Response to commentary on the multimodal treatment study of ADHD (MTA): mining the meaning of the MTA

In the December 2000 issue of the Journal of Abnormal Child Psychology, we published a set of papers presenting secondary analyses of the Multimodal Treatment Study of ADHD (MTA), and R. A. Barkley (2000) provided a commentary. A critique of the design of the study (MTA Cooperative Group, 1999) was presented based on a theoretical perspective of a behavioral inhibition deficit that has been hypothesized as the core deficit of ADHD (R. A. Barkley, 1997). The commentary questioned the design and analysis of the MTA in terms of (1) the empirical criteria for selection of components of behavioral (Beh) intervention, (2) the effectiveness of the Beh intervention, (3) the methods for analyses at the group and individual level, (4) implications of the MTA findings for clinical practice, (5) the role of genetics in response to treatment, and (6) the lack of a nontreatment control group. In this response, we relate the content of the papers to the commentary, (1) by reviewing the selection criteria for the Beh treatment, as outlined by K. C. Wells, W. E. Pelham, et al. (2000), (2) by addressing the myth that the MTA Beh treatment was ineffective (Pelham, 1999), (3) by describing the use of analyses at the level of the individual participant, as presented by J. S. March et al. (2000) and W. E. Pelham et al. (2000) as well as elsewhere by J. M. Swanson et al. (2001) and C. K. Conners et al. (2001), (4) by relating some of the suggestions from the secondary analyses about clinically relevant factors such as comorbidity (as presented by J. S. March et al., 2000) and family and parental characteristics (as presented by B. Hoza et al., 2000, S. P. Hinshaw et al., 2000, and K. C. Wells, J. N. Epstein, et al., 2000), (5) by discussing the statistical concept of heritability and the lack of a significant difference in the presence of ADHD symptoms in parents of the MTA families compared to parents in the classmate-control families (as presented by J. N. Epstein, et al., 2000), and (6) by acknowledging that an ethically necessary weakness of the MTA design is that it did not include a no-treatment control group. We discuss the use of secondary analyses to suggest how, when, and for what subgroups effectiveness of the Beh treatment may have been manifested. Finally, we invite others to use the large and rich data set that will soon be available in the public domain, to perform secondary analyses to mine the meaning of the MTA and to evaluate theories of ADHD and response to treatments.     

Knowledge and attitudes about attention-deficit hyperactivity disorder (ADHD): a comparison between practicing teachers and undergraduate education students

The knowledge and attitudes of practicing teachers regarding ADHD were compared with those of undergraduate education students. Key elements of studies of American and Canadian teachers by Jerome, Gordon, and Hustler (1994) and Jerome, Washington, Laine, and Segal (1999) were replicated. Information was gathered about participants' demographic background (training in ADHD), attitudes towards ADHD, and knowledge about its diagnosis and treatment. Results confirmed the existence of some knowledge gaps, although both practicing teachers and undergraduate education students possessed sound information about ADHD. Misconceptions about ADHD primarily concerned dietary treatment. Attitudes and knowledge were significantly correlated and most participants regarded ADHD as a valid diagnosis with implications for the school setting, and expressed a desire for comprehensive training. Despite similar results for both samples, teachers achieved higher accuracy on knowledge-based questions. These results are discrepant from those of Jerome et al. (1999) who found teachers and students to be similar in factual knowledge. Implications of these findings for curriculum development in academia and in-service teacher training are highlighted.     

Impairment of executive functions in boys with attention deficit/hyperactivity disorder.

The main aim of the present study is to compare the efficiency of executive control processes in 24 boys with attention deficit/hyperactivity disorder (ADHD) and 58 normal controls of similar age (between 8 and 11 years). Three reaction time (RT) paradigms were utilized: a dual task that requires coordination of two tasks responses, a shift task that makes it necessary to disengage attention from one task and engage into another one, and a stimulus-response spatial compatibility task that requires participants to inhibit a prepotent response. Another purpose of the study is to examine whether Barkley's (1997) executive dysfunction or Sergeant et al.'s (1999) resource allocation/arousal model best account for the behavioral deficits associated with ADHD. Examination of raw RT data showed significantly poorer performance in ADHD children with respect to age-matched controls on both the higher-level cognitive functions of executive control and on lower-level abilities (e.g., speed of processing) of all tasks of this study. However, using proportional transformations of raw RT data, we could demonstrate that, in addition to differences in processing speed, also executive control processes were significantly impaired in children with ADHD.     

