William E. Pelham

Evidence-Based Psychosocial Treatments for Attention-Deficit/Hyperactivity Disorder.

Pelham, Wheeler, and Chronis (1998) reviewed the treatment literature on attention-deficit/hyperactivity disorder (ADHD) and concluded behavioral parent training (BPT) and behavioral classroom management (BCM) were well-established treatments for children with ADHD. This review updates and extends the finding of the prior review. Studies conducted since the 1998 review were identified and coded based on standard criteria, and effect sizes were calculated where appropriate. The review reinforces the conclusions of Pelham, Wheeler, and Chronis regarding BPT and BCM. Further, the review shows that intensive peer-focused behavioral interventions implemented in recreational settings (e.g., summer programs) are also well-established. The results of this update are discussed in the context of the existing treatment literature on ADHD. Implications for practice guidelines are suggested, as are directions for future research.

Attention-Deficit Hyperactivity Disorder and Problems in Peer Relations: Predictions From Childhood to Adolescence

OBJECTIVE To determine whether childhood attention-deficit hyperactivity disorder (ADHD) and persistence of the disorder are associated with later difficulty in adolescent peer relations. METHOD One hundred eleven children with ADHD were interviewed as adolescents and compared with 100 adolescents without an ADHD history (aged 13-18 years). The multi-informant assessment strategy included parents, teachers, and adolescents. RESULTS Parents of probands reported fewer close friendships and greater peer rejection compared with the non-ADHD group. Probands reported that their friends were less involved in conventional activities compared with the non-ADHD group. Childhood aggression predicted less self-perceived social competence for probands. The long-term effects of ADHD on social functioning were more pronounced for probands with persistent ADHD or conduct disorder in adolescence. CONCLUSIONS Impairments in peer relations for ADHD youths, known to be common in childhood, also exist in adolescence. Given the developmental significance of peer relations, further research into the causes and treatment of poor social functioning in youths with ADHD is recommended.

A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder

There is currently controversy regarding the need for and the effectiveness of behavior modification for children with attention-deficit hyperactivity disorder (ADHD) despite years of study and multiple investigations reporting beneficial effects of the intervention. A meta-analysis was conducted by identifying relevant behavioral treatment studies in the literature. One-hundred seventy-four studies of behavioral treatment were identified from 114 individual papers that were appropriate for the meta-analysis. Effect sizes varied by study design but not generally by other study characteristics, such as the demographic variables of the participants in the studies. Overall unweighted effect sizes in between group studies (.83), pre-post studies (.70), within group studies (2.64), and single subject studies (3.78) indicated that behavioral treatments are highly effective. Based on these results, there is strong and consistent evidence that behavioral treatments are effective for treating ADHD.

Clonidine for attention-deficit/hyperactivity disorder: I. Efficacy and tolerability outcomes

OBJECTIVE To determine the efficacy and safety of clonidine, used alone or in combination with methylphenidate, in treating attention-deficit/hyperactivity disorder (ADHD). METHOD A 16-week, randomized, double-blind, placebo-controlled clinical trial was conducted in 122 children, ages 7 to 12, with any subtype of ADHD, randomly assigned to clonidine, methylphenidate, clonidine in combination with methylphenidate, or placebo according to a 2 x 2 factorial design. In two successive 4-week titration periods, clonidine (or matching placebo) and added methylphenidate (or matching placebo) were adjusted to optimal doses and then continued for 8 weeks. The primary efficacy outcome was changed from baseline to week 16 on the Conners Teachers Abbreviated Symptom Questionnaire. Secondary outcomes included the Conners Abbreviated Symptom Questionnaire for Parents and the Childrens Global Assessment Scale. RESULTS On the Conners Teachers Abbreviated Symptom Questionnaire, clonidine was not found to improve ADHD symptoms, whereas subjects treated with methylphenidate showed significant improvement compared to those not treated with methylphenidate. Subjects treated with clonidine had greater improvements on the Conners Abbreviated Symptom Questionnaire for Parents and Childrens Global Assessment Scale, but also a higher rate of sedation compared with subjects not treated with clonidine. CONCLUSIONS Based on the Conners Teachers Abbreviated Symptom Questionnaire, methylphenidate offers the best combination of efficacy and tolerability for ADHD. Clonidine was well tolerated despite the frequency of sedation and did offer some benefit.

Attention-Deficit/Hyperactivity Disorder and Risk of Substance Use Disorder: Developmental Considerations, Potential Pathways, and Opportunities for Research

Many opportunities to explain attention-deficit/hyperactivity disorder (ADHD)-related risk of substance use disorder (SUD) remain available for study. We detail these opportunities by considering characteristics of children with ADHD and factors affecting their outcomes side by side with overlapping variables in the developmental literature on SUD etiology. Although serious conduct problems are a known contributor to ADHD-related risk of SUD, few studies have considered their emergence developmentally and in relation to other candidate mediators and moderators that could also explain risk and be intervention targets. Common ADHD-related impairments, such as school difficulties, are in need of research. Heterogeneous social impairments have the potential for predisposing, and buffering, influences. Research on neurocognitive domains should move beyond standard executive function batteries to measure deficits in the interface between cognitive control, reward, and motivation. Ultimately, maximizing prediction will depend, as it has in the SUD literature, on simultaneous consideration of multiple risk factors.

