Anil Chacko

Transdermal methylphenidate, behavioral, and combined treatment for children with ADHD

Stimulant medication and behavioral treatments are evidence-based for children with attention-deficit/hyperactivity disorder, but the combination of the 2 treatments has been understudied. In this investigation, methylphenidate (MPH) was crossed with 2 levels of behavior modification (BMOD) in a summer treatment program. Twenty-seven children with attention-deficit/hyperactivity disorder, aged 6-12, participated. Children received placebo and 3 doses of transdermal MPH (12.5 cm(2), 25.0 cm(2), and 37.5 cm(2)). BMOD was implemented on alternating weeks. Both treatments produced large and significant effects. Combined treatment was superior to either treatment alone. The effects of transdermal MPH were comparable to those found in this setting in previous studies with multiple stimulant medications and formulations. Consistent with other research, low doses of MPH--even lower than in previous studies--yielded enhanced effects in combination with behavior modification.

Enhancing Traditional Behavioral Parent Training for Single Mothers of Children with ADHD

Behavioral parent training is an efficacious treatment for attention-deficit/hyperactivity disorder (ADHD). However, single-mother households are at high risk for poor outcomes during and following behavioral parent training. This study randomly assigned cohorts of 120 single mothers of children (ages 5–12 years) with ADHD to a waitlist control group, a traditional behavioral parent training program, or an enhanced behavioral parent training program—the Strategies to Enhance Positive Parenting (STEPP) program. Intent-to-treat analysis demonstrated benefits of participating in behavioral parent training, in general, and the STEPP program more specifically at immediate posttreatment on child and parental functioning. Moreover, the STEPP program resulted in increased engagement to treatment. However, results indicated that behavioral parent training does not normalize behavior for most children and treatment gains are not maintained.

The Efficacy and Tolerability of Methylphenidate and Behavior Modification in Children with Attention-Deficit/Hyperactivity Disorder and Severe Mood Dysregulation

OBJECTIVES This study examines the tolerability and efficacy of methylphenidate (MPH) and behavior modification therapy (BMOD) in children with attention-deficity/hyperactivity disorder (ADHD) and severe mood dysregulation (SMD). METHODS Children (ages 5-12) from a summer program for ADHD were screened for SMD and additional manic-like symptoms using structured assessments and direct clinical interview with the Young Mania Rating Scale (YMRS). The SMD group was comprised of 33 subjects with SMD and elevated YMRS scores (mean = 23.7). They underwent weekly mood assessments plus the daily ADHD measures that are part of the program. The comparison group (n = 68) was comprised of the rest of the program participants. Using a crossover design, all subjects in both groups were treated with three varying intensities of BMOD (no, low, high) each lasting 3 weeks, with MPH dose (placebo, 0.15 mg/kg t.i.d., 0.3mg/kg t.i.d., and 0.6 mg/kg t.i.d.) varying daily within each behavioral treatment. RESULTS Groups had comparable ADHD symptoms at baseline, with the SMD group manifesting more oppositional defiant disorder/conduct disorder (ODD/CD) symptoms (p < 0.001). Both groups showed robust improvement in externalizing symptoms (p < 0.001). There was no evidence of differential treatment efficacy or tolerability. Treatment produced a 34% reduction in YMRS ratings in SMD subjects (p - 0.001). However, they still exhibited elevated YMRS ratings, more ODD/CD symptoms (p < 0.001), and were more likely to remain significantly impaired at home than non-SMD subjects (p < 0.05). CONCLUSIONS MPH and BMOD are tolerable and effective treatments for children with ADHD and SMD, but additional treatments may be needed to optimize their functioning.

A Comparison of Behavioral Parent Training Programs for Fathers of Children with Attention-Deficit/Hyperactivity Disorder.

