What does the MTA study tell us about effective psychosocial treatment for ADHD?

Discussed the initial findings from the recently published, National Institute of Mental Health-sponsored Multimodal Treatment Study (MTA) of attention deficit hyperactivity disorder (ADHD). These findings can be summarized as follows: Medical management alone was found to be significantly more effective for the core symptoms of ADHD as compared to behavioral treatment alone and routine (community) care, and behavioral treatment did not significantly improve outcome when combined with medical treatment. In discussing these findings, it is important to be explicit about the research questions the study was and was not designed to answer. The MTA study provided useful information regarding the question, "Does a very intensive form of behavioral treatment deliver greater benefits than the less intensive forms of behavioral treatment investigated in prior studies?" but little insight on the question, "What type of treatment by what type of therapist is most effective in dealing with what specific problems among specific children with ADHD?" It is suggested that the clearest finding from the MTA study is that the effectiveness of psychosocial intervention for ADHD hinges on the degree to which a broad range of treatment ingredients are considered, carefully selected, matched, and tailored to the individual needs of each child with the disorder, and implemented and monitored over the long term.     

Preschoolers at risk for attention-deficit hyperactivity disorder and oppositional defiant disorder: family,parenting, and behavioral correlates

This community study assigned 129 4-year-olds to groups at risk for attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), both ADHD and ODD, or no problems. Mothers of children at risk for ODD reported more family dysfunction, felt less competent as parents, suggested fewer solutions to child behavior problems, demonstrated a less assertive approach to child management, and reported more child internalizing problems than did mothers of children not elevated on ODD symptoms. Mothers of children at risk for ADHD reported higher personal depression scores than did those of the non-ADHD subgroup. Children at risk for ADHD evidenced the most difficulties in school where teachers reported more social behavior, classroom management, and internalizing problems relative to other children not at risk for ADHD. When solving child management problems, mothers of children in all groups suggested twice as many controlling/negative management strategies as positive/preventive strategies. In addition, faced with oppositional and conduct problems, mothers of children in all groups increased controlling/negative suggestions and decreased positive/preventive suggestions. Mothers of girls at risk for ADHD, ODD, and ADHD/ODD gave more rewards per positive behavior than did mothers of boys.     

Comorbid ADHD: Implications for the Treatment of Anxiety Disorders in Children and Adolescents

Despite high comorbidity rates and potential clinical implications, the influence of co-occurring attention-deficit/hyperactivity disorder (ADHD) on outcomes of cognitive-behavioral treatment (CBT) for anxious youth remains poorly understood. In this qualitative review, the current literature on the influence of comorbid ADHD on CBT of youth with diverse anxiety disorders is explored. Peer-reviewed studies examining ADHD, at the diagnostic and symptom level, received highest priority. In addition, inasmuch as some studies did not isolate the effects of ADHD from other disruptive behavior disorders (DBDs: oppositional defiant disorder, conduct disorders), studies with the three DBDs were explored as well. Ten studies met our specified methodological criteria. Findings are discussed in relation to the following two factors: type of anxiety disorder and measurement of ADHD (diagnostic or symptom level) in these studies. There was evidence that youth with a variety of anxiety disorders and with co-occurring ADHD fared worse than their counterparts without ADHD. Additionally, grouping ADHD with other DBDs tended to obscure the negative impact of ADHD on treatment outcomes. Additional research is needed to delineate the influence of comorbid ADHD specifically on treatment outcomes for the various anxiety disorders. Clinical implications of treating anxious youth with comorbid ADHD are explored.     

The epidemiology of attention-deficit/hyperactivity disorder (ADHD): a public health view

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder of childhood. However, basic information about how the prevalence of ADHD varies by race/ethnicity, sex, age, and socio-economic status remains poorly described. One reason is that difficulties in the diagnosis of ADHD have translated into difficulties developing an adequate case definition for epidemiologic studies. Diagnosis depends heavily on parent and teacher reports; no laboratory tests reliably predict ADHD. Prevalence estimates of ADHD are sensitive to who is asked what, and how information is combined. Consequently, recent systematic reviews report ADHD prevalence estimates as wide as 2%-18%. The diagnosis of ADHD is complicated by the frequent occurrence of comorbid conditions such as learning disability, conduct disorder, and anxiety disorder. Symptoms of these conditions may also mimic ADHD. Nevertheless, we suggest that developing an adequate epidemiologic case definition based on current diagnostic criteria is possible and is a prerequisite for further developing the epidemiology of ADHD. The etiology of ADHD is not known but recent studies suggest both a strong genetic link as well as environmental factors such as history of preterm delivery and perhaps, maternal smoking during pregnancy. Children and teenagers with ADHD use health and mental health services more often than their peers and engage in more health threatening behaviors such as smoking, and alcohol and substance abuse. Better methods are needed for monitoring the prevalence and understanding the public health implications of ADHD. Stimulant medication is the treatment of choice for treating ADHD but psychosocial interventions may also be warranted if comordid disorders are present. The treatment of ADHD is controversial because of the high prevalence of medication treatment. Epidemiologic studies could clarify whether the patterns of ADHD diagnosis and treatment in community settings is appropriate. Population-based epidemiologic studies may shed important new light on how we understand ADHD, its natural history, its treatment and its consequences.     

