcome studies of ADHD have attempted to incorporate interventions that specifically target academic outcomes, the studies that are available suggest that these interventions may be beneficial. The state of the treatment literature for addressing academic impairment in children and adolescents with ADHD will be reviewed herein, as well as limitations of current research, and directions for future research.     

Pivotal areas in intervention for autism

Discusses several core pivotal areas that appear to be influential in intervention for autism. Literature and outcome data are reviewed with respect to several core areas that appear to be particularly helpful in intervention for autism, including improving motivation, responsivity to multiple cues, self-management, and self-initiation of social interactions. A conceptual framework is described, and outcome data are reviewed suggesting that when children with autism are motivated to initiate complex social interactions, it may reverse a cycle of impairment, resulting in exceptionally favorable intervention outcomes for many children. Because the peripheral features of autism can be numerous and extensive, the concept of intervention for pivotal areas of functioning may be critical if children are to be habilitated in a time- and cost-efficient manner.     

Yoga,Mindfulness, and Meditation Interventions for Youth with ADHD: Systematic Review and Meta-Analysis

Attention-deficit/hyperactivity disorder (ADHD) is a chronic developmental disorder affecting 3–7% of children. In light of the growing utilization of yoga, mindfulness, and meditation in ADHD populations and potential benefits it has on ADHD symptoms, executive function deficits, and social functioning, we sought to evaluate these interventions for youth with ADHD. The primary aim of this review paper is to identify the efficacy of these programs for the treatment of youth with ADHD through a systematic review and meta-analysis. A systematic literature search was conducted in the following electronic databases: PsychINFO, ERIC, PubMed, and MEDLINE. Studies were included in the meta-analytic review if participants were between 5–17 years old, had a diagnosis of ADHD or met symptom threshold on psychometrically-validated measure of ADHD symptoms, was a treatment outcome study, and was published in a peer-reviewed English-language journal. The effect sizes of eleven studies demonstrate that yoga, mindfulness-based interventions, and/or meditation had a statistically significant effect on the outcomes of ADHD symptoms, hyperactivity, and inattention (parent and teacher report), as well as parent-child relationship, executive functioning, on-task behavior, parent stress, and parent trait-mindfulness (p?<?0.05). The effect sizes range from small to large effects across these outcomes. Considerable risk for bias was found across studies. Given significant methodological limitations of the literature, positive effect sizes found in studies should be interpreted with caution; these interventions should not be considered first-line interventions for ADHD. However, preliminary findings suggest yoga, mindfulness, and meditation may be beneficial for youth with ADHD, but extensive research is required to validate the efficacy of these interventions.     

Sluggish cognitive tempo in children and adolescents with higher functioning autism spectrum disorders: Social impairments and internalizing symptoms

Sluggish cognitive tempo (SCT) was introduced in 1980s in the field of attention deficit hyperactivity disorder (ADHD). Studies indicate that symptoms of SCT are separate from symptoms of ADHD and independently associated with multiple domains of functioning in clinical groups and in typical development. We assessed whether similar pattern would apply to higher functioning autism spectrum disorders (ASD). Children with higher functioning ASD (N = 55; 5?15 years) were divided into the ASD+High SCT (n = 17), the ASD+Medium SCT (n = 18) and the ASD+Low SCT (n = 20) groups based on parent‐rated daydreaming and slowness on the Five to Fifteen questionnaire (FTF). The groups were compared on SCT‐related impairments found in previous studies: social skills, academic functioning, psychiatric symptoms, and processing speed. Assessment methods were the FTF, the Development and Well‐Being Assessment, and the Coding subtest of the WISC‐III. The ADHD symptoms were statistically controlled due to the overlap between SCT and ADHD. The ASD+High SCT and ASD+Medium SCT groups were significantly more likely to have the most pronounced social impairments, and the ASD+High SCT group had significantly higher rate of internalizing disorders compared to the ASD+Low SCT group. Our results suggest that children with higher functioning ASD and high or medium levels of SCT symptoms could be at higher risk for psychosocial impairments than children with higher functioning ASD with low levels of SCT symptoms. Co‐occurring ADHD symptoms do not explain the finding. Recognizing SCT symptoms in higher functioning ASD would be important to targeting preventive support.     