Few behavioral parent training (BPT) treatment studies for attention-deficit/hyperactivity disorder (ADHD) have included and measured outcomes with fathers. In this study, fathers were randomly assigned to attend a standard BPT program or the Coaching Our Acting-Out Children: Heightening Essential Skills (COACHES) program. The COACHES program included BPT plus sports skills training for the children and parent-child interactions in the context of a soccer game. Groups did not differ at baseline, and father ratings of treatment outcome indicated improvement at posttreatment for both groups on measures of child behavior. There was no significant difference between groups on ADHD-related measures of child outcome. However, at posttreatment, fathers who participated in the COACHES program rated children as more improved, and they were significantly more engaged in the treatment process (e.g., greater attendance and arrival on time at sessions, more homework completion, greater consumer satisfaction). The implications for these findings and father-related treatment efforts are discussed.

Cogmed Working Memory Training for Youth with ADHD: A Closer Examination of Efficacy Utilizing Evidence-Based Criteria

The current review applied the evidence-based treatment criteria espoused by the Society for Clinical Child and Adolescent Psychology (Silverman & Hinshaw, 2008) to specifically evaluate the short-term and longer term efficacy of Cogmed Working Memory Training (CWMT) as a treatment for youth with Attention-Deficit/Hyperactivity Disorder (ADHD). Utilizing a systematic literature search, 7 studies that employed the school-age version of CWMT were identified for this review. The data reviewed herein suggest mixed findings regarding the benefit of CWMT for youth with ADHD. Two randomized controlled studies have demonstrated that CWMT led to improvements in neuropsychological outcomes and parent-rated ADHD symptoms relative to wait-list control and placebo treatment conditions. Another study demonstrated effects of CWMT relative to a placebo condition on an analog observation of behavior during an academic task, although this study did not find an effect of CWMT on parent-rated ADHD. Finally, an additional study utilizing an active comparison control condition did not find incremental benefits of CWMT on parent- or teacher-rated ADHD. Critical issues in interpreting existing studies include lack of alignment between demonstrated outcomes and the hypothesized model of therapeutic benefit of CWMT, issues with equivalence of control conditions, and individual differences that may moderate treatment response. Collectively, the strengths and limitations of the studies reviewed suggest that CWMT is best defined as a Possibly Efficacious Treatment for youth with ADHD. We suggest future directions for research and conclude with clinical implications of our findings for the treatment of youth with ADHD.

Training executive, attention, and motor skills: a proof-of-concept study in preschool children With ADHD.

Objective: To examine whether cognitive enhancement can be delivered through play to preschoolers with ADHD and whether it would affect severity of ADHD symptoms. Method: Twenty-nine 4- and 5-year-old children and their parents participated in separate group sessions (3-5 children/group). Child groups were introduced games designed to enhance inhibitory control, working memory, attention, visuospatial abilities, planning, and motor skills. Parent groups were encouraged playing these games with their children at least 30 to 45 min/day and taught strategies for scaffolding difficulty levels and dealing with obstacles to daily playing. Results: Parent ratings and session attendance indicated considerable satisfaction with the program. Parent (p < .001) and teacher (p = .003) ratings on the ADHD-Rating Scale–IV (ADHD-RS-IV) indicated significant improvement in ADHD severity from pre- to post-treatment, which persisted 3 months later. Conclusion: This play-based intervention for preschoolers with ADHD is readily implemented at home. Preliminary evidence suggests efficacy beyond the termination of active treatment.

A Collaboratively Designed Child Mental Health Service Model: Multiple Family Groups for Urban Children with Conduct Difficulties.

This article presents preliminary outcomes associated with an experimental, longitudinal study of a Multiple Family Group (MFG) service delivery approach set within 13 urban outpatient clinics serving children and their families living in inner-city, primarily African American and Latino communities. Specifically, this article focuses on parent reports of child oppositional behavior and parenting stress over time. The MFG is a flexible, protocol-driven approach designed to address the most common reason for referral to outpatient child mental health clinics, childhood behavioral difficulties. The MFG also aims to enhance family-level engagement and retention in ongoing care. Further, the service delivery model was collaboratively developed with intensive input from parents rearing children with conduct difficulties, parent advocates, community-based child mental health providers, and services research staff in order to ultimately expand the number of effective service models that can be situated within “real world,” urban child mental health settings.