Psychosocial Treatments for Children with Attention Deficit/Hyperactivity Disorder

This article reviews studies examining the efficacy of behavioral interventions for the treatment of attention-deficit/hyperactivity disorder (ADHD). A specific emphasis is placed on evidence-based interventions that include parent training, classroom, academic, and peer interventions. Results indicate that school-aged children respond to behavioral interventions when they are appropriately implemented both at home and in the classroom setting. Combined treatments (behavioral management and stimulant medication) represent the gold standard in ADHD treatment and are often recommended as the first-line treatment option due to the many problems faced by children with ADHD. Diversity issues, although an important consideration in the treatment of ADHD, continue to remain an understudied area. Recommendations for future research are made pertaining to treatment sequencing with regard to behavior management as well as for subgroups of ADHD children who may respond best to specific treatments.     

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.     

The relation between attention deficit hyperactivity disorder and substance abuse: what role does conduct disorder play?

This paper presents a comprehensive review of the literature examining the relation between childhood attention deficit hyperactivity disorder (ADHD) and substance abuse. A number of researchers have statistically controlled for conduct disorder (CD) when examining the ADHD—substance-abuse relation. These studies have generally found that the ADHD—substance-abuse relation disappears when the high overlap between ADHD and CD is taken into account. On this basis, one may conclude that ADHD is unimportant to substance abuse. However, there is some evidence from both empirical studies and related fields that ADHD and CD may interact to afford a higher risk for substance abuse than may either disorder alone. Thus, ADHD appears to be important to substance abuse in that it interacts with CD to increase the risk. This paper calls for more research that directly examines the joint effects of ADHD and CD on risk for substance abuse. There is also a need for more research that examines gender differences, and mechanisms of the relations among ADHD, CD, and substance abuse.     

Neurobiological models of attention-deficit/hyperactivity disorder: a brief review of the empirical evidence

Attention-deficit/hyperactivity disorder (ADHD) is a psychiatric disorder characterized by inattention, impulsivity, and overactivity that begins in childhood. While considerable research has focused on the neurobiological substrates of this disorder, the specific nature of the brain dysfunction in ADHD has remained elusive. However, early data from pharmacological treatment studies, as well as from basic research in animals and humans, initially led several investigators to develop neurobiological models of ADHD. These models of ADHD and more recent evidence from neuropsychological, neuroimaging, neurochemical, and genetic research are briefly reviewed. While not completely consistent, the empirical data suggest that dysfunction in prefrontal-striatal neural circuits, as well as in brain stem catecholamine systems that innervate these circuits, may underlie the executive function deficits in ADHD.     

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.     

Adults With Attention‐Deficit/Hyperactivity Disorder: Assessment and Treatment Strategies

Attention‐deficit/hyperactivity disorder (ADHD) among adults is characterized by inattentiveness and impulsivity. This article provides counselors with information about the etiology, assessment, and treatment of adult ADHD. The identification of the genetic and neurological features of ADHD has led to improvements in evaluation and treatment. Assessment of ADHD requires knowledge of the defining characteristics, subtypes, comorbid features, and functional aspects of ADHD. Effective treatments include both medical management and counseling to address psychosocial deficits.     

Diagnosis and Treatment of Adults With Attention Deficit Hyperactivity Disorder

It is estimated that between 30% and 50% of children diagnosed with attention deficit hyperactivity disorder (ADHD) will continue to exhibit symptomatology that is disruptive throughout their adult lives. Identification and diagnosis of adult ADHD, as well as primary and secondary characteristics and comorbid disorders, are discussed in this article. Counseling strategies are suggested to help clinicians treat adults with ADHD, such as educating the client about the disorder and providing training in attention management techniques, self-management skills, interpersonal and social skills, stress and time management, anger management, and problem-solving skills. Clinicians are encouraged to prepare themselves for understanding, identifying, diagnosing, and treating the adult population with ADHD.     