海洛因延迟强化物超快速折扣倾向的心理机制

以124名处于不同戒除时相的男性海洛因戒除者为被试, 采用金钱和海洛因延迟折扣任务(DDT), 并以基于线索暴露的渴求感测量为效度指标, 探讨了该类人群对海洛因延迟强化超快速折扣倾向及其心理机制。结果发现: (1) 相对于金钱延迟强化, 戒除者对海洛因延迟强化表现出显著的超快速折扣倾向, 且该倾向不随戒除期的延长而改变; (2) 戒除者对海洛因延迟强化的超快速折扣行为可能是其冲动性特质与海洛因相关线索共同作用的结果, 海洛因相对于金钱折扣率的增量部分可能反映了海洛因及其相关线索对该类人群主观渴求感的诱发效应。     

奖惩对注意缺陷多动障碍儿童情感决策的影响

采用简化版儿童赌博任务,其中操纵了奖励和惩罚的强度,探察两种亚型（注意缺陷型和混合型）ADHD儿童的情感决策能力,同时采集儿童在任务中的皮肤电活动以探析ADHD儿童在情感决策中的生理机制。结果发现,在不同的奖惩强度下,ADHD儿童情感决策模式不同,在即刻奖励条件下,ADHD儿童情感决策的能力明显弱于正常对照组儿童,倾向于不利选择,所产生的预测性皮电振幅也明显低于正常对照组;在即刻惩罚条件下,ADHD儿童的情感决策能力未见异常。两种亚型ADHD儿童的表现模式相似。上述结果证明,ADHD儿童仅存在对奖励的异常敏感性,并确实影响了其决策能力,而其回避惩罚的能力正常。两种亚型ADHD儿童存在的问题相似     

Improving Compliance With Diabetes Management in Young Adolescents With Attention-Deficit/Hyperactivity Disorder Using Behavior Therapy

Medical adherence to complex diabetes regimens can be challenging, particularly for adolescents, and therefore represents the most common reason for referral to behavioral psychologists among this population. Attention-deficit/hyperactivity disorder (ADHD), when present in children and adolescents with diabetes, presents unique barriers to compliance with diabetes management. Existing research on the co-occurrence of diabetes and ADHD is reviewed, and a framework is presented in which evidence-based behavioral treatments for ADHD may be applied to target diabetes management for this population. Case illustrations of two young adolescents with co-occurring diabetes and ADHD are offered, in which evidence-based ADHD treatments were successful in increasing medical compliance. Recommendations for larger clinical trials with this population are made.     

An Evaluation of a Summer Treatment Program for Adolescents With ADHD

Although adolescents with attention-deficit/hyperactivity disorder (ADHD) experience serious life impairment (Molina et al., 2009; Wolraich et al., 2005), very few effective psychosocial interventions exist to treat this population (Pelham & Fabiano, 2008; Smith, Waschbusch, Willoughby, & Evans, 2000). Intensive child-directed interventions are an important component in the treatment of childhood ADHD (Pelham et al., 2005), yet no study exists that fully evaluates an intensive adolescent-directed intervention. The current investigation is a pilot study of 19 adolescents with ADHD (age range: 11-16) who participated in an 8-week intensive Summer Treatment Program–Adolescent (STP-A) during the summer of 2009. The program was developed to address specific difficulties associated with ADHD in adolescence. As such, the program was designed to be ecologically valid, age appropriate, and parent-involved. Results suggest that almost all adolescents who attended the STP-A benefitted from the program according to parent, self, and staff ratings and objective measures. These ratings also indicated that participants showed moderate improvement in each of the 6 domains targeted by treatment (i.e., conduct problems, adult-directed defiance, social functioning, inattention/disorganization, mood/well-being, and academic skills). All parents indicated that both they and their children benefitted from the program and all but 1 parent indicated that the STP-A was more effective than the treatments they had utilized in the past. A case example is presented to illustrate typical improvement patterns during the STP-A. Discussion addresses the role of the STP-A in the treatment of ADHD in adolescence.     