Stimulant Medication Effects in a Summer Treatment Program Among Young Children With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE This study examined the effectiveness of stimulant medication on multiple domains of functioning in 36 young (5 to 6 years old) children diagnosed with attention-deficit/hyperactivity disorder (ADHD). METHOD Five- and 6-year-old children attending a summer treatment program between 1987 and 1997 underwent a randomized clinical assessment of the effect of two doses of methylphenidate (0.3 mg/kg versus 0.6 mg/kg) and placebo on social behavior and academic performance. RESULTS Methylphenidate had an effect on all four social behaviors and improved two of the three areas of academic functioning. Dose effects were present for three of the seven dependent measures. Individual analyses indicated a therapeutic response rate between 39% and 100% across dependent measures. Furthermore, individual analyses of response indicated that across several important dependent measures, 39% to 98% of children showed little incremental improvement with the higher dose compared with the lower dose of stimulant medication. CONCLUSIONS Stimulant medication is an effective treatment for young children diagnosed with ADHD; however, multiple domains of functioning must be assessed to determine the most effective dose for young children with ADHD.

Improving Medication Adherence in Chronic Pediatric Health Conditions: A Focus on ADHD in Youth

Chronic pediatric health conditions pose a significant challenge for youth, their families and professionals who treat these conditions. Long-term adherence to interventions, including and often-times, pharmacological interventions, is necessary but often problematic. Understanding factors related to poor adherence and intervening to improve adherence is essential in order to maximize long-term outcomes. Attention-deficit/hyperactivity disorder (ADHD) is one such chronic health condition requiring long-term adherence to treatment. The aims of this review are to 1) review the extant literature regarding rates of adherence to medication for youth with ADHD; 2) summarize what is known regarding factors that impede and support greater adherence to medication; 3) introduce the Unified Theory of Behavior Change as a conceptual model that may assist in developing adherence treatment packages to support medication adherence; and 4) describe several potential interventions based on the Unified Theory of Behavior Change that may improve adherence to medication for youth with ADHD. Although pharmacological interventions for youth with ADHD have been evaluated for decades, only more recently has adherence to medication been the subject of interest. However, this literature has exclusively focused on understanding factors related to adherence, with no empirical studies of interventions to improve adherence in youth with ADHD. This paper provides a rationale and research agenda for systematic study of interventions to support medication adherence in youth with ADHD.

Evaluating a comprehensive strategy to improve engagement to group-based behavioral parent training for high-risk families of children with ADHD

Behavioral parent training (BPT) is an evidence-based intervention for the treatment of attention-deficit/hyperactivity disorder (ADHD) and related disruptive behavioral disorders of childhood. Despite convincing data on effectiveness, engagement to BPT, particularly for high-risk families, has been a long standing, yet understudied, issue. Data from a clinical trial of a comprehensive BPT approach to enhance engagement and outcomes (the Strategies to Enhance Positive Parenting [STEPP] program) are presented herein. The STEPP program was compared to a traditional group-based BPT program on propensity to attend treatment, propensity to complete homework over the course of treatment, and dropout from BPT. Additionally, factors empirically related to engagement to treatment and targeted by the STEPP program were analyzed to determine whether these factors were enhanced by participation in the STEPP program. In a randomized cohort of 80 single-mothers of school-age children with ADHD, analyses demonstrated that the STEPP program lead to greater propensity to attend treatment over time and a greater propensity to complete homework over the course of treatment. Furthermore, participation in the STEPP Program was associated with a lower rate of dropout. Finally, data suggested that parents assigned to the STEPP program reported significant improvements in factors empirically related to engagement that were targeted within the STEPP program (i.e., amount and quality of social support from their group members, expectations for treatment, and perceived barriers to treatment participation). Results of the study have implications for targeting engagement throughout the process of BPT, particularly for high-risk families.