Katie C. Hart

Treatment Sequencing for Childhood ADHD: A Multiple-Randomization Study of Adaptive Medication and Behavioral Interventions

Behavioral and pharmacological treatments for children with attention deficit/hyperactivity disorder (ADHD) were evaluated to address whether endpoint outcomes are better depending on which treatment is initiated first and, in case of insufficient response to initial treatment, whether increasing dose of initial treatment or adding the other treatment modality is superior. Children with ADHD (ages 5–12, N = 146, 76% male) were treated for 1 school year. Children were randomized to initiate treatment with low doses of either (a) behavioral parent training (8 group sessions) and brief teacher consultation to establish a Daily Report Card or (b) extended-release methylphenidate (equivalent to .15 mg/kg/dose bid). After 8 weeks or at later monthly intervals as necessary, insufficient responders were rerandomized to secondary interventions that either increased the dose/intensity of the initial treatment or added the other treatment modality, with adaptive adjustments monthly as needed to these secondary treatments. The group beginning with behavioral treatment displayed significantly lower rates of observed classroom rule violations (the primary outcome) at study endpoint and tended to have fewer out-of-class disciplinary events. Further, adding medication secondary to initial behavior modification resulted in better outcomes on the primary outcomes and parent/teacher ratings of oppositional behavior than adding behavior modification to initial medication. Normalization rates on teacher and parent ratings were generally high. Parents who began treatment with behavioral parent training had substantially better attendance than those assigned to receive training following medication. Beginning treatment with behavioral intervention produced better outcomes overall than beginning treatment with medication.

Impact of Group Size on Classroom On-Task Behavior and Work Productivity in Children With ADHD

This study sought to systematically examine the academic behavior of children with ADHD in different instructional contexts in an analogue classroom setting. A total of 33 children with ADHD participated in a reading comprehension activity followed by a testing period and were randomly assigned within days to either small-group instruction, whole-group instruction, or independent seatwork. The effects of instructional contexts on on-task behavior during instruction and on-task behavior and work productivity during testing were examined. Children with ADHD were found to be more on task during small-group instruction than both whole-group and independent seatwork instructional conditions. In the testing context, children with ADHD were found to be less productive in small-group than in the whole-group and independent seatwork conditions. The findings of this study have implications for future research evaluating the standard educational practices and accommodations made for children with ADHD in the classroom setting.

Comparative Cost Analysis of Sequential, Adaptive, Behavioral, Pharmacological, and Combined Treatments for Childhood ADHD

We conducted a cost analysis of the behavioral, pharmacological, and combined interventions employed in a sequential, multiple assignment, randomized, and adaptive trial investigating the sequencing and enhancement of treatment for children with attention deficit hyperactivity disorder (ADHD; Pelham et al., 201X; N = 146, 76% male, 80% Caucasian). The quantity of resources expended on each child’s treatment was determined from records that listed the type, date, location, persons present, and duration of all services provided. The inputs considered were the amount of physician time, clinician time, paraprofessional time, teacher time, parent time, medication, and gasoline. Quantities of these inputs were converted into costs in 2013 USD using national wage estimates from the Bureau of Labor Statistics, the prices of 30-day supplies of prescription drugs from the national Express Scripts service, and mean fuel prices from the Energy Information Administration. Beginning treatment with a low-dose/intensity regimen of behavior modification (large-group parent training) was less costly for a school year of treatment (

Beyond behavior modification: Benefits of social-emotional/self-regulation training for preschoolers with behavior problems.

961) than beginning treatment with a low dose of stimulant medication (

Self-regulation assessment among preschoolers with externalizing behavior problems.

1,669), regardless of whether the initial treatment was intensified with a higher “dose” or if the other modality was added. Outcome data from the parent study (Pelham et al., 201X) found equivalent or superior outcomes for treatments beginning with low-intensity behavior modification compared to intervention beginning with medication. Combined with the present analyses, these findings suggest that initiating treatment with behavior modification rather than medication is the more cost-effective option for children with ADHD.

Executive Functioning and School Readiness Among Preschoolers With Externalizing Problems: The Moderating Role of the Student–Teacher Relationship

The current study evaluated the initial efficacy of three intervention programs aimed at improving school readiness in preschool children with externalizing behavior problems (EBP). Participants for this study included 45 preschool children (76% boys; Mage=5.16years; 84% Hispanic/Latino background) with at-risk or clinically elevated levels of EBP. During the summer between preschool and kindergarten, children were randomized to receive three newly developed intervention packages. The first and most cost effective intervention package was an 8-week School Readiness Parenting Program (SRPP). Families randomized into the second and third intervention packages received not only the weekly SRPP, but children also attended two different versions of an intensive kindergarten summer readiness class (M-F, 8a.m.-5p.m.) that was part of an 8-week summer treatment program for pre-kindergarteners (STP-PreK). One version included the standard behavioral modification system and academic curriculum (STP-PreK) while the other additionally contained social-emotional and self-regulation training (STP-PreK Enhanced). Baseline, post-intervention, and 6-month follow-up data were collected on childrens school readiness outcomes including parent, teacher, and objective assessment measures. Analyses using linear mixed models indicated that childrens behavioral functioning significantly improved across all groups in a similar magnitude. Children in the STP-PreK Enhanced group, however, experienced greater growth across time in academic achievement, emotion knowledge, emotion regulation, and executive functioning compared to children in the other groups. These findings suggest that while parent training is sufficient to address childrens behavioral difficulties, an intensive summer program that goes beyond behavioral modification and academic preparation by targeting socio-emotional and self-regulation skills can have incremental benefits across multiple aspects of school readiness.