ADHD and female specific concerns: a review of the literature and clinical implications

ADHD was once thought of as a predominantly male disorder. While this may be true for ADHD in childhood, extant research suggests that the number of women with ADHD may be nearly equal to that of men with the disorder (Faraone et al., 2000). There is accumulating research which clearly indicates subtle but important sex differences exist in the symptom profile, neuropathology and clinical course of ADHD. Compared to males with ADHD, females with ADHD are more prone to have difficulties with inattentive symptoms than hyperactive and impulsive symptoms, and females often receive a diagnosis of ADHD significantly later than do males (Gaub & Carlson, 1997; Gershon, 2002a, 2002b). Emerging evidence suggests differences exist in the neuropathology of ADHD, and there are hormonal factors which may play an important role in understanding ADHD in females. Although research demonstrates females with ADHD differ from males in important ways, little research exists that evaluates differences in treatment response. Given the subtle but important differences in presentation and developmental course of ADHD, it is essential that both clinical practice and research be informed by awareness of these differences in order to better identify and promote improved quality of care to girls and women with ADHD.     

Modulation of Response Timing in ADHD,Effects of Reinforcement Valence and Magnitude

The present study investigated the impact of reinforcement valence and magnitude on response timing in children with ADHD. Children were required to estimate a 1-s interval, and both the median response time (response tendency) and the intrasubject-variability (response stability) were investigated. In addition, heart rate and skin conductance were measured to examine the autonomic responses to reinforcement. Feedback-only trials were compared to low response cost trials (response cost for incorrect responses), low reward trials (reward for correct responses), high response cost and high reward trials. In feedback-only trials, children with ADHD underestimated more severely the interval and responded more variably than controls. Children with ADHD, unlike controls, were unaffected by the reinforcement conditions in terms of time underestimations. The variability of responding, on the other hand, decreased under conditions of reinforcement to a larger extent in children with ADHD than controls. There were no indications that children with ADHD were abnormally affected by the valence or magnitude of reinforcement. Furthermore, skin conductance responses increased when feedback was coupled with reinforcement, an effect which was larger in children with ADHD than controls. This could be interpreted as demonstrating that children with ADHD suffer from a diminished awareness of the significance of feedback in the feedback-only condition. The current study suggests that children with ADHD suffer from motivation problems when reinforcement was not available, at least when variability in responding was measured. Underestimations of time may reflect more stable deficits in ADHD.     

Acute Stimulant Treatment and Reinforcement Increase the Speed of Information Accumulation in Children with ADHD

The current studies utilized drift diffusion modeling (DDM) to examine how reinforcement and stimulant medication affect cognitive task performance in children with ADHD. In Study 1, children with (n = 25; 88 % male) and without ADHD (n = 33; 82 % male) completed a 2-choice discrimination task at baseline (100 trials) and again a week later under alternating reinforcement and no-reinforcement contingencies (400 trials total). In Study 2, participants with ADHD (n = 29; 72 % male) completed a double-blind, placebo-controlled trial of 0.3 and 0.6 mg/kg methylphenidate and completed the same task utilized in Study 1 at baseline (100 trials). Children with ADHD accumulated information at a much slower rate than controls, as evidenced by a lower drift rate. Groups were similar in nondecision time and boundary separation. Both reinforcement and stimulant medication markedly improved drift rate in children with ADHD (ds = 0.70 and 0.95 for reinforcement and methylphenidate, respectively); both treatments also reduced boundary separation (ds = 0.70 and 0.39). Reinforcement, which emphasized speeded accuracy, reduced nondecision time (d = 0.37), whereas stimulant medication increased nondecision time (d = 0.38). These studies provide initial evidence that frontline treatments for ADHD primarily impact cognitive performance in youth with ADHD by improving the speed/efficiency of information accumulation. Treatment effects on other DDM parameters may vary between treatments or interact with task parameters (number of trials, task difficulty). DDM, in conjunction with other approaches, may be helpful in clarifying the specific cognitive processes that are disrupted in ADHD, as well as the basic mechanisms that underlie the efficacy of ADHD treatments.     

Item Response Theory Analyses of the Parent and Teacher Ratings of the DSM-IV ADHD Rating Scale

The graded response model (GRM), which is based on item response theory (IRT), was used to evaluate the psychometric properties of the inattention and hyperactivity/impulsivity symptoms in an ADHD rating scale. To accomplish this, parents and teachers completed the DSM-IV ADHD Rating Scale (DARS; Gomez et al., Journal of Child Psychology and Psychiatry, 40, 265–274, 1999) for a group of 1,475 primary school-aged children. The results for the discrimination parameters showed that all symptoms for both groups of respondents were generally good for discriminating their respective latent traits. For virtually all symptoms, their threshold values showed moderate to large increases in the level of the latent trait at each subsequent response dichotomy, with the symptoms being especially good at representing the appropriate traits from mean to moderately high trait levels. The item information function values for most symptoms indicated reasonable reliability from, approximately, the mean trait levels to moderately high trait levels. These findings indicate good psychometric properties for the parent and teacher ratings of the DARS. The implications of the findings for the use of the DARS and other similar scales are discussed.     