“?rgerlich!?“ Neuronale Korrelate der Verhaltenshemmung auf emotionale Signale

Psychotherapeutic interventions for attention deficit hyperactivity disorder (ADHD) primarily aim at the three core symptom clusters of inattention, hyperactivity and impulsivity, which are characteristic for this mental disorder. However, social and emotional difficulties are also very obvious. The ADHD patients experience conflicts with parents and partners, rejection by peers and less friendships, which negatively affects everyday life. Neuroscientific research points to a deficit in ADHD to recognize specific emotions displayed by another person. This dysfunction can be found in children as well as in adults afflicted with this disorder and is especially pronounced for anger. Additionally, the patients have problems to utilize facial anger expressions of others to regulate or inhibit their own behavior. New therapy components are needed in order to reduce this deficit. The possibilities for improving psychotherapy for ADHD by means of neuroscientific methods are discussed.     

Heterogeneity in ADHD: Neurocognitive predictors of peer,family, and academic functioning

Childhood attention-deficit/hyperactivity disorder (ADHD) is associated with impairments in peer, family, and academic functioning. Although impairment is required for diagnosis, children with ADHD vary significantly in the areas in which they demonstrate clinically significant impairment. However, relatively little is known about the mechanisms and processes underlying these individual differences. The current study examined neurocognitive predictors of heterogeneity in peer, family, and academic functioning in a well-defined sample of 44 children with ADHD aged 8–13 years (M = 10.31, SD = 1.42; 31 boys, 13 girls; 81% Caucasian). Reliable change analysis indicated that 98% of the sample demonstrated objectively-defined impairment on at least one assessed outcome measure; 65% were impaired in two or all three areas of functioning. ADHD children with quantifiable deficits in academic success and family functioning performed worse on tests of working memory (d = 0.68 to 1.09), whereas children with impaired parent-reported social functioning demonstrated slower processing speed (d = 0.53). Dimensional analyses identified additional predictors of peer, family, and academic functioning. Working memory abilities were associated with individual differences in all three functional domains, processing speed predicted social functioning, and inhibitory control predicted family functioning. These results add to a growing literature implicating neurocognitive abilities not only in explaining behavioral differences between ADHD and non-ADHD groups, but also in the substantial heterogeneity in ecologically-valid functional outcomes associated with the disorder.     

Cognitive Behavioral Therapy for Attention-Deficit/Hyperactivity Disorder in College Students: A Review of the Literature

The current review presents a theory-guided review of the existing cognitive behavioral therapy (CBT) interventions for attention-deficit/hyperactivity disorder (ADHD) in college students. Across the eight studies that investigated this topic, moderate reductions were shown in inattentive symptoms but little to no change was reported in hyperactive/impulsive symptoms. Results indicated a moderate treatment effect on self-reported quality of life and school/work functioning, yet less of an impact on GPA, response inhibition, social functioning, and executive functioning. Methodological and statistical problems and inconsistencies were noted. Since college students are emerging adults, it is likely that the optimum CBT intervention for college students with ADHD lies somewhere in between the existing clinic-based adult ADHD CBT interventions as well as the school-based adolescent ADHD psychosocial interventions. Directions for future research and recommendations for clinicians in university settings are provided in an attempt to further develop the existing college students CBT clinical research evidence base.     

Consultation-based Academic Interventions for Children with ADHD: Effects on Reading and Mathematics Achievement

The purpose of this investigation was to evaluate the relative efficacy of two consultation-based models for designing academic interventions to enhance the educational functioning of children with attention-deficit/hyperactivity disorder (ADHD). Children (N=167) meeting DSM-IV criteria for ADHD were randomly assigned to one of two consultation groups: Individualized Academic Intervention (IAI; interventions designed using a data-based decision-making model that involved ongoing feedback to teachers) and Generic Academic Intervention (GAI; interventions designed based on consultant-teacher collaboration, representing "consultation as usual"). Teachers implemented academic interventions over 15 months. Academic outcomes (e.g., standardized achievement test, and teacher ratings of academic skills) were assessed on four occasions (baseline, 3 months, 12 months, 15 months). Hierarchical linear modeling analyses indicated significant positive growth for 8 of the 14 dependent variables; however, trajectories did not differ significantly across consultation groups. Interventions in the IAI group were delivered with significantly greater integrity; however, groups did not differ with respect to teacher ratings of treatment acceptability. The results of this study provide partial support for the effectiveness of consultation-based academic interventions in enhancing educational functioning in children with ADHD; however, the relative advantages of an individualized model over "consultation as usual" have yet to be established.     