Non-stimulant treatment of attention-deficit/hyperactivity disorder

Stimulants are a highly efficacious and safe treatment for attention-deficit/hyperactivity disorder (ADHD), with 75% to 90% of patients responding well if two different stimulants (amphetamine and methylphenidate) are used. Nonetheless, a subset of ADHD patients will either fail to respond to stimulants or have side effects that preclude their use (tics, severe loss of appetite, marked insomnia). For such patients, there are a number of non-stimulant agents that serve as second-line treatments. Tricyclic antidepressants (TCAs) are the most studied of these drugs. They are superior to placebo in the treatment of ADHD and may reduce abnormal movements in patients with ADHD/tic disorder. TCAs often produce side effects of sedation, dry mouth, and constipation. Bupropion is superior to placebo in the treatment of ADHD and has a more favorable side-effect profile than the TCAs. A new selective norepinephrine reuptake inhibitor, atomoxetine, has been shown to be efficacious in the treatment of ADHD and has recently received an approvable letter from the Food and Drug Administration. The a-agonists clonidine and guanfacine have also been used as alternative agents in ADHD, though the controlled data are more limited. A recent controlled clinical trial suggests a combination of methylphenidate and clonidine has advantages in the treatment of comorbid ADHD and tics over either medication alone. Clinical guidelines for each of these agents, as well as their use in combination with stimulants in comorbid conditions, will be discussed.     

Children with Comorbid Speech Sound Disorder and Specific Language Impairment are at Increased Risk for Attention-Deficit/Hyperactivity Disorder

This study focuses on the comorbidity between attention-deficit/hyperactivity disorder (ADHD) symptoms and speech sound disorder (SSD). SSD is a developmental disorder characterized by speech production errors that impact intelligibility. Previous research addressing this comorbidity has typically used heterogeneous groups of speech-language disordered children. This study employed more precise speech-language diagnostic criteria and examined ADHD symptomatology in 108 SSD children between the ages of 4 and 7 years old with specific language impairment (SLI) (n = 23, 14 males, 9 females) and without SLI (n = 85, 49 males, 36 females). We also examined whether a subcategory of SSD, persistent (n = 39, 25 males, 14 females) versus normalized SSD (n = 67, 38 males, 29 females), was associated with ADHD and/or interacted with SLI to predict ADHD symptomatology. Results indicated that participants in the SSD + SLI group had higher rates of inattentive ADHD symptoms than those in the SSD-only and control groups. In addition, an unexpected interaction emerged such that children with SLI and normalized-SSD had significantly higher ADHD inattentive ratings than the other subgroups. A proposed explanation for this interaction is discussed.     

Anxiety as a Predictor and Outcome Variable in the Multimodal Treatment Study of Children with ADHD (MTA)

Initial moderator analyses in the Multimodal Treatment Study of Children with ADHD (MTA) suggested that child anxiety ascertained by parent report on the Diagnostic Interview Schedule for Children 2.3 (DISC Anxiety) differentially moderated the outcome of treatment. Left unanswered were questions regarding the nature of DISC Anxiety, the impact of comorbid conduct problems on the moderating effect of DISC Anxiety, and the clinical significance of DISC Anxiety as a moderator of treatment outcome. Thirty-three percent of MTA subjects met DSM-III-R criteria for an anxiety disorder excluding simple phobias. Of these, two-thirds also met DSM-III-R criteria for comorbid oppositional-defiant or conduct disorder whereas one-third did not, yielding an odds ratio of approximately two for DISC Anxiety, given conduct problems. In this context, exploratory analyses of baseline data suggest that DISC Anxiety may reflect parental attributions regarding child negative affectivity and associated behavior problems (unlike fearfulness), particularly in the area of social interactions, another core component of anxiety that is more typically associated with phobic symptoms. Analyses using hierarchical linear modeling (HLM) indicate that the moderating effect of DISC Anxiety continues to favor the inclusion of psychosocial treatment for anxious ADHD children irrespective of the presence or absence of comorbid conduct problems. This effect, which is clinically meaningful, is confined primarily to parent-reported outcomes involving disruptive behavior, internalizing symptoms, and inattention; and is generally stronger for combined than unimodal treatment. Contravening earlier studies, no adverse effect of anxiety on medication response for core ADHD or other outcomes in anxious or nonanxious ADHD children was demonstrated. When treating ADHD, it is important to search for comorbid anxiety and negative affectivity and to adjust treatment strategies accordingly.     