Weighing evidence for the Rorschach's validity: a response to Wood et al. (1999)

Wood, Nezworski, Stejskal, Garven, and West (1999) challenged Ganellen's (1996) characterization of the revised Rorschach Depression Index (DEPI; Exner, 1991) as a promising psychometric marker of depression that deserves serious attention by researchers and clinicians. To the contrary, however, a careful examination of existing studies indicates that no compelling empirical evidence exists indicating that Ganellen's conclusions should be modified at the present time, although no firm conclusions about the DEPI can be reached until further evidence accumulates. Furthermore, although Wood et al. (1999) suggested that evidence supporting the reliability and validity of the Rorschach in general is weak, ample evidence exists demonstrating that the Rorschach can be scored reliably (Meyer, 1997), that Rorschach variables in general have respectable levels of criterion-related validity (Bornstein, 1996; Hiller, Rosenthal, Bornstein, Berry, & Brunnel-Neuleib, 1999), and that the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943) and Rorschach have comparable levels of criterion-related validity, with the MMPI outperforming the Rorschach in certain respects and the Rorschach outperforming the MMPI in others (Bornstein, 1999; Hiller et al, 1999).     

An alternative perspective on von Winterfeldt et al.'s (1997) test of consequence monotonicity

D. von Winterfeldt, N.-K. Chung, R. D. Luce, and Y. Cho (1997) provided several tests for consequence monotonicity of choice or judgment, using certainty equivalents of gambles. The authors reaxiomatized consequence monotonicity in a probabilistic framework and reanalyzed von Winterfeldt et al.'s main experiment via a bootstrap method. Their application offers new insights into consequence monotonicity as well as into von Winterfeldt et al.'s 3 experimental paradigms: judged certainty equivalents (JCE), QUICKINDIFF, and parameter estimation by sequential testing (PEST). For QUICKINDIFF, the authors found no indication of violations of "random consequence monotonicity." This sharply contrasts the findings of von Winterfeldt et al., who concluded that axiom violations were the most pronounced under that procedure. The authors found potential evidence for violations in JCE and certainty equivalents derived from PEST.     

Modifying Dialectical Behavior Therapy for Deaf Individuals

Therapies that rely on written materials, information, or procedures involving familiarity with the dominant culture (e.g., colloquialisms, history) often pose barriers to people who use another language, have low English literacy, or are less familiar with the dominant culture. All this applies deaf individuals. One of the most well-validated mental health treatments for reducing suicidality in those diagnosed with borderline personality disorder is Dialectical Behavior Therapy (DBT; Koons et al., 2001; Linehan et al., 1999; Linehan et al., 2006; Linehan et al., 2002; Verheul et al., 2003). Unfortunately, its heavy reliance on written materials, prevalent use of metaphors, and other culture-bound characteristics make DBT inaccessible to the average deaf consumer. We describe the potential benefits that DBT could offer deaf clients, some of which are uniquely related to the life experiences and societal challenges faced by deaf people. Barriers to accessing standard DBT treatment and the materials used are described. Modifications of DBT materials and methods that we have found effective with deaf clients are detailed. It is concluded that DBT materials and methods can be successfully modified for use with this population. Available resources and additional benefits of employing DBT with deaf clients are noted.     

Traumatische Trauer – ein eigenständiges Krankheitsbild?

Grief is a highly individualized process influenced by intrapsychic, interpersonal and social factors. The definition of normal and pathological grief is complicated by the variety of grief reactions. Empirical research indicates that pathological grief may be concerned considered as a separate entity. Two research groups developed empirically validated criteria with a special focus on the traumatic aspect of grief. The current state of research allows, however, in our opinion not the conclusion, that the proposed diagnostic criteria for complicated (Horowitz et al. 1997) or traumatic grief (Prigerson et al. 1999b) do not enclose all types of grief. Further empirical research on representative samples is necessary to validate previous findings and to differentiate specific subgroups of pathological grief.     