Supporting Japanese Mothers of Children with ADHD: Cultural Adaptation of the New Forest Parent Training Programme

International practice guidelines recommend medication and behavioral intervention as evidenced‐based treatments for attention deficit hyperactivity disorder (ADHD). Currently in Japan, the availability of non‐pharmacological interventions for ADHD is limited. We report the results of a pilot and a proof‐of‐concept study for a new behavioral intervention for Japanese mothers of children with ADHD. The pilot study delivered a standard six‐session behavioral intervention and two parent‐support sessions. Participants approved the group format and requested additional support to change parenting practices and behavioral strategies targeting ADHD symptoms. For the proof‐of‐concept study, the intervention was revised to include five sessions of pre‐intervention support followed by six sessions of the New Forest Parent Training Programme (NFPP), an evidence‐based intervention for ADHD. The revised intervention, NFPP‐Japan, was associated with reductions in the mothers’ reports of children's ADHD symptoms and aggression, more effective parenting practices, and reduced parenting stress. The pilot and proof‐of‐concept studies indicate that it is possible to successfully modify Western behavioral interventions for Japanese mothers and to justify a randomized controlled trial evaluation of the NFPP‐Japan, which is currently underway.     

Managing Frustration for Children (MFC) Group Intervention for ADHD: An Open Trial of a Novel Group Intervention for Deficient Emotion Regulation

Deficient emotion regulation is a common and impairing area of difficulty among children with ADHD. Few interventions specifically address deficient emotion regulation. The Managing Frustration for Children With ADHD (MFC) group treatment was developed to specifically target deficient emotion regulation deficits common to children with ADHD. The MFC was developed as a 12-week multisystemic intervention for emotion regulation deficits among children with ADHD. An open trial assessed the effectiveness of the MFC as an adjunctive treatment for deficient emotion regulation among children with ADHD. Fifty-two children with ADHD ages 9–11 (42 boys, 10 girls) were enrolled in the MFC, with 44 completing treatment. The majority (71.2%) of participants had at least one comorbid internalizing, externalizing, or learning disorder. Intent-to-treat repeated-measures ANCOVA suggested significant decreases in emotion regulation deficits, mood difficulties, and externalizing difficulties following completion of treatment. More than half (53%) of children who completed treatment experienced reliable and clinically significant improvement in at least one area of functioning. The MFC demonstrated promising initial effectiveness in addressing the emotion regulation deficits of children with ADHD.     

Bending the Curve: A Community-Based Behavioral Parent Training Model to Address ADHD-Related Concerns in the Voluntary Sector in Denmark

Limited access to evidence-based behavioral parent training (BPT) for addressing attention deficit/hyperactivity disorder (ADHD) has been a growing concern internationally. Models to improve access to BPT are needed, particularly those that can be readily implemented in community settings and that leverage the potential workforce to increase capacity to deliver BPT. The purpose of this study was to evaluate a BPT model which included oft-used content, methods, processes of BPT (common-elements), non-professionally delivered (task-shifted/shared) BPT intervention, and an efficient ancillary support system (training, fidelity, and supervision methods) for families of youth with parental concerns about ADHD. In a randomized controlled trial of 161 families of children (79% male; mean age 7.04 [1.55]), the Caring in Chaos (CiC) BPT model, delivered by community volunteers across 12 community-based sites in Denmark, was compared to a wait-list control condition on key child and parent outcomes at immediate post-treatment and 4-month follow-up assessment points. Results suggested that the CiC model led to significantly greater improvement in parenting behavior, parenting sense of competence, child functional impairment, parental stress and parental depressive symptoms compared to the wait list condition at immediate post-treatment, with maintenance of gains in most of these areas at follow-up assessment. No effect of intervention was found on ADHD symptoms. The results of this study suggest that developing efficient BPT intervention models, such as the CiC model, can result in readily implemented interventions by a variety of individuals in community settings. Such models are necessary to bend the curve on addressing unmet needs of families of youth with concerns about ADHD.     