Elementary and Middle School Teachers' Self-Reported Use of Positive Behavioral Supports for Children with ADHD: A National Survey.

This study examined the construct validity and clinical utility of a brief self-regulation assessment (Head-Toes-Knees-Shoulders, HTKS) among a clinical sample of children with externalizing behavior problems (EBP). Participants for this study included 101 preschool children (72% male; Mage = 5.10 years; 79% Hispanic) with at-risk or clinically elevated levels of EBP. Self-regulation measures included the HTKS task, 4 standardized subtests from the Automated Working Memory Assessment (AWMA), parent and teacher reports of childrens executive functioning (EF), and childrens self-regulation performance across a series of executive functioning classroom games conducted as part of a summer treatment camp. Additional outcomes included school readiness as measured by standardized achievement tests, and parent and teacher reports of kindergarten readiness and behavioral impairment related to academic functioning. Performance on the HTKS task was moderately correlated with childrens performance on the standardized working memory tasks and observed self-regulation performance in the classroom. Low to moderate correlations were observed between performance on the HTKS task and parent report of childrens EF difficulties, as well as parent and teacher reports of childrens kindergarten readiness and behavioral impairment related to academic functioning. Moderate to high correlations were observed between performance on the HTKS task and standardized academic outcomes. These findings highlight the promise of the HTKS task as a brief, ecologically valid, and integrative EF task tapping into both behavioral and cognitive aspects of self-regulation that are important for children with EBPs success in school.

Early Intervention for Children With Behavior Problems in Summer Settings Results From a Pilot Evaluation in Head Start Preschools

ABSTRACT Research Findings: The objective of this study was to examine the student–teacher relationship as a potential moderator of the link between executive functioning (EF) and children’s early school readiness among a clinical sample of preschoolers with externalizing behavior problems (EBP). Participants for the study included 139 preschool children (75.54% boys, M age = 5.01 years, 84.94% Hispanic/Latino) with at-risk or clinically elevated levels of EBP. The student–teacher relationship was assessed using the Student–Teacher Relationship Scale. School readiness data were composed of standardized achievement test scores and teacher reports of kindergarten readiness. EF was measured via parent and teacher reports along with standardized measures of EF, including the Head–Toes–Knees–Shoulders task and 4 standardized subtests from the Automated Working Memory Assessment. Poorer student–teacher relationship quality was predictive of lower teacher-reported kindergarten readiness and higher academic impairment. Main effects were qualified by an interaction between EF and student–teacher relationship quality such that worse EF (parent/teacher reports and standardized performance) was only associated with lower teacher-rated kindergarten readiness for children with poorer student–teacher relationship quality. Practice or Policy: EF appears to be an important predictor of school readiness for preschool children with EBP, particularly for children experiencing poorer student–teacher relationships.

Comparing working memory in bilingual and monolingual Hispanic/Latino preschoolers with disruptive behavior disorders

This study examined elementary and middle school teachers’ self-reported use of behavioral supports for students with attention-deficit/hyperactivity disorder (ADHD) from a national sample of teachers. This information is important given increased attention and emphasis on universal and targeted strategies within problem-solving models in schools. Participants were teachers surveyed from 26 states across North America about their use of behavioral supports for their students with ADHD. Results are grouped by primary (K–2), intermediate (3–5), and middle (6–8) school levels. Results from this survey demonstrate that teachers report using significantly more universal and targeted strategies in the primary and intermediate school levels than teachers in the middle school level, revealing a reduction of behavioral supports for students with ADHD as they move into the middle school years. These findings have have implications for targeting school-based interventions for students with ADHD as they transition into middle school.

Parent Perceptions of Medication Treatment for Preschool Children with ADHD

The objective of this study was to evaluate two early intervention packages to promote successful transitions to kindergarten for preschoolers with behavior problems recruited from Head Start preschools. Fifty children (Mage = 61 months; 76% male; 98% minority) referred by teachers due to early externalizing behavior problems were randomly assigned to one of the two groups. Group 1 (high intensity; HI) received a 4-week intensive summer program before the start of kindergarten, weekly parent workshops, and monthly school consultation and parent workshops throughout kindergarten. Group 2 (low intensity; LI) received only parent workshops. Program feasibility, child improvement, and parental satisfaction data were collected along with parent and teacher reports and measures of school readiness. Children in the HI group demonstrated fewer problem behaviors and less student–teacher conflict as reported by teachers. Early intensive summer interventions prior to kindergarten were found to be a promising avenue to promote successful transitions to school for children from Head Start preschools with behavior problems.