David J. Marks

Efficacy of Meta-Cognitive Therapy for Adult ADHD

OBJECTIVE The authors investigated the efficacy of a 12-week manualized meta-cognitive therapy group intervention designed to enhance time management, organization, and planning in adults with attention deficit hyperactivity disorder (ADHD). METHOD Eighty-eight clinically referred adults who met DSM-IV criteria for ADHD according to clinical and structured diagnostic interviews and standardized questionnaires were stratified by ADHD medication use and otherwise randomly assigned to receive meta-cognitive therapy or supportive psychotherapy in a group modality. Meta-cognitive therapy uses cognitive-behavioral principles and methods to impart skills and strategies in time management, organization, and planning and to target depressogenic and anxiogenic cognitions that undermine effective self-management. The supportive therapy condition controlled for nonspecific aspects of treatment by providing support while avoiding discussion of cognitive-behavioral strategies. Therapeutic response was assessed by an independent (blind) evaluator via structured interview before and after treatment as well as by self-report and collateral informant behavioral ratings. RESULTS General linear models comparing change from baseline between treatments revealed statistically significant effects for self-report, collateral report, and independent evaluator ratings of DSM-IV inattention symptoms. In dichotomous indices of therapeutic response, a significantly greater proportion of members of the meta-cognitive therapy group demonstrated improvement compared with members of the supportive therapy group. Logistic regression examining group differences in operationally defined response (controlling for baseline ADHD severity) revealed a robust effect of treatment group (odds ratio=5.41; 95% CI=1.77-16.55). CONCLUSIONS Meta-cognitive therapy yielded significantly greater improvements in dimensional and categorical estimates of severity of ADHD symptoms compared with supportive therapy. These findings support the efficacy of meta-cognitive therapy as a viable psychosocial intervention.

Neuropsychological outcome in adolescents/young adults with childhood ADHD: profiles of persisters, remitters and controls.

BACKGROUND This study examined neuropsychological functioning in a longitudinal sample of adolescents/young adults with attention deficit/hyperactivity disorder (ADHD) and controls as a function of the persistence of ADHD. We hypothesized that measures of executive processes would parallel adolescent clinical status, with ADHD-persisters, but not remitters, differing significantly from controls. In contrast, persisters and remitters were hypothesized to perform similarly, and different from controls, on tasks requiring less effortful processing. METHODS Ninety-eight participants diagnosed with ADHD in childhood were reevaluated approximately 10 years later. Eighty-five never-ADHD controls similar in age, IQ, and sex distribution served as a comparison group. Participants were administered a psychiatric interview and neuropsychological test battery. RESULTS Those with childhood ADHD demonstrated broad neuropsychological deficits relative to controls. When the group with childhood ADHD was subdivided based on adolescent ADHD status, compared to controls, both persisters and remitters showed deficient perceptual sensitivity and response variability, and increased ankle movements recorded by a solid-state actigraph. Only persisters differed from controls on several measures of more effortful executive processes. CONCLUSIONS Findings provide preliminary support to the hypothesis that ADHD is associated with early-appearing and enduring subcortical dysfunction, while recovery over the course of development is associated with improvements in executive control functions.

Development of a New Psychosocial Treatment for Adult ADHD

Objective: The purpose of this study was to assess the effectiveness of a new manualized group Meta-Cognitive Therapy (MCT) for adults with ADHD that extends the principles and practices of cognitive-behavioral therapy to the development of executive self-management skills. Method: Thirty adults diagnosed with ADHD completed an 8- or 12-week program designed to target impairments in time management, organization, and planning skills. Treatment efficacy was measured using pre- and posttreatment self-report standardized measures (CAARS-S:L & Brown ADD Scales). Results: General linear modeling revealed a robust significant posttreatment decline on the CAARS DSM-IV Inattentive symptom scale (p < .001) as well as improvement on the Brown ADD Scales (p < .001). Conclusion: The findings indicate that participants in the MCT program showed marked improvement with respect to core ADHD symptoms of inattention, as well as executive functioning skills, suggesting that this program has promise as a treatment for meta-cognitive deficits in adults with ADHD. (J. of Att. Dis. 2008; 11(6) 728-736)

Stimulant Treatment in Children with Attention-Deficit/Hyperactivity Disorder Moderates Adolescent Academic Outcome

Treatment with psychostimulant medication has been shown to improve scholastic functioning in children with attention-deficit/hyperactivity disorder (ADHD). However, the extent to which long-term academic gains are apparent in those having received such treatment remains elusive. This study examined prospectively the relationship of childhood stimulant treatment to academic functioning during adolescence. Children (n = 169) were initially recruited and diagnosed with ADHD when they were 7-11 years old. A subsample of those with childhood ADHD (n = 90) was reevaluated on average 9.13 (SD = 1.5) years later. Probands who did and did not receive treatment with stimulant medication were compared to each other and to a never-ADHD comparison group (n = 80) on three subtests from the Wechsler Individual Achievement Test-II (WIAT-II), as well as high school grade point average (GPA) and number of retentions in school as derived from school records. Analyses of covariance controlling for severity of childhood ADHD symptoms indicated that probands treated with psychostimulant medication achieved better academic outcomes, as measured by WIAT-II subtests and high school GPA, than those not treated with psychostimulants (p < .05). However, treated probands did not fare as well as the never-ADHD comparison group. Psychostimulant treatment for children with ADHD may benefit long-term adolescent academic performance, although the extent of improvement is likely to vary as a function of multiple factors.