The Effectiveness of Coping Power Program for ADHD: An Observational Outcome Study

The present study evaluates the implementation of the Coping Power Program (CPP)-Child Component in a group of patients with attention deficit/hyperactivity disorder (ADHD), and explores the effects of this treatment on changes in the primary and associated symptoms of ADHD. A clinical sample of 50 children and preadolescents (8–13 years) with ADHD was involved. The clinical sample was split into a treatment group (TG; N?=?26), which was included in the child training program (CPP), and a control group (CG; N?=?24), which was placed on a waiting list. The Clinical Global Impression-Severity (CGI-S) and the Child Behavior Checklist 6–18 (CBCL 6–18) were assessed at baseline and at the end of treatment. The outcomes were assessed as a CBCL-subscale response rate and a CGI-S shift. Our results showed a significant improvement in children’s global functioning and in emotional and behavioral symptoms. The children in the TG were more likely to shift from a more severe functional impairment class to a less severe one (69.2% of TG vs. 20.8% of CG). Further, the CGI-S scores diminished significantly in the TG (p?<?0.01). There were significant differences in the changes in Social Problems (p?<?0.05), Attention Problems (p?<?0.05) and Rule-Breaking Behavior Scales (p?<?0.05). CPP seemed to be effective in children and adolescents with ADHD without comorbidity for ODD or CD. Our study revealed an improved outcome, not only in the core symptoms of ADHD, but also in global functioning and social adjustment. Possible improvements to the present formulation of CPP-C are discussed.     

Review of the Evidence for Motivation Deficits in Youth with ADHD and Their Association with Functional Outcomes

Preeminent theories of attention-deficit/hyperactivity disorder (ADHD) suggest that motivation deficits are core underlying features of the disorder. However, it is currently unclear whether empirical evidence supports the assertion that significant group (ADHD v. comparison) differences in motivation exist or that problems with motivation contribute to the functional impairments that youth with ADHD experience. Accordingly, this review focused on evaluating and summarizing the empirical literature on the presence of motivation deficits and their association with functional outcomes in samples of youth with ADHD. Twenty studies met the review inclusion criteria. Results support the assertion that youth with ADHD have lower academic-related motivation in comparison to their peers and that motivation plays an important role in academic outcomes, with the strongest evidence to date for reading achievement. However, the available evidence is limited, and few existing studies are aligned with the much larger theoretical and empirical motivation literature in typically developing youth. Given preliminary evidence that motivation plays a role in the academic impairments of youth with ADHD, the review concludes with a discussion of whether current ADHD interventions adequately target motivation and highlights important future directions.     

Use of Gilliam Asperger's disorder scale in differentiating high and low functioning autism and ADHD

Little is known about the validity of Gilliam Asperger's Disorder Scale (GADS), although it is widely used. This study of 199 children with high functioning autism or Asperger's disorder, 195 with low functioning autism, and 83 with attention deficit hyperactivity disorder (ADHD) showed high classification accuracy (autism vs. ADHD) for clinicians' GADS Quotients (92%), and somewhat lower accuracy (77%) for parents' Quotients. Both children with high and low functioning autism had clinicians' Quotients (M=99 and 101, respectively) similar to the Asperger's Disorder mean of 100 for the GADS normative sample. Children with high functioning autism scored significantly higher on the cognitive patterns subscale than children with low functioning autism, and the latter had higher scores on the remaining subscales: social interaction, restricted patterns of behavior, and pragmatic skills. Using the clinicians' Quotient and Cognitive Patterns score, 70% of children were correctly identified as having high or low functioning autism or ADHD.     