Fehldiagnose Aufmerksamkeitsdefizit- und Hyperaktivit?tssyndrom?

Although it is assumed both by healthcare professionals as well as by public opinion that attention deficit hyperactivity disorder (ADHD) is widely overdiagnosed, so far there is little empirical evidence to support this presumption. However, the presented study shows clear evidence for an overdiagnosis of ADHD. Furthermore, the data demonstrate that based on identical symptoms, boys more often receive a diagnosis for ADHD than girls. A false ADHD diagnosis also correlates with a recommendation for medical and psychotherapeutic treatment. One explanation for misdiagnosis is the fact that therapists in the course of diagnosis, as with other everyday decision-making processes, are influenced by heuristics. The most common heuristics that can lead to misdiagnosis are the representativeness heuristic and the availability heuristic. Such mistakes could be avoided by clearly following diagnostic criteria and the use of structural interviews.     

Contribution of ADHD symptoms to substance problems and delinquency in conduct-disordered adolescents

We examined adolescents with conduct disorder (CD) and substance problems to determine if those with attention deficit hyperactivity disorder (ADHD) symptomatology had more severe delinquency and substance involvement. ADHD symptomatology was assessed in two ways: (1) by self-reports using the Diagnostic Interview Schedule for Children (DISC) and (2) by use of DISC plus reports of others (parents, program staff, and program teacher). We divided boys into three ADHD groups based on DISC: those who met criteria, those who reported at least eight current symptoms, and those who reported fewer than eight symptoms. We also divided the same boys into two groups: those with reports of ADHD by two or more sources and those without this multisource ADHD. Examining these definitions of ADHD revealed that boys with either self- or multisource ADHD had more CD symptoms, earlier age of CD onset, more substance dependence diagnoses, and more comorbid depression and anxiety.This investigation was supported by the National Institute on Drug Abuse Grant No. DAO6941.     

基于时间顺序的多动症共病的概述

多动症是一种常见的行为障碍,它以注意力不集中、多动、行为冲动为主要特征。同时多动症是一组异质性疾病,常与一种或几种精神或非精神障碍相伴发生。以往关于多动症合并症状的研究,大都局限在一个或几个合并症状上,缺乏关于其合并症状的系统认识。基于以往研究,文章以多动症合并症状发生的时间顺序为线索,将其分为前期、同期、后期合并症,并逐一详细介绍。未来应该加强关于多动症患者的纵向研究,以了解症状的发展状况,更好的诊断和治疗多动症。     

A review of the biological bases of ADHD: what have we learned from imaging studies?

Attention Deficit Hyperactivity Disorder (ADHD) is a common and impairing neuropsychiatric disorder with onset at preschool age. Although a significant amount of progress has been made investigating the neurobiology of this disorder, its precise etiology still remains unclear. Converging evidence from studies of the neuropharmacology, genetics, neuropsychology, and neuroimaging of ADHD imply the involvement of fronto-striatal circuitry in ADHD. However, while it does appear that poor inhibitory control and the deficits in fronto-striatal circuitry associated with it are central, there is evidence to suggest that more posterior cerebral areas are also implicated in this disorder. Anatomical studies suggest widespread reductions in volume throughout the cerebrum and cerebellum, while functional imaging studies suggest that affected individuals activate more diffuse areas than controls during the performance of cognitive tasks. The future impact of new MR imaging methodologies on the field is discussed.     

Psychosocial treatment issues in the MTA: a reply to Greene and Ablon

Discussed several of Greene and Ablon's (this issue) key points in their article about the Multimodal Treatment Study (MTA) of Children with Attention Deficit Hyperactivity Disorder (ADHD). In particular, the following issues are addressed: (a) whether the medication management and behavioral arms of the MTA individualized treatment to comparable degrees; (b) whether cognitive-behavioral interventions were incorporated to an adequate extent; (c) whether core ADHD symptoms were overemphasized relative to other functional domains, both as treatment targets and outcome measures; and (d) whether parent and teacher characteristics warranted more emphasis than they were given. These issues are discussed and an attempt is made to fit the MTA findings into the larger context of prior studies on treatment of childhood ADHD. A theme of this commentary is the concern that in the current age of biological emphasis in the field of ADHD research, social, family, and motivational processes may not get the attention they deserve.