Exposure to Gestational Diabetes Mellitus and Low Socioeconomic Status: Effects on Neurocognitive Development and Risk of Attention-Deficit/Hyperactivity Disorder in Offspring

OBJECTIVE To examine the independent and synergistic effects of gestational diabetes mellitus (GDM) and low socioeconomic status (SES) on neurodevelopment and attention-deficit/hyperactivity disorder (ADHD) outcomes. DESIGN Cohort study. SETTING Flushing, New York. PARTICIPANTS A total of 212 preschool children as a part of the ongoing cohort study. MAIN EXPOSURES Gestational diabetes mellitus and low SES. MAIN OUTCOME MEASURES Primary outcomes are ADHD diagnosis based on Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria at age 6 years and several well-validated measures of neurobehavioral outcomes, cognitive functioning, ADHD symptoms, and temperament at age 4 years. Secondary outcomes are parent and teacher reports of behavioral and emotional problems at age 6 years. Neurobehavioral measures in relation to GDM and low SES were examined using generalized estimating equations and multivariate logistic regression analyses. RESULTS Both maternal GDM and low SES were associated with an approximately 2-fold increased risk for ADHD at age 6 years. However, the risk by GDM was greater among lower SES families than among higher SES families. Children exposed to both GDM and low SES demonstrated compromised neurobehavioral functioning, including lower IQ, poorer language, and impoverished behavioral and emotional functioning. A test of additive interaction found that the risk for ADHD increased over 14-fold (P = .006) when children were exposed to both GDM and low SES. Neither children exposed to maternal GDM alone nor those exposed to low SES alone had a notable increased risk for ADHD. CONCLUSIONS Maternal GDM and low SES, especially in combination, heighten the risk for childhood ADHD. Long-term prevention efforts should be directed at mothers with GDM to avoid suboptimal neurobehavioral development and mitigate the risk for ADHD among their offspring.

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.

Differential Prefrontal Cortex Activation During Inhibitory Control in Adolescents With and Without Childhood Attention-Deficit/Hyperactivity Disorder.

The authors examined inhibitory control processes in 8 adolescents diagnosed with attention-deficit/ hyperactivity disorder (ADHD) during childhood and in 8 adolescent control participants using functional MRI with the Stimulus and Response Conflict Tasks (K. W. Nassauer & J. M. Halperin, 2003). No group differences in performance were evident on measures of interference control and/or response competition created by location and direction stimuli. However, the ADHD group demonstrated significantly greater activation of the left ventrolateral prefrontal cortex during interference control as well as greater activation of the left anterior cingulate cortex, right ventrolateral prefrontal cortex, and left basal ganglia during the dual task of interference control and response competition. The magnitude of the prefrontal and basal ganglia activation was positively correlated with severity of ADHD. Response competition alone did not yield group differences in activation.

Comorbidity in Adults with Attention-Deficit/Hyperactivity Disorder

Abstract: This paper describes the clinical manifestations of attention‐deficit/hyperactivity disorder (ADHD) in adulthood, with particular emphasis placed on issues relating to comorbidity. Prospective and retrospective studies are reviewed to evaluate the degree to which adults with ADHD exhibit clinical features that mirror their childhood counterparts with analogous comorbid psychiatric (e.g., antisocial, mood, and anxiety) and/or cognitive (i.e., learning) disorders. We also address the question of whether comorbid disorders in adults represent independent diagnostic entities and whether the presence of psychiatric comorbidity varies as a function of ADHD subtype (i.e., inattentive, hyperactive‐impulsive, combined, and residual). As is the case for ADHD in childhood, comorbidity is not uncommon among adults with ADHD. However, the reported prevalence of comorbid conditions among adults with ADHD varies considerably depending upon whether the research used a prospective or retrospective design.

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.

Psychometric Properties of the Alabama Parenting Questionnaire–Preschool Revision

The psychometric properties of the Alabama Parenting Questionnaire–Preschool Revision (APQ–PR) were explored in a sample of hyperactive–inattentive preschool children (N = 47) and nonimpaired controls (N = 113). A subset of parents completed the questionnaire on 2 occasions, approximately 1 year apart. Factor analysis revealed a 3-factor solution, accounting for 32.28% of the variance. The resultant Positive Parenting, Negative/Inconsistent Parenting, and Punitive Parenting factors demonstrated good internal consistency and temporal stability. At baseline, parents of hyperactive–inattentive and control children did not differ on any APQ–PR subscale. However, over time parents of controls increased their use of positive parenting techniques, whereas the use of positive parenting practices decreased over time in the hyperactive–inattentive group.