Jousting with straw men: comment on Westen, Novotny, and Thompson-Brenner (2004)

Empirically supported treatments (ESTs) do not cure every patient, and the randomized trial is not a flawless methodology. Upon these often-noted and widely accepted points, D. Westen, C. M. Novotny, and H. Thompson-Brenner (2004a; see record 2004-15935-005) built a critique of ESTs and EST research. However, important work developing effective, clinically relevant treatments for serious problems was omitted from the Westen et al. (2004a) review. Little documentation was offered for the purported "assumptions" of EST methodology that Westen et al. (2004a) criticized; and different review standards were applied to studies supporting versus those disagreeing with Westen et al.'s (2004a) views. Finally, the correlational research designs proposed as a remedy by Westen et al. (2004a) have far more serious weaknesses than randomized trials, thoughtfully applied to real-world clinical care.     

儿童社交回避行为：成因、测量方式及适应功能

社会退缩行为是指儿童在社会情境中抑制自己参与同伴互动并表现出独处的行为。根据不同的社交动机,社会退缩行为包含多种亚类型,其中社交回避行为这一亚类型指儿童总是表现出主动避免各种社交场合的行为。总体而言,社交回避是目前研究最少的一种,其形成的主要原因可能是由于儿童本身较高的抑郁感所致,而研究者已开始尝试以间接和直接的方式测量其水平。来自以变量为中心和以个体为中心的研究分别表明,社交回避儿童面临着最高的适应风险。鉴于这一研究领域的广泛前景,未来的研究亟需关注社交回避影响儿童适应的过程机制及其年龄发展特点,测量工具的进一步开发,直接的跨文化比较以及社交回避的干预方案开发。     

儿童社交回避行为：成因、测量方式及适应功能

社会退缩行为是指儿童在社会情境中抑制自己参与同伴互动并表现出独处的行为。根据不同的社交动机,社会退缩行为包含多种亚类型,其中社交回避行为这一亚类型指儿童总是表现出主动避免各种社交场合的行为。总体而言,社交回避是目前研究最少的一种,其形成的主要原因可能是由于儿童本身较高的抑郁感所致,而研究者已开始尝试以间接和直接的方式测量其水平。来自以变量为中心和以个体为中心的研究分别表明,社交回避儿童面临着最高的适应风险。鉴于这一研究领域的广泛前景,未来的研究亟需关注社交回避影响儿童适应的过程机制及其年龄发展特点,测量工具的进一步开发,直接的跨文化比较以及社交回避的干预方案开发。     

Sequential modulations of logical-recoding operations in the Simon task

The Simon effect consists of faster responses to the color (or another nonspatial feature) of spatially corresponding stimuli than to spatially noncorresponding stimuli. Recently, several studies observed the Simon effect after corresponding predecessor trials, but not after noncorresponding predecessor trials. To explain these sequential modulations, Stürmer et al. (2002) proposed a mechanism modulating the ability of stimulus position to automatically activate a response. The present study investigated which events are effectively triggering this mechanism in a variant of the Simon task, in which both stimuli and responses varied in color (participants wore colored gloves) as well as in horizontal position. In the same-color task (e.g., green stimulus-green response), a normal Simon effect showed up after corresponding trials, but no effect occurred after noncorresponding trials. In the alternate-color task (e.g., green stimulus-red hand), no effect occurred after spatially corresponding trials, whereas an inverted Simon effect was found after noncorresponding trials. Additional analyses showed that repetition (or alternation) effects did not affect the results. The results are discussed in terms of a conflict-monitoring account (Stürmer et al., 2002), and in terms of a feature-integration account (Hommel et al., 2002).     

A Preliminary Study of Clinical Process in Relation to Outcome in Psychodynamic Psychotherapy for Panic Disorder

This study identified psychotherapeutic processes that relate meaningfully to psychotherapeutic outcome for patients with panic disorder undergoing Panic-Focused Psychodynamic Psychotherapy (PFPP) (Milrod et al., 1997). Subjects were 21 patients who participated in an open clinical trial of PFPP (Milrod et al., 2000; Milrod et al., 2001). The Interactive Process Assessment (IPA) (Klein, Milrod, and Busch, 1999), a process measure developed specifically to identify the process of PFPP, was used. Process-outcome relationships were calculated between process factors at early, mid, and late treatment and outcome measures at termination. Results showed that the therapist's focus on the transference late in treatment was associated with a decrease in panic symptoms. Transference focus early in the treatment, however, was correlated with an increase in related symptomatology, as measured by the HAM-A and SDS. It was unclear from the present study how focusing on panic symptomatology affected the treatment. This process might be better investigated by comparing this aspect of PFPP with alternative psychotherapies.