正念冥想在ADHD儿童干预中的应用

正念冥想是有意识、非评判地将注意集中于当下经验的方法。近年来,正念冥想作为一种潜在的方法被引进到ADHD儿童干预领域。因为ADHD儿童的特异性,为了增加正念冥想方案对ADHD儿童的适切性,研究者从练习设置、奖励系统、解释方式和家长纳入几个方面对标准的正念减压训练方案做了改编。越来越多的研究证据表明,正念冥想训练能有效地减轻ADHD儿童的核心缺陷、改善其内外化症状和亲子关系。本文通过对已有相关实证研究的分析认为这些积极的影响可能与ADHD儿童的执行功能与去中心化等心理功能的改善有关,而大脑相关区域激活模式的变化和结构的积极改变可能是正念冥想影响ADHD儿童的神经基础。文章也提出已有研究在内容和方法学上的不足及其以后的探究方向。     

The Effects of Thematic Importance on Story Recall among Children with Attention Deficit Hyperactivity Disorder and Comparison Children

This study examined the recall of televised stories for younger (4-6 years) and older (7-9 years) children with and without attention deficit hyperactivity disorder (ADHD) under two different viewing conditions (toys present/toys absent). Each child watched two Rugrats television programs, once with toys present and once with toys absent. Immediately after viewing a program, the child completed a free recall of the observed story. Comparison children's recall increased more than ADHD children's as importance level increased, and comparison children recalled more information overall than children with ADHD. When toys were present, children with ADHD retold less coherent stories than comparison children, as indexed by smaller correlations between the story units recalled and the order of these units in the story. In summary, children with ADHD demonstrated multiple difficulties in story comprehension. These findings add to our understanding of the differences in higher-order cognitive processing abilities between children with ADHD and comparison children, and suggest important areas of focus in designing more effective academic interventions for children with ADHD.     

L’entraînement de la mémoire de travail par le programme Cogmed et le TDAH

IntroductionAttention-deficit/hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder. Inattention, hyperactivity, and impulsivity are key symptoms of ADHD. It is typically associated with working memory deficits at the cognitive level. For this reason, interventions have been designed to train working memory in ADHD. Currently, Cogmed Working Memory Training program is the most commonly used and studied program in clinical practice and research. This program is proposed as an intervention for ADHD that targets working memory deficits with specific exercises through intensive training sessions.ObjectivesThe goal of this literature review is to examine the effects of the Cogmed program in children and adolescents with ADHD on working memory, inhibition, non-verbal reasoning, attention functioning, ADHD symptoms and academic achievement. All existing studies on the subject that included a control group (n = 8) are reviewed.ResultsIt is clear from most studies that Cogmed training program increases and verbal and visuospatial working memory (or the phonological loop and visuospatial sketchpad in Baddeley's model (1986, 2007), among ADHD participants. However, transfer of learning is not demonstrated on other components of working memory that are not directly targeted by the program such as the central executive described in Baddeley's model or the secondary memory defined by Unsworth & Engle (2007). With regards to far transfer measures, results are controversial for inhibition, non-verbal reasoning, ADHD symptoms reported by parents, and reading abilities. No improvement is demonstrated for attentional capacities, ADHD symptoms reported by teachers and mathematic reasoning.ConclusionCogmed training improves verbal and visuospatial working memory, two cognitive functions that play an important role in ADHD. However, Cogmed's exercises need to be modified in order to train more complex working memory components such as the central executive (Baddeley, 1986, 2007) and the secondary memory (Unsworth & Engle, 2007), which are more impaired in ADHD than the phonological loop and visuospatial sketchpad. Another approach would be to design programs that can tackle a larger range of cognitive functions that are impaired in ADHD (e.g., inhibition). In future, studies evaluating such modified programs, direct observation instruments that are more sensitive to short-term changes need to be included. Follow-up measures should also be systematically included.     

注意缺陷多动障碍-发展性阅读障碍共患儿童的干预效果及其内在机理

注意缺陷多动障碍和发展性阅读障碍是两类常见的儿童神经发育障碍, 二者共患率高达25%~48%。共患问题不仅使儿童自身面临着严重的认知、行为和心理损害, 还给家庭、学校和社会带来了沉重的负担, 对共患儿童的干预是极为必要且重要的。以共患病理机制假说为基础, 可将既往共患儿童的干预研究划分为以下两大类：(1)基于表型假说的干预方案, 如药物干预、阅读干预以及二者联合干预, 相应方案干预效果的迁移性和稳定性均有待深入考究; (2)基于共同缺陷假说的干预方案, 如针对核心共同认知缺陷之一的加工速度问题的干预已初显成效, 但相关研究较少, 干预效果需更多研究进一步系统性地考察。最后就共患儿童的干预方案现状进行了反思和展望。