A Discrete Choice Conjoint Experiment to Evaluate Parent Preferences for Treatment of Young, Medication Naive Children with ADHD

The current study examined treatment preferences of 183 parents of young (average age = 5.8 years, SD = 0.6), medication naive children with ADHD. Preferences were evaluated using a discrete choice experiment in which parents made choices between different combinations of treatment characteristics, outcomes, and costs. Latent class analysis yielded two segments of parents: (a) medication avoidant parents constituted 70.5% of the sample whose treatment decisions were strongly influenced by a desire to avoid medication, and (b) outcome oriented parents constituted 29.5% of the sample whose treatment decisions were most influenced by a desire for positive treatment outcomes. Parents in the outcome oriented segment were more stressed and depressed, had lower socioeconomic status and education, were more likely to be single parents, and had more disruptive and impaired children. Simulations predicted that parents would prefer treatments with behavior therapy over treatments with stimulant medication only.

The Effects of Incentives on Visual–Spatial Working Memory in Children with Attention-deficit/Hyperactivity Disorder

Working memory is one of several putative core neurocognitive processes in attention-deficit/hyperactivity disorder (ADHD). The present work seeks to determine whether visual–spatial working memory is sensitive to motivational incentives, a laboratory analogue of behavioral treatment. Participants were 21 children (ages 7–10) with a diagnosis of ADHD-combined type. Participants completed a computerized spatial span task designed to assess storage of visual–spatial information (forward span) and manipulation of the stored information (backward span). The spatial span task was completed twice on the same day, once with a performance-based incentive (trial-wise feedback and points redeemable for prizes) and once without incentives. Participants performed significantly better on the backward span when rewarded for correct responses, compared to the no incentive condition. However, incentives had no effect on performance during the forward span. These findings may suggest the use of motivational incentives improved manipulation, but not storage, of visual–spatial information among children with ADHD. Possible explanations for the differential incentive effects are discussed, including the possibility that incentives prevented a vigilance decrement as task difficulty and time on task increased.

Behavioral Intervention in Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is a chronic disorder of childhood characterized by abnormally high levels of inattention, impulsivity, and overactivity (American Psychiatric Association, 1994). ADHD children have serious impairment in many domains of functioning, including school, family, and peer domains, that not only highlight the seriousness of ADHD as a childhood problem but also predict the development of even more serious problems and a poor outcome in adolescence and adulthood (see Chapter 12, this volume). Thus, effective treatment for childhood ADHD is a major public health agenda.

Comprehensive, sustained behavioral and pharmacological treatment for attention-deficit/hyperactivity disorder: A case study*

Treatment for attention-deficit/hyperactivity disorder (ADHD) must be long-term, be intensive, address functional impairment across important domains and settings, and be sensitive to individual differences. This case illustrates comprehensive, combined behavioral and pharmacological treatment for a child diagnosed with ADHD and conduct disorder over a period of 3 years. Specific treatment components included an intensive summer treatment program (STP), behavioral parent training, behavioral classroom interventions, individually titrated stimulant medication, and a cognitive-behavioral depression-prevention program for the childs mother. Although substantial improvements were found in the degree of functional impairment, this child remained impaired in many domains. This suggests that treatment for ADHD, particularly in severe cases such as this, must be intensive and ongoing.

Examining Parents’ Preferences for Group and Individual Parent Training for Children with ADHD Symptoms

Parent training (PT) programs have been found to reduce some behavioral impairment associated with childrens attention deficit hyperactivity disorder (ADHD) as well as improve parenting competence, but poor uptake and participation by parents are formidable barriers that affect service effectiveness. We used a discrete-choice experiment (DCE) to examine how parent preferences for treatment format (i.e., group vs. individual) might influence their participation in PT. Participants were 445 parents seeking mental health services for children with elevated symptoms of ADHD in Ontario, Canada. Parents completed a DCE composed of 30 choice tasks used to gauge PT format preference. Results showed that 58.7% of parents preferred individual PT; these parents were most interested in interventions that would make them feel more informed about their childs problems and in understanding—as opposed to solving—their childs problems. A minority of parents (19.4%) preferred group PT; these parents were most interested in active, skill-building services that would help them solve their childs problems. About one fifth of parents (21.9%) preferred the Minimal Information alternative (i.e., receiving neither individual or group PT); these parents reported the highest levels of depression and the most severe mental health problems in their child. Results highlight the importance of considering parent preferences for format and suggest that alternative formats to standard PT should be considered for multiply stressed families.